5-Step Guide To Improving HEDIS Quality Measure Performance

May 25, 2022

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.

5 Actionable Steps to Improving HEDIS Score:

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.

1. Adopt a value-based care model

Not without challenges along the way, payers have worked hard to shift to a value-based approach for several reasons:

  1. Quality of care and mental health services provided
  2. Patient experience
  3. Cost efficiencies

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.

Example of a value-based care model

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:

  • Mild and moderate conditions - Patients who experience mild to moderate conditions fall under a “pay-for-performance” approach. Providers will receive a financial incentive for operational and quality performance (i.e. speed to care, assessment improvement and completion, and HEDIS measures).
  • Severe (high acuity) conditions - Patients who experience severe mental health conditions are part of a “pay-for-value” approach. Reimbursement is based on the value of care provided by showing reductions in visits to ER and in-patient visits and the decrease in total costs of care.
  • Severe subset (e.g., SMI/SUD) - The subset of the severe acuity patients is categorized under “case rate” reimbursement. These mental health conditions drive high costs of care. Providers are accountable for the overall health of these patients by treating them under specific care models that ultimately help reduce the total cost of care. 

2. Streamline documentation for HEDIS reporting

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).

3. Screening and monitoring for HEDIS quality measurement

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:

  • What are the current readmission rates to emergency rooms, and how have the rates improved?
  • Do patients have access to medications with their providers, or do they have to be referred to an in-person psychiatrist?
  • Are providers able to offer low to high acuity levels for varying levels of mental health conditions?
  • What is the time to access to care when patients are seeking help?
  • Do patients have convenient access to care (i.e. virtual care rather than traditional in-person care)
  • Are your positive patient outcomes rates increasing?
  • How exactly have you decreased overall healthcare costs?

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.

Example of how to screen and monitor for HEDIS quality measurement

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.

4. Increase provider and patient engagement

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.

Cerebral provider engagement metrics
  • Visit note submissions
  • Prescription entries
  • Lab orders
Cerebral Patient engagement metrics:
  • Clinical survey fill rate
  • Mobile app usage
  • Use of educational materials
  • Communications with the care team
  • Medication fill rates

5. Increase reimbursement for payers and providers

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:

High-quality care indicators for patients:
  • Speed to care - Cerebral connects 90% of patients with mental health specialists within 5 days
  • The right level of care, at the right time with individualized treatment plans (Cerebral offers regimens that include medication management, therapy, and counseling as needed)
  • Medication adherence - Cerebral has achieved an overall medication adherence rate of 94% by sending medication directly to patients’ homes
  • Diversity among clinicians to create a welcoming environment for patients - 50% of clinicians at Cerebral identify as non-white, which makes us the most diverse behavioral health provider in the industry.

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:

  • Encouraging health systems to invest in training to improve clinical expertise and skill by use of the measurement-based care facilities system
  • Improved workflows, higher patient engagement, and sophisticated technology to improve work efficiency and communication
  • Improved patient outcomes through care coordination and management between appointments as a patient engagement strategy

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 lynn.blau@cerebal.com for additional questions.

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