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How Health Insurers Can Improve HEDIS Quality Measure Performance

HEDIS Quality Measure PerformanceHEDIS or Healthcare Effectiveness Data and Information Set is a widely used group of measures that enumerate quality performance among providers and health payers in any given year. HEDIS quality measures are created and defined by the NCQA or the National Committee for Quality Assurance. Some of these quality measures are cancer screenings, flu shots, childhood immunization status, heart attack treatment, high blood pressure treatment, and asthma medication management. HEDIS medical record review is one of the ways in which NCQA collects HEDIS data. Other methods include surveys, and health insurance claims. NCQA uses the Healthcare Organization Questionnaire as well as the Interactive Data Submission System to collect HEDIS data. Health insurers utilize HEDIS chart review services to obtain accurate HEDIS data.

The 2017 HEDIS quality measures are segmented into the following five categories.

  • Effectiveness of care.
  • Experience of care
  • Access or availability of care
  • Health plan descriptive information
  • Utilization and relative resource use

The NCQA has the discretion to add, delete or revise the HEDIS measures on an annual basis. Before reporting the HEDIS quality measures publically, the NCQA would audit the data with the help of an NCQA-approved audit firm. Consumers use the information available in the public space to compare multiple health plans and local medical facilities.
HEDIS is designed to close gaps in health care and reduce the use of costly acute care through preventive services. It places a greater focus on quality improvement across healthcare organizations and value-based care, thereby enabling providers to achieve these objectives.

Health insurers face the following challenges with improving their performance on HEDIS quality measures.

  • Designing quality reporting scores
  • Administrative workload involved in handling excess of quality data
  • Low preventive screening among the provider networks
  • Lack of health IT adoption for reporting HEDIS scores among providers

Let us consider some of the best practices that will help health insurers surmount these challenges and improve their HEDIS quality scores.

  • Insurers must properly align their risk adjustment and quality management. This will help reduce healthcare spending, improve patient outcomes and gain revenue growth. The risk adjusted data will help determine whether changes in performance are largely tied to an organizational factor. This will make it simpler to drive financial incentives or penalties to impact quality improvement.
  • Health insurance companies can utilize statistical analysis to determine whether any performance measures need to be changed or eliminated.
  • Population health management and patient data analytics could help improve HEDIS quality scores.
  • Patient engagement can be included in payers’ clinical quality measures and financial incentives, which will help ensure that patient outreach is achieved.
  • Patient engagement and wellness can be improved by incorporating beneficiary incentive programs. This involves offering economic incentives to health plan members who show healthy lifestyle choices. State Medicaid programs have included incentives in the form of cash, meals, gift cards, transportation and child care among others.
  • Insurance companies will also have to focus on provider engagement. Providers are in charge of managing HEDIS quality scores and patient outcomes. With increased provider engagement, there will also be increased rates of preventive screening.

Health insurers must therefore focus on adopting new health IT solutions, improving healthcare documentation, increasing preventive screening rates, population health management, patient engagement, provider engagement and on transitioning reimbursement contracts to value-based care payment models. Adopting the right strategies will help payers close gaps in care, and improve quality. They can achieve their goals in improving their HEDIS quality measures performance.

About MOS Medical Reviews

Headquartered in Tulsa, Oklahoma, Managed Outsource Solutions (MOS) provides quality medical record review services to physicians, attorneys, medical legal consultants, insurance companies, private corporations, case or chart review firms, and other organizations.