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Why HEDIS Quality Measures Matter for Value-Based Care

HEDIS measures are being followed by public health payers that are moving into the value-based care sphere as well.

By Vera Gruessner

The Healthcare Effectiveness Data and Information Set (HEDIS) is used by more than 90 percent of health payers to assess and collect data on the performance of providers. HEDIS consists of a number of different measures on which healthcare providers are evaluated. As value-based care reimbursement protocols continue to become a mainstay in the healthcare industry, more payers are bringing HEDIS measures to the forefront.

HEDIS Quality Measures

For example, the commercial health payer Humana has partnered with Mount Sinai Health Partners to ensure Medicare Advantage beneficiaries obtain greater healthcare access to Mount Sinai’s hospitals and physician practices, according to a company press release. More importantly, this particular value-based care reimbursement arrangement will consist of making providers accountable for meeting HEDIS quality measures as outlined by the National Committee for Quality Assurance.

HEDIS quality measures involve ensuring that providers follow clinical protocols for cancer screenings, diabetes management, and more. Humana is looking to ensure that at least 75 percent of their Medicare Advantage beneficiaries receive treatment through a value-based care payment arrangement by the year 2017.

“When physicians, health systems, and health plans work together to align efforts and incentives, patient outcomes improve,” Niyum Gandhi, chief population health officer for the Mount Sinai Health System, said in a public statement. “Our strategy is to transform from a traditional fee-for-service model to a population health model — and partnerships like this one with Humana help us move in this direction by aligning all players in the health care system to focus on a population’s overall health and long-term well-being.”

HEDIS measures are also being followed by public health payers that are moving into the value-based care sphere as well. WellCare of New York, which operates under WellCare Health Plans, signed value-based care contracts with an additional six healthcare providers last month, according to a company news release.

READ MORE: Can Value-Based Purchasing Work with Pharmaceutical Companies?

The six providers that will now be in WellCare of New York’s network include Corinthian Medical IPA, Bronx United IPA, Coalition of Asian-American IPA, Eastern Chinese American Physicians IPA, the Community Healthcare Network, and the Children's Medical Group.

“With the New York Medicaid landscape rapidly shifting toward value-based purchasing, we’re excited to partner with WellCare on implementing this value-based purchasing arrangement,” David Gross, general counsel for Community Healthcare Network, stated in the press release. “Collaborating with WellCare on this initiative, and working together to deliver high-quality care in an efficient manner, positions us for success in the evolving New York Medicaid marketplace.”

The way these value-based care arrangements will incentivize better patient outcomes is by bringing more focus to HEDIS quality measures. It is hoped that following HEDIS will enable providers to complete quality improvement projects. Additionally, CMS Star Ratings will be used to ensure patient satisfaction, superior customer service, and better quality care.

“Value-based care agreements provide financial incentives for providers who have a record of delivering the high-quality care that our members need to get and stay healthy,” said John J. Burke, president of WellCare of New York. “These types of agreements place the focus on health outcomes, preventive services and patient satisfaction.”

There are specific steps that health payers should take to assist providers within their network in meeting HEDIS quality measures. First, it is helpful for providers to have superior documentation since any errors in a patient’s medical record could make it nearly impossible to meet certain HEDIS quality measures.

READ MORE: Humana Expands Medicare Orthopedic Bundled Payment Programs

With the switch to ICD-10 codes, all paperwork must also be in the new diagnostic coding set in order to both receive reimbursement and meet HEDIS quality measures in the new value-based care payment environment.

Payers can also incentivize providers to support patient outcomes and preventive screenings. HEDIS quality measures rely on reducing any gaps in care and expanding preventive services including immunizations, pap and mammogram screenings, and hypertension or cholesterol management.

Finally, it is vital for health payers and providers to focus on population health management and patient engagement in order to succeed in a value-based care environment and meet HEDIS quality measures.

Outreach to the consumers and patient engagement strategies are advised for health payers to incorporate in order to reach HEDIS performance benchmarks. Population health data analysis and greater outreach could play a major role in boosting these scores.

For better patient engagement, improving patient-physician communication channels is key as well as incorporating patient portals for faster appointment scheduling and secure messaging capabilities with doctors. This will allow patients to reduce the number of visits necessary while also ensuring they are managing their medical conditions well.

READ MORE: Humana Expands Orthopedic Bundled Payment Program to NC, VA

Blue Cross Blue Shield of Rhode Island is another health payer that has worked to ensure its provider network is working toward achieving HEDIS performance benchmarks. Consumers can view these HEDIS scores annually to ultimately decide whether their health plan is working as effectively as they prefer.

For more information about the steps Blue Cross Blue Shield of Rhode Island took to increase its HEDIS scores, spoke with Nancy Mamo, AVP/Managing Director of Population Health Analytics at Blue Cross Blue Shield of Rhode Island.

“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,” Mamo explained.

“First, I wanted to create a very substantial pay-for-performance program where our providers are our partners in closing gaps in care,” Mamo continued. “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.”

Population health management and patient data analysis was also a major part of supporting HEDIS scores among this particular payer, Mamo pointed out.

“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. We started to create this population health registry, which is named Blue Insights.”

“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,” concluded Mamo.

Within a value-based care environment, health payers will need to keep their HEDIS scores at high levels in order to improve patient satisfaction and ensure provider performance is superior.


Dig Deeper:

HEDIS Quality Performance Measures Assist Consumers, Insurers

How Quality Metrics Affect Value-Based Care Reimbursement


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