Health Equity, Featured

How to Advance Health Equity in HEDIS 2023

By Unite Us on August 25, 2022
woman and child smiling


What’s New in HEDIS 2023?

Confirming its long-term focus on advancing health equity, NCQA announced changes for Healthcare Effectiveness Data and Information Set (HEDIS) in measurement year 2023 including:

  • Race/ethnicity stratification in eight additional HEDIS measures with integration to additional measures planned over the next several years
  • Gender affirming approaches to ensure that HEDIS measures appropriately by acknowledging and affirming member gender identity
  • New social needs screenings and interventions measure to encourage plans to assess and address members’ unmet food, housing and transportation needs using pre-specified instruments


Diverse Social Needs Through Risk Stratification

Measuring stratification by race, ethnicity, gender, as well as other social risk factors, is critical to understanding diverse social needs in the population and to addressing disparities.


Looking beyond clinical encounters and claims data, health plans can uncover hidden risks and devise proactive whole-person approaches. 

It’s important to note that social and economic indicators such as Z-codes, surveys, and geographic-aggregated data can help but have limitations. On average 11,000 people live in a single zip code. Incomplete information or broad categories make assumptions about larger populations and do not facilitate understanding or action. More detailed and standardized data fields help:

  • generate greater trust in data collection efforts
  • better capture critical information on ‘hard-to-reach populations'
  • increase efficiency and leverage meaningful and actionable data


Empowering Partners to Drive Change 

At Unite Us, we work with community-based organizations, health systems, and government partners to ensure all women and infants, particularly those at risk of poor health outcomes, have a chance at a safe and healthy life.


We believe innovative and collaborative strategies should focus on removing barriers to accessing care, emphasizing preventative approaches and integrated community programs. Our shared, community-wide platform makes it easier for health, human, and social service providers to:

  • Connect underserved pregnant people and new parents to coordinated care and resources, so they can get the care they need when they need it.
  • Leverage proactive interventions such as home-visitation programs, prenatal care providers, and breastfeeding support. 
  • Increase access to high-quality maternal care by partnering with credible provider networks and social service agencies; building strong partnerships and learning collaboratives with public and private stakeholders help advance equitable maternal health care in the U.S.


Unite Us’ Social Needs System (SNS) analytics framework helps zero in on the impact of social determinants of health. For example, we have observed that highly socially vulnerable members represent 30% higher regression on mental and physical health.


Measure stratification can help not only better assess how social vulnerability impacts plan performance and quality outcomes but also better drive targeted interventions, and measure and prove impact.


Close the Loop on Care with Social Screenings and Interventions

Social needs screenings and referral tools should be integrated into systems of record to create a seamless and intuitive experience for care teams and ultimately members. 


Feedback from our users highlights the importance of integrating social care in their care management platform and workflows to achieve true community care coordination.


Data standards, pre-built forms, and collaborative workflows not only reduce errors and improve efficiency in working with the community, they also improve the ability to measure impact and close the loop on care.


Health plans can now build on social needs measures, assessments, and referrals to make sure their investments are driving impact on quality outcomes in their population, turning this from an additional effort to the key to unlocking value.


By connecting members with a consistent, accountable community network, and with real-time actionable metrics, health plans can monitor and optimize impact on outcomes such as:

  • Decreased waiting time
  • Percentage of needs resolved
  • Co-occurring needs and service gaps that need attention


Dedicated reporting can offer a health equity lens to help ensure and monitor that all individuals are receiving equitable access to care.

HEDIS 2023 updates are part of a larger industry and policy trend to shift focus and funding to advancing health equity through effective and preventive whole-person interventions. The business case of health equity interventions rests on the ability to connect these interventions to impact outcomes, lowering costs while promoting access to care and long-term sustainability.

Explore our solutions to learn how Unite Us enables health plans to succeed in meeting these new requirements, advancing health equity, and increasing value in HEDIS 2023.


Exlpore Our Solutions



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