Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

Payers Could Boost HEDIS Quality Measures by Exchanging Data

When payers and providers exchange patient data to close gaps in care, there is an upward pressure in meeting HEDIS quality measures.

By Vera Gruessner

HEDIS quality measures are managed by the National Committee for Quality Assurance (NCQA), which allows consumers to compare the quality of health plans among more than 90 percent of health payers around the country. HEDIS quality measures require payers to collect more data and analyze their overall performance.

National Committee for Quality Assurance

These measures revolve around a variety of important medical procedures such as immunizations, cancer screenings, diabetes care management, medication adherence, and high blood pressure management.

NCQA reports on its website that there are currently 81 HEDIS quality measures across five domains. It is vital to address that in today’s changing healthcare landscape, HEDIS quality measures are an important aspect of transitioning toward value-based care reimbursement while leaving fee-for-service payment arrangements behind.

Healthcare payers will need to work toward improving their HEDIS scores in order to succeed in the new payment landscape. Humana, for example, partnered with Mount Sinai Health Partners in a value-based care payment arrangement that brings focus to HEDIS quality measures.

Blue Cross Blue Shield of Rhode Island has also worked at boosting their HEDIS quality measures, said Nancy Mamo, AVP/Managing Director of Population Health Analytics at BCBS.

READ MORE: How Payers Could Assist Primary Care Docs with Value-Based Care

“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,” Mamo told

“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,” Mamo continued. “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.”

“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,” she concluded.

For more information about HEDIS quality measures and how healthcare payers can support providers in meeting these benchmarks, conducted an interview with NCQA’s Vice President for Performance Measurement Mary Barton.

When it comes to payers supporting and encouraging their provider networks to meet these quality measures, Barton explained that, “Many HEDIS measures are focused on population health topics, so the approach to keeping people healthy using cancer screenings apply to a large number of people. All men and women over age 50 should get colorectal screenings, for example. All women over 50 should get mammography every other year.”

READ MORE: AHA Urges D.C Appeals Court to “Uphold Cigna-Anthem Ruling”

“What could the health plan do to support their practice partners? There is a laundry list of activities that a plan could engage in. They could use their data of who has and hasn’t gotten these tests to provide lists back to the providers of quality care gaps. They could take that information themselves and send postcard reminders to patients about the fact that they need to get these services,” Barton mentioned.

“They could make it easier for providers to get these services done by the way that they pay for the claims or the way they make the services accessible to providers,” she continued.

Barton also pointed toward the idea that payers could invest in a mobile van that would provide medical care for patients at their homes or jobs. The providers would then be credited with meeting certain HEDIS quality measures even when the payer takes on the costs of providing this mobile van.

“They may have information about flu shots and which patients who have diabetes or other high-risk conditions like asthma [in need of flu shots] have already gotten a flu shot,” she continued. “That same kind of gap analysis could enable the health plan to partner with the practice and let the practice know who still needed a flu shot.”

Within the value-based care environment, it grows more important than ever before to close gaps in care and meet performance benchmarks. Barton discussed some key tips for payers attempting to contract through value-based care regarding how best to negotiate with a provider network.

READ MORE: Aetna Will Exit Iowa ACA Health Insurance Exchange in 2018

“There are definitely some great examples of insurance companies that have set up value-based contracts with provider networks,” she added. “This helps align the incentives for provider networks to do preventive screenings and to take good care of their patients with cardiovascular disease. Using measures exactly like HEDIS measures that we ask health plans to report on or, in some cases, slightly altered measures. One of the hallmarks of the HEDIS measures that health plans are subject to is that they are focused on the denominator of patients who are enrolled in the health plan.”

“Practices don’t always have that same kind of assignment of patients,” Barton continued. She explained how health plans need to answer “a question of attribution” regarding which practices are accountable for certain patient populations.

When asked how health plans can incentivize their provider network to improve the rate of preventive screenings and reduce gaps in care, Barton responded, “I don’t think there’s a single answer. There are probably implications around financial incentives that we don’t understand completely.”

“We know what a fee-for-service universe aligned incentives for clinicians to do more stuff and they did more stuff. That was pretty clear how it worked. Now as we’re in a transition as a nation from a fee-for-service based healthcare economy to a more value-based economy, we need to learn the best way to use financial incentives,” she acknowledged. “You would not hear me say that we should rush headlong into only using financial incentives to get the provider groups to do what the health plans want.”

“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,” she pointed out. “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.”


Dig Deeper:

Top 3 Ways to Meet HEDIS Quality Measures, Improve Performance

NCQA Proposes New Changes to HEDIS Quality Measures in 2017


Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...