Rich Morino

Posted on: October 17, 2018

With over 90% of US health plans and 42 of 50 States using it, the NCQA’s HEDIS scores dominate our discussion around measuring quality (with an obvious exception of CMS’ STAR ratings for Medicare). Health plans use HEDIS scores to:

  • Assess quality of care
  • Pick which plans an Employer will include in a bid for benefits
  • Determine which providers a plan might offer alternative contracts
  • Be the backbone of a pay-for-quality effort

Because literally millions are at stake based on a single metric going up or down even a ½ point, health plans have allocated resources and dollars to maintain or improve their results. The process of collecting properly coded claims from providers to demonstrate quality can be complex, but there are simple solutions that can have quick impact.

The NCQA divided HEDIS measures into 3 categories, each with their own weight:

HEDIS Scores Categories

Many plans have benefited from increased HEDIS scores from deploying quick fixes such as:

Process Measures

Process Measures, such as Breast Cancer Screening, can be improved by utilizing third party member contact data that can:

  • Identify incorrect addresses and out-of-date phone numbers
  • Supply updated phone numbers and addresses
  • Supplement member contact data with emails

All of these lead to increased member engagement. As a result, more members attend provider visits for vital screening services. According to Boston Consulting Group, a plan’s enrollment contact information can be anywhere from 10-50% inaccurate on day 1, depending upon the line of business (with Medicaid being the worst).

Patient Experience Measures

Patient Experience Measures, such as CAHPS, can also be improved by utilizing 3rd party member contact data. A recent example was one health plan that found:

  • 42% out of date member addresses; updates were required to prevent the mail being returned.
  • Over 35% of submitted phone numbers unconfirmed, resulting in new ones being supplied.
  • Industry research indicates that a phone follow-up can improve CAHPS response rates by 4 to 20 percentage points. (compared to mail only)

At 1.5 points per response measure, this is an easy fix with a good return.

Patient Outcome Scores

Patient Outcome Scores, such as Observed-to-Expected Readmissions or Observed-to-Expected ER Utilization (Frequent Flyers) can be improved by utilizing scores built on Social Determinants of Health data alone, or combined with claims data. Examples of this include:

  • a 30 day Readmission Risk score built on only socioeconomic attributes that can predict which members are at risk for readmission
    • A recent analysis found 0.15% of a population fell in the highest risk bucket.
    • 5.68% fell in the 2nd highest risk bucket.
  • Socioeconomic Attributes can be combined with claims data to predict which members are likely to be frequent flyers. (heavy use of the ER)
    • Information such as the banking experience of the member, the number of address changes in the last 5 years and a crime index for their neighborhood have high correlation to ER use.

Deploying solutions such as the risk score immediately upon discharge from a hospital can quickly identify those most at risk for a return. Therefore, health plans are able to deploy resources to coordinate care for at-risk members. It also helps them deploy PCP follow-ups and other risk-mitigation strategies to increase the member’s health, while reducing the “Observed” ER / readmissions.

Final thought on a HEDIS Booster Shot

You don’t always have to take complicated steps to yield significant results. Rather, simple steps such as cleaning up contact data can increase your members’ engagement in preventative and treatment measures. Furthermore, deploying analytics that can predict at-risk members for readmissions and ER utilization will positively impact Patient Outcome Measures, and can lead to increased HEDIS scores.

Learn more. Reach out to us with your questions in the comments or via our Contact form.

  1. Rich,

    Nice article, I agree with the need for simple disciplined solutions and the impact they can achieve. This helps cement my belief that every member of the team counts and that all employees that handle data are key to strategic success of any business model.

    v/r
    Dan

    • Thank you for taking time to comment. This is an important topic and we hope to blog more about it in the future. We are pleased that you found this piece to be insightful.

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