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Claims Management News

3 Key Steps for Health Payers to Meet HEDIS Quality Measures

Documentation, patient engagement, and data sharing between payers and providers can help organizations meet HEDIS quality measures.

By Vera Gruessner

Health insurance companies are slowly moving toward adopting alternative payment models based on pay-for-performance metrics. This means more payers and providers are focused on meeting HEDIS quality measures. The scores payers receive on HEDIS quality measures enable consumers to compare and contrast which health plans will meet their needs.

Patient and Provider Engagement

There are a number of different steps that payers can take to ensure they’re meeting HEDIS quality measures. This includes adequate documentation in electronic medical records, patient and provider engagement, and effective data exchange.

Payer performance is tied to effective documentation including claims and clinical data as well as information stored in electronic medical records. Accuracy is key since any errors would cause significant issues for payers and providers in meeting the benchmarks of HEDIS quality measures.

Dr. Thomas Mackey, PhD., a Nurse Practitioner from the University of Texas Health Services, spoke with about the importance of documentation in electronic medical records for meeting HEDIS quality measures.

“[Providers need to] have HEDIS measures all adequately listed in their electronic medical record. When a physician hasn’t met a particular HEDIS measure, it turns up in red,” explained Mackey. “Doctors need to make sure that the EMR health maintenance templates are up to date with the current HEDIS measures. The EMR is so important  because they drive provider behavior."

READ MORE: APMs, Health Data Exchange among Top Payer Reform Goals

“If I see I need to make a checkmark or something is in red on the screen, it is a reminder and I don’t want red after my name in a patient’s record. I want to make sure I check those things off, so the EMR is driving my behavior to do something positive and to meet measures. I’m not sure a lot of people have looked at how much EMRs drive provider behavior,” Mackey noted.

Patient and provider engagement are also needed in meeting HEDIS quality measures. Payers could take steps to engage their consumer base through direct outreach efforts, which could improve patient experience scores and population health management. For instance, Mackey recommended for payers to send out health screening reminders in the mail to their members.

“I suggest health insurance companies to do mail outs to patients letting them know what health maintenance (i.e. HEDIS measures) needs to be done for them on a yearly basis. I have never gotten that from my insurance company, Mackey continued. “They can send out mailings saying get your pap smear or get skin checked for cancer. If I were sitting as an executive at an insurance company, I would think about doing mail outs to patients based on their profile of what has been paid for them.”

Engaging the staff at a medical facility will also make it easier to reach HEDIS benchmarks. Dr. Mackey discussed the difficulties and challenges surrounding engaging medical staff in reaching HEDIS quality measures.

“The number one thing I would suggest is to make sure your staff is engaged,” Mackey said.

READ MORE: How to Develop HEDIS Quality Measures for Pediatric Care

“The challenges have to do with getting the practice and the people in that practice - I don’t mean just the physicians or the nurse practitioners but I mean the front desk as well as the nurses in the back - to help meet the HEDIS measures when a patient comes in. If we’re talking about colorectal cancer screening, the challenge is a patient may come in for a health maintenance visit or a respiratory infection and we might not see them for a year or two years, to try and get some of the HEDIS measures met for that patient becomes a big challenge. You need enough time to do all the things that are required,” Mackey explained. “Part of the challenge is to get patients to accept the responsibility of allowing us to meet HEDIS measures.”

Dr. Mackey went onto to discuss how vital it is for the staff to help get patients screened for colorectal cancer and other medical conditions. In his practice, Dr. Mackey incorporates Cologuard, which is a stool DNA (sDNA) colon cancer screening at-home test. Cologuard is an alternative to a standard colonoscopy.

When it comes to screening, provider engagement is necessary and it includes everyone on staff such as nurse practitioners, front desk coordinators, and physicians.

Another key strategy that healthcare entities can use to reach the benchmarks of HEDIS quality measures is effective data sharing between payers and providers. In a previous interview, Nancy Mamo, AVP/Managing Director of Population Health Analytics at Blue Cross Blue Shield of Rhode Island, discussed how important of a role data sharing plays in meeting HEDIS benchmarks.

“I think there is a lot of information that the health plan has and power that the health plan has that the provider groups would like,” Mamo noted. “There could be a very virtuous cycle of events. If the health plan gives timely data about which patients have been hospitalized or had a diagnosis or medication ordered, providers would be able to use that timely information to manage that patient better. It’s an aligned interest. The practice wants to have that up-to-date information and the health plan wants the practice to improve their HEDIS scores.”

Dr. Mackey also explained how his primary care practice works with their health plans to exchange claims data.

“The insurance companies extract data from patients’ insurance records themselves. For example, if we send somebody to receive a mammogram, the radiology staff bills the insurance company. They know that the mammogram has been completed. The same thing happens when we do colorectal screening or colonoscopies - the insurance companies have that invoice,” said Mackey.

Efficient data exchange, provider and patient engagement, and sufficient documentation in EMR systems can all go a long way to reaching HEDIS quality measures.


Dig Deeper:

How Health Insurance Mergers Could Change the Payer Industry

Time, Commitment Required for ACO, Value-Based Care Success


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