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Simplify gaps in care and improve member compliance


Data is key to helping providers increase member compliance, and technology has made this delivery simpler and more effective.

Data is a driver of change, but the first step is to deliver that data in a format that can be easily utilized and applied by those at the front lines of care.

This was the concept at the center of a presentation on improving HEDIS performance through data management delivered by Linda Lee, vice president of quality improvement at Medical Card System, Inc., and Frances Johnson, BSN, MBA/HCM, director of quality management at Blue Cross Blue Shield of North Carolina at Qualipalooza, the second annual RISE quality leadership summit June 29 to 30, in San Antonio, Texas.

Lee used the presentation to outline methods for improving Healthcare Effectiveness Data and Information Set (HEDIS) ratings, a tool used by more than 90% of the nation’s health plans to measure performance. The tool evaluates performance using 81 measures across five domains of care, enabling equivalent comparison of how different health plans perform.

As these measures are evaluated, gaps in care are identified. These gaps can lower health plan ratings, and are an important indicator of areas where performance can be improved. By identifying these gaps and communicating that data to the front lines of care, interventions can be targeted to increase performance and improve ratings.

The problem is how to translate ratings into measurable interventions and communicate gaps in care to providers.

“It’s important to determine how we can partner with our providers to give them gaps in care reports so that when they have a patient in their office they can try to close some of those gaps,” Lee told Managed Healthcare Executive in an interview about her presentation prior to the summit.

HEDIS measures are used to determine Star Ratings, which evaluate a health plan’s Medicare Advantage program. For plans earning four stars and up, there are bonuses to be had. While there are no penalties for lower ratings, Lee said lower ratings will make it difficult for plans to remain competitive in the marketplace.

“There’s definitely a monetary plus if you can close as many of these gaps or noncompliance measures for an individual as you can,” Lee said. “If you don’t its probably harder to exist because, at some point, you’re not giving that quality of service.”

For health plans serving low-income populations where compliance and health outcomes are typically difficult to manage, gaps in care reports can highlight areas for improvement, as well as which members may be to most receptive to change.

“A lot of times we don’t get to pick the demographics we want, but it’s what we have to work with,” said Lee, whose company works with patients in low-income areas of Las Vegas and Puerto Rico. “It’s not ideal, and it certainly isn’t a population with the best compliance rates. But if you’re a plan that works with your membership for a few years, you find unique strategies to close the gap.”

For MCS, that meant developing a tool that made it easy for providers to target specific interventions at the patients that need it the most.

Gap in care reports, developed first as paper reports but now available electronically through the plan’s provider portal, give providers an overall picture of how they are performing on the HEDIS measures for all of their patients who are members in the plan. The report then goes further, breaking down the ratings by measure, and then further to identify which members in each measure are noncompliant.

“We do this at every touch point for a patient,” Lee said. “We give the tools in a macro and in a micro, so if you have a member come in to your office, we train your office staff on how, before that appointment, you should check what they’re not compliant in.”

The reports also offer a stratification tool that helps providers identify which patients are most likely to take advantage of interventions to improve compliance. For example, a provider might have 500 members on the plan who have not received a mammogram. The stratification tool can identify which of those patients have had a mammogram in the past and might be more likely to get one again.

“There’s probably a greater propensity that they’ll be compliant if you just give them a little nudge,” Lee said, noting that patients who don’t have a history of compliance in that area might be more difficult to target.

The tool allows provider to focus their efforts and limited time on those patients that might be most receptive to compliance, resulting in a more significant increase in ratings.

Although the gap in care reports have been delivered for some time in a hard copy format, moving to an electronic report that is easily accessible and updated in real-time has dramatically improved the plan’s ratings, Lee said.

“There was a rapid movement to four stars once the electronic provider tool came into play,” Lee said.

Plans vary greatly in the level of data they offer to providers, but Lee said plans have to realize how important it is to give providers the information they need to target improvement.

“At the very least, let them know where are the gaps so they can try to close them,” Lee said. “Providers deal with many plans. You as the plan need to give them some help.”

Reports don’t have to be complex, Lee said, adding that MCS started out suing simple spreadsheets and expanded them from there.

“It’s all about how to gain a compliant member and a lot of times that’s helping the provider,” Lee said. “You don’t have to have a lot of expensive tools or bells and whistles. You can start small and add to it every year.”



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