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How Payers Can Succeed Under Updated 2019 HEDIS Measures

Payers need to understand emerging healthcare challenges related to preventive care and public health in order to succeed under the updated HEDIS measures for 2019.

Payers can succeed in new HEDIS measures with heightened preventive care, public health administration

Source: Thinkstock

By Thomas Beaton

- The Healthcare Effectiveness Data and Information Set (HEDIS) provides 90 percent of America’s health plans with the ability to directly compare performance across the national stage.  

Currently, the HEDIS set contains 92 measures that evaluate if health plans are providing necessary care related to issues including medication adherence, chronic disease management, and immunizations.  

In order to maintain a competitive edge in a crowded consumer market, health plans need to ensure that they have the capabilities in place to excel in as many performance measures as possible.

As the industry moves closer to the 2019 plan year, newly announced changes to the HEDIS measure set will give payers the opportunity to excel in areas of care that influence consumer decision-making, says Mary Barton, Vice President of Performance Measurement at the NCQA.

“Health plans are usually busy throughout the second half of the year trying to make sure they are addressing gaps in patient care,” Barton said to “It’s a good time to identify any pain points and try to work on them.”

READ MORE: How Payer Philanthropy Can Address Social Determinants of Health

Preventive care should be at the top of that to-do list, Barton advised, since many of the HEDIS measures record basic population health management tasks such as providing screenings and vaccines.

Mary Barton, Vice President of Performance at NCQA Source: Xtelligent Media

Some of the changes to some of the requirements around preventive care and chronic disease management for 2019 may require payers to work with their contracted providers to ensure delivery of care, while others will alter the way payers report on successful screenings and services.

“One of the biggest changes is to the measure about controlling high blood pressure,” said Barton. “That measure was the only one to include obligatory chart review, because there was a step in the measure to confirm a diagnosis of high blood pressure.  There was also the problem of accessing blood pressure reading results, which were not typically found in claims.”

“After the ACC and AHA revised the guideline around blood pressure control to 140 over 90, we updated our target to match.  We also updated the approach to define the population, using two visits with a diagnosis of hypertension, and we got rid of the requirement to confirm the diagnosis completely.”

READ MORE: How HEDIS, CMS Star Ratings, CQMs Impact Healthcare Payers

The changes will likely help to reduce administrative burdens for payers while providing a more accurate and up-to-date portrait of blood pressure control and hypertensive populations.

“We think that this is important news and really a big update,” Barton said.

There are also new measures in 2019 for adult immunizations, she added.  Payers will now be scored on their performance rates of vaccinations for influenza, Tdap, tetanus, and diphtheria among pregnant women.  The measure also records when non-pregnant adults aged 19 or older receive vaccinations for this set of diseases.

Adults will also be monitored for rates of shingles (herpes zoster) vaccinations and pneumococcal vaccines for older adults.

 “The measure is constructed to use age bands to determine how many immunizations a patient needs,” explained Barton. A person who's between the ages of 40 and 50 may have two recommended immunizations,” Barton explained.

READ MORE: NCQA Updates, Adds HEDIS Performance Measures for Plan Year 2019

“Between 50 and 65, there might be three recommended immunizations measured, and for patients 65 and older, there may be four. The measure will be measuring the percentage [of members] who are up to date.”

Payers should use data from multiple sources to ensure vaccination rates are being measured accurately, Barton suggested.  State registries or immunization databases and health information exchange networks can contain data on vaccines that may have been performed somewhere other than the patient’s primary care provider, for example.

“It is really important to encourage health plans to use those data sources where they're available,” Barton said. “If health information exchanges or state registries have the information about your members, then health plans can go directly there and find it.”

In addition to focusing on preventive care, health plans must also focus on long-term outcomes, including preventing readmissions for patients receiving care in the post-acute provider community.

HEDIS now includes a measure that tracks if older beneficiaries are readmitted to the hospital within 30 and 60 days after discharge into the community from a skilled nursing facility (SNF). Barton said that adding the measure to the 2019 HEDIS set will provide extra accountability for payers with older, more vulnerable beneficiaries.

Commercial payers, including those that offer Medicare Advantage, have not been held sufficiently accountable for post-acute care under HEDIS, according to Barton. A growing number of Medicare Advantage members are utilizing acute care facilities, such as an SNF, but commercial health plans have not had to track their post-acute experiences.

“CMS has various ways to assess post-acute care, and it has data sources to use for looking at nursing homes.  But this is really a first in terms of tying responsibility for quality post-acute care to commercial payers,” Barton said.  “We think that there's a role for the payers to try and assure their members that they're going to high quality post-acute care settings.”

Barton pointed out that HEDIS has separate measures for frail individuals and those with multiple chronic conditions in order to ensure that patients nearing the end of their lives or those with extremely severe conditions do not skew performance data on post-acute care or other metrics.

“We don’t want to conflate results when a payer has a situation where the patient is not going to benefit from a particular service, or is not going to see the same kind of benefit that someone who is in a healthier situation might see,” she said.  “We are increasingly able to create measures that target these populations and provide separate analyses of that data.”

Payers will face another significant challenge in 2019 and beyond: addressing opioid abuse and reducing opioid-related patient safety risk as the nation’s opioid crisis drags on.

Payers have been working to address opioid-related patient safety concerns by educating patients and providers about the dangers of over-prescribing, funding opioid-prevention programs and workshops, and by limiting prescriptions via prior authorization and quantity limits.

Newly added HEDIS measures will now test if payers are effectively curbing patient safety risks for opioid prescriptions.

A new measure tracks when a patient receives an opioid prescription that lasts 15 days in a 30-day period or when a patient’s opioid use lasts 31 days out of a 60-day period.

Barton said that the new measure was developed to help health plans indicate if members are at a higher risk opioid abuse, since these time periods provide a more accurate assessment of high-risk behaviors and outcomes.

“Extended durations of opioid use are connected with longer term use and abuse, including overdose and opioid overdose related mortality,” Barton said. “We think clinicians and health plans can both address the problem by restricting extended prescriptions from the start. A lot can be done to decrease risk by just decreasing people's access to opioids.”

Payers using the updated HEDIS performance set can measure opioid abuse among commercial populations by performing retrospective analytics on medical and pharmacy claims to identify patients receiving new opioid prescriptions and monitoring how long those prescriptions last..

 Health plans that are new to the HEDIS set or are unsure of how to adapt to HEDIS need to invest in data infrastructure and data sharing capabilities to access similar insights, Barton stressed.

 “Health plans have to make sure that they've got an electronic database that's clean, and where standard, comparable data elements are imported in ways that fit into standard sockets, so that they know how to find their data,” she said. “It is key for health plans to know how to find their data and then how to use it.”

Barton believes that payers and providers need to encourage each other to effectively share data, so that health plans and health systems can earn high performance scores and create positive outcomes for beneficiaries. She says that data sharing is not a one-way street and that both organizations play an equivalent role in managing performance data.

“The more that health plans share information back with practices, the more practices should be able and willing to share information in turn,” she said.  “That is going to create a virtuous cycle of information sharing that will allow both parties to be more open and perform better on these critical patient care tasks.


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