By Monica E. Oss, Chief Executive Officer, OPEN MINDS
The stars have it. And by “it”—I mean Healthcare Effectiveness and Data Information Set (HEDIS) reporting. The National Committee for Quality Assurance (NCQA) recently released its 2024 Health Plan Ratings, which evaluated over 1,000 commercial, Medicare, and Medicaid plans based on patient experience and clinical quality.
Of the 1,019 health plans assessed, only five received the highest rating of five stars. Two were Kaiser Permanente plans: its commercial plan available in the mid-Atlantic states area (Baltimore, suburban Maryland, Northern Virginia, and Washington, D.C.) and its Medicare plan in Colorado. The other 5-star winners were Blue Cross Blue Shield of Massachusetts’ commercial PPO plan, New York-based Independent Health Association’s commercial HMO/POS combined, and Wisconsin-based Network Health Insurance’s Medicare PPO.
The star ratings are based on almost 50 measures of consumer outcomes and experience, including measures of clinical quality from NCQA’s HEDIS and CMS’s Health Outcomes Survey (HOS); measures of consumer experience using the Consumer Assessment of Healthcare Providers and Systems or CAHPS; and NCQA’s review of health plan quality improvement processes from NCQA Accreditation data. The overall rating is the weighted average of a plan’s HEDIS, CAHPS, and HOS measure ratings, plus accreditation bonus points, calculated on a 1 to 5 scale and displayed as stars.
The ratings are important to health plans because their reimbursement if often tied to ratings. According to Dr. Margaret Mays, former National Vice President Of Quality Improvement of Magellan Health (and now a senior associate at OPEN MINDS), “The impact to health plan can be in the millions if HEDIS performance falls short.”
The measures are also important to provider organizations because health plans are looking for organizations that can improve their scores. And HEDIS measures are often used as the basis for performance-based and value-based contracting.
The challenge is that most provider organization executive teams don’t know how their organization stacks up on these measures. Often, interoperability problems play a role in this disconnect—with provider organization managers not having access to data on consumer hospitalizations or medications. But it is critical for executive teams to find a workaround in order to gauge their performance on HEDIS measures.
We got a look at strategies for managing HEDIS measures at The 2024 OPEN MINDS Institute For Operational Excellence in the session “Strategies From Magellan Health & Coleman Health Services For Using HEDIS Measures To Improve Performance.” The session featured Brian Welsh, M.D., Chief Medical Officer, Coleman Health Services, Inc.
Coleman Health Services (Coleman) is based in Kent, Ohio, and provides behavioral and rehabilitation services in 42 counties in Ohio. They have a budget of $70 million in annual revenue and 900 employees. The organization operates a social enterprise division providing employment for consumers with disabilities.
Coleman’s HEDIS story began with a contract with a health plan that had financial incentives for meeting certain HEDIS metrics. The initial HEDIS metrics in their contract included two areas of focus: increased medication adherence and improved follow-up after hospitalization.
Coleman’s strategies for increasing medication adherence included a collaboration with a pharmacy to assist with medication prior authorizations and to identify consumers who were not picking up their medication. These consumers were also referred to a mental health case manager—both to assist the consumer in obtaining medication and to communicate concerns about non-adherence.
To improve their scores on follow-up after hospitalization, Coleman designated a team member for each consumer’s post-hospital follow up including scheduling consumers for post-hospitalization appointments several days before hospital discharge. They also developed a plan to reduce isolation by referring clients to peer support groups.
Dr. Mays and Dr. Welsh offered some advice for executive teams of provider organizations entering into agreements with incentives based on HEDIS performance. These include reengineer clinical processes to gather data as needed; mapping out and estimating the costs of consumer support services to improve the performance measures, and using technology to manage and measure performance.
Reengineer clinical processes to gather necessary performance data. Organizations can’t measure performance without data. The collection of data needs to be embedded in standard clinical processes or the data collection won’t happen. “We’re just going to be in the learning curve right now with tracking and pulling the data. We get a lot of measures from our EHR. We’re also obtaining outcome measures through evidence-based, level-of-care screening tools, like the Level of Care Utilization System for Psychiatric and Addiction Services,” Dr. Welsh explained.
Don’t underestimate the costs of the consumer support services required to improve performance. Providing consumers with the support to improve their health—and perform well on the HEDIS measures—takes time. Dr. Welsh acknowledged that the time required surprised them. He said that extensive staff time is needed for data collection and management, team training around HEDIS measures and interventions, and the management of the HEDIS measures. (For more on the costs of care coordination and support services, see $60 PMPM?).
Use technology where possible to reduce costs. Executives should think about how to use technology to decrease the costs of data gathering, the analysis of that data, and the operationalization of that data in improving consumer health. There are a wide array of technologies for consumer assessments and for consumer engagement. There are new tools for spotting opportunities for individual consumer interventions and for managing populations. And, clinician-facing and consumer-facing technologies can be used to intervene in improving consumer care.
The importance of value measures in general, and HEDIS measures in particular, is going to increase. While the measures are far from perfect and bring with them administrative challenges, the focus on measurement and performance management is generally positive for the field. Dr. Welsh said that working with HEDIS data has provided him with a professional “ah-ha” moment. “It’s been a great experience learning how to improve our measures…We’re providing better care when we’re assertive in tracking people down. Like I said, we (used to) let no-shows or disinterested people just go their own way…and (now with follow-up) we’re getting better customer satisfaction as well.”
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