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Key Ways Blue Cross Blue Shield Raises its HEDIS Scores

"We have contracts that are based on quality measures and we have ... an incentive bonus for closing gaps in care and raising our HEDIS scores."

By Vera Gruessner

The Healthcare Effectiveness Data and Information Set (HEDIS) is used by more than 90 percent of all health plans situated around the country to compare performance and year-to-year success. HEDIS scores allow health plans to determine where they need to improve over the coming year.

National Committee for Quality Assurance

Additionally, HEDIS scores benefit consumers by allowing the opportunity to review which potential health plans are best for them based on a payer’s year-to-year performance. Health insurance companies must submit their data to the National Committee for Quality Assurance (NCQA), which then processes the data through an auditing procedure.

The question remains: how can health payers boost their HEDIS scores in order to effectively compete in the market? Nancy Mamo, AVP/Managing Director of Population Health Analytics at Blue Cross Blue Shield of Rhode Island, answered this question in an exclusive interview with What steps should health payers take to improve their HEDIS scores?

Nancy Mamo: “When  I walked in the door two years ago, there was no infrastructure in place here at Blue Cross Blue Shield Rhode Island to support HEDIS or even the broader Stars program.”

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“The Stars programs is a CMS program and health plans have to get at least four stars in order to get their quality bonus every year. The bonus could be in the tens of millions of dollars.”

“What I did here is I had a 5-pronged approach to what I wanted to put in place. First, I wanted to create a very substantial pay-for-performance program where our providers are our partners in closing gaps in care. It’s all about closing gaps in care for HEDIS.”

“So we put in place a very robust pay-for-performance program in the millions of dollars that we rolled out to our providers. It has a subset of measures in each product line where they could earn substantial amount of money by closing gaps in care. The second thing we did was work with MedeAnalytics, a cloud-based analytics platform, to build a population health registry. It was new to MedeAnalytics but I have done it in past. We started to create this population health registry, which is named Blue Insights.”

“That tool has all the clinical measures, the HEDIS measures, and all the pay-for-performance information. Every provider can go in and see the listed members who are high risk.”

“They can also see what their gaps in care are and how many pharmacy scripts they fill over the last 24 months. It’s a very robust solution. Providers can actually go in and enter data in the tool to let us know they completed a service and closed a gap in care.”

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“Last year, we rolled this out on October 1 and we allowed providers to enter data through the middle of February. We were able to close 34,000 gaps in care. That was true success.”

“We also created reminder cards for members regarding particular services like diabetes, cancer screenings, and childhood immunizations. We sent out these reminder cards last year to tell members that they were due for services. All those things combined built an infrastructure to support raising HEDIS scores very significantly.” How can payers promote disease prevention and reduce emergency situations or hospitalizations?

Nancy Mamo: “We have a couple things we use. We have created a longitudinal disease registry. It goes back to 2010. Any member that falls into the top six disease brackets are entered into the longitudinal disease registry.”

“We identify new members every month with those patients who fall into those diseases. We also have a methodology and algorithm that we put in place to identify high-risk members. Using predictive analytics, we define members who cost a certain amount in the next 12 months. These are the members who have a high overall spend and high-risk.”

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“We have an algorithm that we run through and we identify new high-risk members every month. We put this in our population health registry for primary care physicians to manage, but we also have put in place nurse care managers that we actually embedded into some of these practices. We send them these lists on a monthly basis.”

“They then engage with these members, outreach to them, and set goals for them for care. Then they send us back reports every month letting us know who they’ve engaged with and what the goals are.”

“All of that combined actually does a lot to minimize utilization for members. They can also use a registry to track members’ experience over time. They can see any member who had an inpatient visit, had radiology, ER or urgent care visit in the last 24 months. This is key to having timely, actionable data to impact care for members.” How can health payers succeed in properly documenting and reporting data to the National Committee for Quality Assurance?

Nancy Mamo: “Specifically if you’re talking about HEDIS, this is a highly audited function. From the moment that you start HEDIS, typically you start cleaning up data in November and then you report it to NCQA on June 15.”

“It’s highly regulated and highly audited. As we go through - we’re working on HEDIS all year-round - then it comes time for pulling members and their medical records to create a list in January. At Blue Cross Blue Shield Rhode Island, we hire temporary nursing staff to retrieve the records, review them, and enter them into a tool.”

“There are two sets of measures in HEDIS: an admin measure and a hybrid measure. When I talk about medical record retrieval, those are the hybrid measures. Not only can you us claims details, but you also can go out and retrieve records and review the records.” Does value-based care reimbursement affect HEDIS scores? In what ways?

Nancy Mamo: “We have contracts written out with systems of care and our systems of care used to just have contracts that, in every year, they would get a bump in their revenue because that’s what was done. Now plans are moving to fee-for-value.”

“We have moved all of our automatic dollars that would have been placed in a fee-for-service schedule bump, have been redirected to be in our contracts. We have contracts that are based on quality measures and we have pay-for-performance, which is some of that aggregation, fee-scheduled bump was turned around and put into an incentive bonus for closing gaps in care and raising our HEDIS scores. We not only have it in our contracts, but we also have it in our pay-for-performance.”


Dig Deeper:

Top 3 Ways to Meet HEDIS Quality Measures, Improve Performance

How ICD-10 Diagnosis Coding Impacts HEDIS Quality Reporting


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