Now that the race to Healthcare Effectiveness Data and Information Set (HEDIS) submission is over, many health plans turn their focus to identifying care gaps and developing initiatives to improve performance in the upcoming season. Avalere has identified 5 best practices that health plans can use during this downtime to boost their HEDIS performance.

1. Gain Member Experience Insights Early Through Mock CAHPS® Surveys

As the Center for Medicare & Medicaid Services (CMS) further increases the weighting of member experience measures, it is essential that health plans understand and intervene early to address their members’ needs. The post-submission period offers a great opportunity to examine measures with suspiciously low rates and perform root cause analyses. A mock Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey mirroring the official survey would offer valuable insights and early intervention opportunities.

In addition to conducing mock CAHPS surveys, plans may also collect a mix of different types of qualitative data to inform a robust member engagement and satisfaction program.  For example, plans could conduct focus group studies or ethnographic interviews with a shadowing approach to tailor their offerings to unique member needs. Insights from such activities can help structure short- and long-term initiatives aimed at improving CAHPS scores and overall member experience.

2. Identify Opportunities to Enhance Medical Record Review and Chart Chase Logic

An efficient medical record review process is a year-round priority. Early identification of gaps and efficient gap closure has several downstream benefits including improved rates and reduced provider abrasion. When health plans help providers with streamlined requests, providers will help health plans with efficient and accurate retrievals. Moreover, reviewing existing medical record chase logic, the mechanism to retrieve and abstract records, will reveal greater insight into (1) how charts are typically lost in the process, (2) where additional provider lead time was needed to ensure full information capture, and (3) trends among patient populations or provider types in terms of suboptimal reporting.

3. Develop Innovative Ways to Engage Providers

Plans with sophisticated provider engagement strategies continuously seek to improve existing physician and practice relationships and develop new partnerships. Plans might evaluate technologies that facilitate easier data collection and submission, offer financial incentives to change provider engagement and behavior, and identify physician leaders to champion HEDIS initiatives. Investing in technological capabilities that improve retrieval efficiency and help providers with administrative burden will also facilitate better communications with providers. For example, better integration with application programming interface systems capable of providing and transferring transparent healthcare data, as required under the 21^st Century Cures Act, will improve interoperability between health plans and providers, thereby resulting in higher quality of care.

4. Review Vendor Capabilities to Determine Effectiveness

The HEDIS submission process can be complex. Many health plans leverage multiple vendors for submissions at significant expense. The post-HEDIS submission period offers the opportunity to evaluate vendors against plans’ operational and strategic needs to ensure optimal vendor selection and elimination of redundancies.

5. Document Processes in a HEDIS Playbook

Most plans have off-season initiatives aimed at improving either the HEDIS submission processes or certain measures, but few continuously track and monitor changes throughout the year in a central repository. Developing and continuously updating a playbook can improve staff awareness of activities, enable leadership review of ongoing activities, and offer a resource for the organization to evaluate the effectiveness of changes and updates in the long term.

The COVID-19 disruption of this past HEDIS season creates a unique off-season for plans to assess their current operations and closely work with auditors to prepare for the upcoming season. The National Committee for Quality Assurance has allowed the submission of HEDIS 2019 hybrid rates for commercial and Medicaid plans if they are better than the 2020 rates but has not provided guidance on the 2021 season. In this unparalleled time, Avalere can help health plans navigate the complex policy environment, assess current gaps in quality performance and infrastructure against industry best practices, and provide strategic guidance and implementation roadmaps for improvement.

To learn more about Avalere’s capabilities in this area, connect with us.

HEDIS® is a registered trademark of the National Committee for Quality Assurance.

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality.