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What is HEDIS, and Why is it Important?

Eye Care
Michael Hecht, OD
Published on: 02-01-2019

The Healthcare Effectiveness Data and Information Set (HEDIS) is a government measurement tool used by most of America's insurance companies to gauge how insured patients are being cared for. Insurance companies receive a score from the government, with significant Medicare financial incentives for providers and insurers if a score exceeds certain thresholds.

The premise behind HEDIS is simple. HEDIS rewards preventive care - a major focus of the government's healthcare system. The concept is that by increasing preventative care, the number of overall doctor visits drops, and patients experience better outcomes.

HEDIS measurements consist of more than 90 measures, such as flu shots, EKGs, colonoscopies, osteoporosis testing, and preventative mammograms.

One of the HEDIS indicators, DRE (Dilated Retina Exam), is eye-related, and it's extremely important.

For those in the eye care industry, receiving excellent HEDIS scores can be financially beneficial while also improving the quality of care. CMS uses a 5-star system to rate Health Plans, with 1 star being "poor" and 5 stars being "excellent." Bonuses for high star ratings range from 1.5 percent to 5 percent. 

Early detection is important in dealing with diabetic eye disease, or diabetic retinopathy, a complication of diabetes that affects the small blood vessels in the back of the eye or retina. These changes can cause mild to severe loss of vision. In fact, diabetes is the leading cause of severe vision loss in Americans between the ages of 20 and 64. 

Dilated Retina Exams are key to the prevention of blindness from diabetes. The longer a patient has diabetes, the greater the chance of developing diabetic eye disease, which may lead to blindness. A recent study concluded that laser surgery significantly reduced the risk of severe vision loss when compared with no treatment.

By providing diabetic eye screenings, insurance companies can effectively monitor a patient's eye health and help to prevent further complications, which could require more involved care later if left untreated.

The key to success with HEDIS is the communication between primary care providers (PCPs) and health plan members.

Many members have formed a strong bond with their primary provider and trust their primary care physician's guidance and expertise. A simple provider-to­member discussion followed up with an annual eye exam is all it takes to meet HEDIS standards and, more importantly, ensure patient eye health.

When you consider all the advantages of HEDIS, it just makes good sense to make meeting the guidelines a priority.


Dr. Michael Hecht, O.D. is the Medical Director and Director of Provider Relations of Premier Eye Care, a third-party administrator of eye care benefits for health plans based in Tampa, Fla. Premier helps health plan partners manage risks while ensuring that their members receive high-quality, cost-effective care. This work includes a focus on helping partners achieve success in meeting and exceeding HEDIS measurements.