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Five Ways to Win at HEDIS Compliance


As the shift to value-based payment accelerates, successful health organizations can take steps to build an effective quality management program that will improve HEDIS scores and deliver care quality and cost savings.

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Shyam Manoj

Shyam Manoj

With its 90 measures across six domains of care, the Healthcare Effectiveness Data and Information Set (HEDIS) is here to stay. According to the National Committee for Quality Assurance (NCQA), more than 90% of health plans use HEDIS to measure their performance. Thus, CMS made HEDIS a key component of its STAR ratings program for Medicare Advantage plans, where enrollment is expected to jump 12% to nearly 23 million people this year.

Managing quality ratings is complex. The Government Accountability Office (GAO) reported that HEDIS-along with the wide variety of quality measurement systems in use today and the lack of alignment among them-can have adverse effects on physicians and other providers and on efforts to improve quality of care.

It’s no wonder the providers who are so critical to that success are burned out. According to a recent survey, nearly one-third of providers say their biggest frustration is constant “busy work,” such as EHR data entry. In today’s value-based payment environment, healthcare organizations continue to struggle to manage their HEDIS program effectively.

Stop the chart-chase cycle

For most healthcare organizations, a repeating annual loop of reactive, inefficient “chart chasing” has developed to close care gaps and document, assemble and report quality data to various entities, especially HEDIS, in time.

However, there is a better way. Building an efficient, highly-effective quality management program is an enterprise-wide strategic initiative that will yield big dividends.

For example, one large payer drives strong provider engagement with daily and weekly reporting, resulting in a 4/4.5 STARs rating across multiple health plans. Another payer achieved an annual savings of $2.5 million by replacing their manual chart-chase with electronic healthcare data.

Related article: Closing Care Gaps: Chart Chasing Has Become Obsolete

To achieve results, begin with a clear assessment of your organization’s current program on the maturity curve, from a tactical to a strategic approach. Then, act on the following five steps to improve HEDIS scores and position your organization for ongoing success.

Pursue the quality management maturity curve

Understanding where your organization falls on the maturity curve enables a plan to achieve maturity over time. The basic level is purely tactical, with no strategy throughout the year. All reporting is done in the last two months of the year with a focus on bumping scores.

At the next level, there is some added strategy and with an analytical emphasis that drives outreach to providers during the year. The next level introduces more care coordination using more clinical data sharing between payers and providers to enable proactive outreach.

Finally, a mature organization employs an enterprise-wide, coordinated program that encompasses a data and analytics infrastructure along with clinical and administrative processes. This facilitates ongoing improvement through organizational learning that supports effective engagement with patients and providers and anticipates and solves problems as they arise.

Five steps to improving HEDIS scores

As the shift to value-based payment accelerates, successful healthcare organizations can take these five steps to build an enterprise-wide, highly effective quality management program that will not only improve HEDIS scores but will also deliver care quality and cost saving benefits:

  • Establish an enterprise-wide HEDIS strategy. Disjointed, tactical approaches to quality reporting and improvement aren’t enough. Organizations need to identify a strong executive leader to drive an enterprise-wide approach that results in centralized data management and analytics, optimized clinical, financial, and administrative processes, and effective engagement of all stakeholders.

  • Take control of your HEDIS reporting environment. It is important to employ a single-data strategy with the infrastructure for seamless collection and advanced analytics. This provides the ability to monitor HEDIS results on a daily, weekly, and even close to real-time basis to support proactive intervention.

  • Tap structured clinical data. Take advantage of the progress in interoperability to tap into the structured clinical data-by standardizing, capturing, and exchanging key data elements-throughout the reporting year. The more control you have over the data captured through clinical and operational work flows, the better positioned you will be during reporting season to fill in missing elements.

  • Embrace AI, machine learning (ML) and natural language processing (NLP). These powerful tools can drive more engagement with providers and members to increase compliance. For example, AI and ML techniques can use historical data to identify which providers to contact and what action you need them to take with patients. Add to that text mining and NLP to leverage information already captured in your charts. Looking ahead, the more actionable data that is available at the point of patient interaction, the more providers can be proactive and drive higher quality outcomes.    

  • Operationalize innovation through data. Technology is evolving quickly and many of most successful health plans already use AI, ML, and NLP along with advanced analytics to improve-and to compete-on HEDIS measures. It’s no longer necessary to wait for slow-moving claims data. With the advent and availability of a broader range of clinical data, more organizations are innovating continuously to drive better care and better processes.   

Make HEDIS a strategic advantage

As evidenced by the integral role HEDIS plays in so many health plans, such fast-growing Medicare Advantage plans, HEDIS is here to stay. A tactical, reactive approach will only erode scores over time, so healthcare organizations need to take a strategic view.

The result is a cohesive, organization-wide approach to HEDIS tracking and improvement that leverages advanced analytics and includes key teams and processes for chart management, risk management, and care management. Healthcare organizations that effectively carry this out will soon stop chart-chasing and win at HEDIS compliance.

Shyam Manoj is vice president of health plans & payers at CitiusTech

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