HEDIS®
Horizon NJ Health’s Quality Improvement Program uses HEDIS (Healthcare Effectiveness Data and Information Set) measures that the National Committee for Quality Assurance (NCQA) established. The NCQA created HEDIS as tool to collect data about the quality of care and services provided by the health plan. This set of standardized measures compares health plans’ performance on important dimensions of care and service. HEDIS is recognized as one of the most proven forms of methodology for data collection and the most widely used set of performance measures in the managed care industry. HEDIS results are based on a statistically valid random sample of members or the entire eligible population.
Horizon NJ Health Providers play a critical role in the delivery of healthcare, assisting us in ongoing quality initiatives by outreach to and educating our members. By communicating with our members the importance of preventive health screenings and age-appropriate exams, providers can help us increase HEDIS scores.
Interactions that focus on the value of preventive care are instrumental in encouraging patients to obtain preventive screenings, such as lead testing, PAP smears, mammography and colonoscopy. All are important services that you can provide to your patients, our members. When you see one of your Horizon NJ Health patients, you have the opportunity to reinforce good health care behavior on topics, such as child development, safety issues appropriate to each age group or disease education. We continue to increase our interactions with members to improve preventive care compliance and recognize that enhanced interactions between provider and member will assist in improving our members’ health outcomes, ultimately and positively impacting our HEDIS rates.
Please document all components of the member’s visit in his or her medical record. As a reminder, please submit encounters for visits in the form of claims. This will assist us when we are performing our audits including HEDIS. Encounter submissions will assist in increasing HEDIS scores.
2021 HEDIS® Results – Medicaid Adult
| HEDIS Accreditation Measure for Medicare | Description | Final HEDIS 2021 Performance Rate | Final HEDIS 2020 Performance Rate | 2021 NJ State Average |
| Breast Cancer Screening | The percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer. | 55.2% | 58.10% | 54.52% |
| Comprehensive Diabetes Care Eye Exam | The percentage of members 18 to 75 years of age who had an eye screening for diabetic retinal disease and includes one of the following: a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. | 50.61% | 62.32% | 51.31% |
| Comprehensive Diabetes Care HbA1c Poor Control (>9.0 percent; Lower is Better) | The percentage of members 18 to 75 years of age whose last HbA1c test had a result of >9.0 percent during the measurement year. | 39.42% | 38.73% | 40.6% |
| Comprehensive Diabetes Care HbA1c Testing | The percentage of members 18 to 75 years of age who had an HbA1c test performed during the measurement year. | 77.86% | 87.68% | 80.69% |
| Controlling High Blood Pressure (Total Rate) | The percentage of members 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled during the measurement year. | 54.74% | 49.88% | 53.87% |
| Flu Shots for Older Adults | The percentage of members 65 years of age and older who received an influenza vaccination between July 1 of the measurement year and the date when the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey was completed. | 33.2% | 41.5% | 35.6% |
| Follow-Up After Hospitalization for Mental Illness (Seven-Day Rate) | The percentage of discharges for members six years of age and older (hospitalized for specified mental illnesses) who had a follow-up visit with a mental health provider within seven days of discharge. | 28% | 20.11% | 27.78% |
| Medical Assistance With Smoking Cessation (Advising Smokers to Quit)
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The percentage of members 18 years of age and older who currently smoke and responded via survey that they received advice from a doctor about quitting during the measurement year. | 69.4% | 75.20% | ND |
| Persistence of Beta-Blocker Treatment After a Heart Attack | The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI)/heart attack and who received persistent beta-blocker treatment for six months after discharge. | 87.14% | 79.81% | ND |
HEDIS® is a registered trademark of the National Committee for Quality Assurance.
CAHPS® is a registered trademark of the Agency of Healthcare Research and Quality.
An Independent Licensee of the Blue Cross Blue Shield Association.
2021 HEDIS® Results – Medicaid Child
| HEDIS Accreditation Measure for Medicaid Child | Description | Final HEDIS 2021 Performance Rate | Final HEDIS 2020 Performance Rate | HEDIS 2021 NJ State Average |
| Childhood Immunization – Combination 2 | The percentage of children two years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. | 71.29% | 72.02% | 63.5% |
| Lead Screening in Children | The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. | 71.34% | 74.70% | 74.26% |
| Immunizations for Adolescents Combination 2 | The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday. The measure calculates a rate for each vaccine and two combination rates. | 31.14% | 35.77% | 29.44% |
| Follow-Up after hospitalization for mental illness 6-17 years 7 day follow-up | The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. | 19.51% | 5.13% | ND |
| Asthma Medication Ratio 5-11 years 12-18 years |
The percentage of members 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. | 75.89% 64.44% |
70.70 60.26% |
70.3% 64.57% |
| Appropriate Treatment for Upper Respiratory Infection | The percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event. | 91.64% | 92.44% | 79.67% |
| Follow-up Care for Children Prescribed ADHD Medication (ADD) Initiation Phase- Continuation and Maintenance Phase- |
The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. | 35.18% 39.44% |
32.20% 34.21% |
37.41% ND |
HEDIS® is a registered trademark of the National Committee for Quality Assurance.
CAHPS® is a registered trademark of the Agency of Healthcare Research and Quality.
An Independent Licensee of the Blue Cross Blue Shield Association.