Which measure is primarily used to evaluate clinical performance in plan evaluations?

• A. CAHPS
• B. Readmission rate
• C. Quality-adjusted life year
• D. HEDIS

Answer: (D)

Evaluating clinical performance in plan evaluations relies on standardized, widely used measures that capture how well a plan delivers care. HEDIS (Healthcare Effectiveness Data and Information Set) is designed for this purpose. It provides a broad, standardized set of performance measures across preventive services, chronic disease management, and access to care, and is the primary tool used by plans for quality reporting and NCQA accreditation. Because the measures are comparable across plans, they allow benchmarking and identify areas for improvement.

CAHPS focuses on patient experience and satisfaction, not direct clinical outcomes, so it plays a complementary role rather than the primary one. Readmission rate is more hospital-focused and reflects inpatient outcomes rather than overall plan-level clinical performance. Quality-adjusted life year is used in economic analyses, not routine plan performance reporting.