According to Health Payer Intelligence, 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. The healthcare industry is experiencing a much-needed shift from a fee-for-service payment model to value-based care to ultimately close the gap between the quality of care and reimbursement. HEDIS quality measures play a crucial role in helping payers to be successful and competitive in a now patient-centric, value-based care environment. HEDIS scores allow consumers to compare the quality of healthcare plans from a birds-eye view of the majority of health plans in the country. This blog includes a 5-step guide to improving HEDIS quality measure performance for payers.
The impending question for health plans now is: How do we improve our HEDIS score to appeal to more customers and employers in such a competitive environment? NCPA reported that 191 million people are enrolled in plans that report HEDIS results. Knowing this, HEDIS is one of health care’s most widely used performance improvement tools. The following 5 steps will help you understand how to increase your HEDIS score as a payer.
Not without challenges along the way, payers have worked hard to shift to a value-based approach for several reasons:
In a recent Healthcare Innovation article about transitioning to value-based care in behavioral health, the moderator at a panel discussion hosted by World Congress said that the traditional fee-for-service environment is focused on getting the consumer to pay more. Whereas value-based care allows us to reimagine patient outcomes, by looking at the whole comprehensive picture of what impacts outcomes, and how to reconfigure the reimbursement structure based on the quality of care and patient outcome data.
Each patient is unique and deserves an individualized care plan. Reimbursement models should mirror that to incentivize providers to provide high-quality care to everyone. Here’s a look into Cerebral’s approach for current health plan clients that considers patients experiencing varying levels of mental health condition acuities:
Although documentation is one of the most crucial steps to improving your HEDIS score, it’s extremely tedious. A big hurdle for healthcare providers and payers to make the shift to value-based care is the amount of administrative work involved in documenting the correct information for reimbursement, and the professional burnout or lack of bandwidth for the current staff to adequately collect data for HEDIS and reimbursement.
This detailed 2022 HEDIS documentation and coding guide provides information necessary to remain compliant with HEDIS measures, documentation, and reporting.
To streamline and automate documentation, you must consider integrating technology into your data collection and documentation strategy. For example, Cerebral has a proprietary EMR for collecting data in multiple important categories, including patient engagement, clinical outcomes, clinician activities, and clinical safety measures (i.e. medication fill rates, patient engagement on clinical surveys, lab ordering frequency for medication that requires lab monitoring, etc).
In addition to documentation, you should have a way to screen and monitor document outcomes for quality measurement. You should be able to answer questions in real-time like:
If you aren’t able to answer these questions within minutes, chances are, you need a software solution to provide more visibility into the total view of each patient’s episode of care comprehensively to effectively demonstrate in HEDIS reporting, and successfully shift to value-based care.
As an example, the technology used by Cerebral health plan partners tracks metrics that impact HEDIS measures.
First, patients are matched, assessed, and begin receiving care in the same time period. We track the first assessment completion and corresponding diagnosis codes that are tied to HEDIS measures such as ASF, IET, AMM, and ADD.
During the “treatment and measurement phase”, we track metrics from continued assessments and a 7-day follow up which impacts HEDIS measures DMS, DDE, and SF.
Finally, while in the “maintain and monitor” phase, we evaluate 90 days for avoided emergency room visits and in-patient visits, while maintaining remission, which positively impacts HEDIS measures MPT, IAD, FUA, FUH, FUI, and FUM.
All data that we screen and monitor is documented and packaged up for HEDIS reporting, eliminating consuming and manual administrative work.
By interpreting information collected from screening and monitoring patients and provider engagement, health insurance companies have the opportunity to identify current areas of opportunity for improvement, that will lead to better patient outcomes, and long-term cost efficiencies.
Below are a few examples of data points that Cerebral looks at to identify gaps in provider and patient engagement, which patients need care or higher engagement, and how providers can adjust care plans to fit patient needs.
We know by now that the value-based care model is built on the premise that healthcare providers will put focus on the quality of care of patients. To increase reimbursement, providers and payers must provide the highest level of mental health care to patients.
Organizations that can demonstrate improvements in patient outcomes will experience higher reimbursement rates. Patients who have access to high-quality mental healthcare quickly, are less likely to be admitted into a hospital for additional care, which reduces readmissions rates, as well.
What qualifies care as high-quality mental health care? There are several important drivers. In our whitepaper, Leveraging Data Science to Reimagine Mental Health Delivery, we break it down:
Psychiatry is one of the lowest salaries among all clinician specialties. There is very little financial incentive to care for populations with high-acuity conditions in the traditional payment model, creating problematic disparities for select populations Value-based care motivates evidence-based clinical practice through incentives.
The article, Clinician Responsibility in Value-Based Payment Systems, states that incentives drive innovation by:
According to Driving Quality in Behavioral Health Using a Closed Loop System, it's essential to have a comprehensive data infrastructure in place that collects patient engagement, clinician behaviors, and medication fill rates. In the case of health insurance companies, tools like Cerebral can be integrated into claims data to develop an even better understanding of which patients need care, and to identify patient subpopulations that could benefit from clinical outreach, ultimately improving clinical outcomes and reducing healthcare costs.
If you have additional questions about how to improve your HEDIS score, we would love to connect. Visit our payer page to learn more about how we can help you meet HEDIS quality measures or reach out to our Director of Commercial Health Plans, Lynn Blau at firstname.lastname@example.org for additional questions.