Improve Your HEDIS and Star Ratings by Closing Patient Care Gaps

HEDIS Care gaps

HEDIS and Star ratings play an important role in ensuring the success of healthcare organizations as both businesses and purveyors of excellent patient care. In this blog, we will cover the basics of HEDIS and Star ratings and end with ways to improve your scores by closing care gaps.

What is HEDIS?

HEDIS stands for Healthcare Effectiveness Data and Information Set. It was created by the NCQA in order to routinely check and assure that healthcare programs and systems were adequately serving patient populations based on predetermined measures.

What are Star Ratings?

Star ratings are just another way healthcare systems are monitored and rated for their efficacy. Instead of applying to all health organizations, they apply mostly to Medicare Advantage plans.

HEDIS Ratings vs Star Ratings

The goals of HEDIS and Star are almost identical in their objectives, but the methods they use as well as the managing organizations differ. HEDIS is managed and defined by the NCQA and applies to essentially everyone in the healthcare space. Star ratings instead are managed by CMS, and they apply to Medicare Advantage plans.

HEDIS and Diabetes

HEDIS has a specific measure for diabetic patients called “comprehensive diabetes care.” It covers the most essential medical attention needed to consider a diabetic patient plan complete. Those measures consist of:

  • Hemoglobin A1c testing (HbA1c poor control >9, HbA1c control <8)
  • Blood pressure control (<140/90 mmHg)
  • Eye exam (retinal) performed
  • Medical attention for nephropathy

Since a retinal exam is an integral part of meeting this measure, proper eye care is an essential aspect for Health Risk Assessment organizations (HRAs) attempting to close gaps in care. HEDIS ratings can be boosted by investing in technologies that make these preventative diabetic exams more accessible and easily administered by HRAs and their employees.

You can read more about the 2023 HEDIS compliance measures here. >>

Why HEDIS and Star Ratings Matter

HEDIS and Star ratings matter most obviously because they are an indication of the efficacy of a healthcare organization’s patient care, or a payor’s preventative healthcare measures. If you have gaps in care, HEDIS ratings will drop. Closing those patient care gaps and boosting the frequency of preventative screenings will help you improve your HEDIS score.

Another reason healthcare organizations and insurance payors should focus on keeping their HEDIS and CMS Star ratings up is because of their effect on potential funding. If an organization has high healthcare Star ratings or HEDIS ratings, it could see a boost in funding. But if an organization has low ratings, it could struggle to qualify for reimbursement and see financial penalties. For example, organizations with less than four stars do not qualify for bonus payments. Low ratings can also cause entities that have contracts or partnerships with these organizations to be less likely to renew them.

To give an idea of how much an organization has to gain from a high HEDIS or CMS Star rating, a health plan with 100,000 members would qualify for $17 million in reimbursement for each quality measure taken.

So what’s the best way to go about closing HEDIS gaps and boosting HEDIS and CMS Star ratings?

How HRAs are Improving NCQA HEDIS and CMS Star Ratings with IRIS

To close gaps in care, HEDIS-based organizations are starting to administer preventative screenings through in-home test kits, in-home evaluation health visits, and screening events. This makes it easier to ensure the closure of care gaps because it gets rid of the need for patients to make it to a doctor’s appointment. Patients benefit because they get the screenings they need in a convenient manner, providers benefit because their HEDIS ratings go up with every additional screening performed, and insurers benefit because the chances of catching the development of a more serious condition are higher.

The IRIS solution helps HRAs close gaps in patient care through in-home screenings because it allows for the performance of retinal screenings in a patient’s home, with no ophthalmology appointment required.


It all starts with a portable camera used by an IRIS-trained HRA employee. Once they capture the fundus image, it is sent through the cloud, enhanced by our algorithm, and delivered to the IRIS Reading Center (IRC) where the image is interpreted by one of the IRC’s physicians. The results are then available to the organization.

Improve Your Preventative Screenings with IRIS Today

For years, IRIS has been working with in-home health evaluation organizations, HRAs, and healthcare providers (HCPs) to improve HEDIS and STAR ratings by making it easier for patients to receive eyesight-saving examinations. Our image-enhancing technology paired with portable fundus cameras make diabetic HEDIS measures easier to meet by helping providers meet diabetic patients wherever they are in their health journey.

Our solution is used by organizations such as Prisma Health, St. Elizabeth’s Healthcare,  and Gateway Medical. You can check out more of our client’s success stories here, or if you’re interested in trying IRIS yourself in order to close HEDIS gaps and improve CMS Star ratings, you can reach out to us today to schedule a demo.



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