The Role of Analytics in the Future of HEDIS: A Medicaid Perspective

We know data analytics play an important role in healthcare. In the right hands and with the right tools and technologies, analytics provide valuable insights that can be used to solve many healthcare challenges.

There are almost limitless possibilities for what analytics can do, and we know they have a place in healthcare quality control. HEDIS (Healthcare Effectiveness Data and Information Set) is one of the healthcare industry’s most widely used performance-improvement tools. Today, more than 90% of U.S. health plans use HEDIS to measure performance in vital areas of care and service. This represents approximately 191 million people enrolled in health plans that use the tool.

HEDIS 2025: Major Changes Impacting Medicaid

For Measurement Year 2025, NCQA has added three new measures, revised multiple existing measures, and made additional updates to gender inclusivity and race-ethnicity stratification. These changes are particularly significant for Medicaid plans, which serve diverse populations with complex health and social needs.

Key 2025 Updates:

• New Breast Cancer Measures: The newest additions to HEDIS address the use of Breast Imaging Reporting and Data System (BI-RADS) assessments, abnormal breast cancer assessment follow-up
• New Blood Pressure Measure: This new measure addresses members with hypertension and keeping their blood pressure under control
• Enhanced Mental Health Coverage: Several new diagnoses are now included in the eligibility criteria, including phobia, anxiety, and additional intentional self-harm diagnoses. Members in residential treatment facilities will no longer be excluded from the measures and will now count as compliant
• Expanded Equity Focus: Expansion of race and ethnicity stratification and updates to advance gender-inclusive quality measurement

Medicaid Core Set Requirements: A New Era of Mandatory Reporting

The landscape has fundamentally changed for Medicaid programs. The Medicaid and CHIP Core Sets of Health Care Quality measures are sets of standardized health care quality measures that CMS and states can use to measure the standard of care delivered to the approximately 80 million Medicaid and CHIP beneficiaries.

Critical Changes for 2025:

• Mandatory Reporting: Beginning in fiscal year (FY) 2025, states are required to report on the core set of quality measures for children enrolled in Medicaid and CHIP and the core set of behavioral health measures for adults enrolled in Medicaid
• Equity Reporting Requirements: Starting in FY 2025, states will be required to report a subset of Child and Adult Core Set measures by race, ethnicity, sex, and geography
• Deadline Pressure: Core Set reporting to CMS must be submitted by December 31^st of the reporting year (i.e. for FY 2025 the deadline is December 31, 2025)

The Future of HEDIS: Six Focus Areas

HEDIS measures continue to evolve based on NCQA’s commitment to ensuring measures remain relevant. The future of HEDIS focuses on six core ideas:

• Allowable adjustments: Enhanced flexibility that allows measures to be modified without changing their clinical intent
• Licensing and certification: Ensures updated requirements are understood and coded correctly for consistent accuracy
• Digital measures: HEDIS specifications that download directly into data systems, bringing greater ease of use
• Electronic Clinical Data Systems (ECDS): A new reporting method that enables better use of electronic clinical data, with NCQA continuing the transition to ECDS reporting
• Equity: Closing gaps to enable better, more equitable care
• Telehealth: Access to care that telehealth enabled during COVID-19 that remains vital to quality

Improving HEDIS Outcomes for Medicaid Populations

Using analytics can help Medicaid organizations meet the most important criteria when it comes to HEDIS reporting measures. Organizations use NCQA-certified HEDIS measures to show they’re achieving acceptable results and ratings. Those that fail to attain passing ratings can lose their accreditation—a critical concern for Medicaid managed care organizations.

Specific Analytics Applications for Medicaid:

• Social Determinants Integration: Medicaid populations face unique social barriers. Analytics can identify members who need transportation assistance, housing support, or other social interventions that impact health outcomes
• Complex Population Management: With enhanced mental health measures and equity requirements, analytics help identify and manage vulnerable sub-populations including justice-involved individuals, those with serious mental illness, and dual eligibles
• Real-Time Intervention: Calculating rates monthly or quarterly helps identify members who haven’t completed preventive screenings, enabling proactive outreach to improve care gaps
• Predictive Modeling: Because HEDIS measures are retrospective, predictive analytics can forecast performance trends and help prioritize interventions
• Benchmarking: Compare performance against state and national Medicaid-specific benchmarks to identify improvement opportunities

Preparing for Medicaid’s Quality Future

These changes represent more than technical updates—they signal a fundamental shift toward equity-focused, data-driven quality measurement. CMS encourages states to use Core Set data to identify disparities in care and develop initiatives and policies to advance health equity.

Medicaid organizations must be prepared not only to retain accreditation but to improve care quality for their most vulnerable members while demonstrating value to state partners and federal oversight.

As HEDIS evolves and Medicaid quality requirements become more sophisticated, Gainwell Technologies has the capabilities to serve as an advisor and partner to organizations focused not only on reporting and improving HEDIS quality measure scores, but on achieving the ultimate outcome: healthier Medicaid members and more equitable communities.