An expert viewpoint: Discover HEDIS improvements beyond standard workstreams

There are excellent strategies to improve your HEDIS performance by reflecting on the past year and making course corrections. But there are even more transformational considerations that can yield exponentially higher benefits.  Ask yourself and your team:

How siloed is the HEDIS effort within your organization?

If the focus starts and stops with the Quality team, your organization is shortchanging its HEDIS potential. In the most successful health plans, HEDIS is a collective, organizational-wide effort. Thoughtfully engaging stakeholders across the system is the best way to yield significant results.

What do your zip codes tell you?

For colorectal screenings, for example, are there more non-compliant members in a specific zip code? Is that because there are fewer provider services in that area? What can be done to address the outliers? Where are your top-performing geographies? Why are they more successful in meeting their care goals? What best practices can you identify and replicate?

Determine the trends that support compliance and the strategies to make them the norm across your footprint. This includes sharing your findings with the provider network teams to combat the limitations of a siloed approach.

What does your age distribution tell you?

Of the people getting breast cancer screenings, for example, which age segments are most out of compliance? These insights help you target communications to engage specific sub-segments. Age distribution analysis can also help you determine who is aging into a measure, giving you an opportunity to track their care patterns and influence their choices. This is particularly useful if you have more flexibility in how you sort age criteria: the ability to start at 50 for breast cancer screenings, for example, instead of waiting until 52. Ask your HEDIS partner to support you in this.  Also evaluate for members who may remain in compliance as they age out of a measure.  These members would not benefit from remaining in improvement initiatives.

Are you able to evaluate claims data against the value set directories? Consider the set of CPT codes for the A1C test, for example. Evaluate your claims data against those codes to reveal useful trends. You will likely find a physician who always codes at a high level, never going deeper to the specificity of a .15. Others code with greater rigor. Or perhaps there is high use of home testing kits. If the CPT code for the kit isn’t allowed in the value set directory, you won’t get credit for that measure impact. These variations affect your ability to be successful.

With so many dollars at stake, it’s important to share issues, opportunities and results across your organization, including your provider network, to enable everyone to contribute to your plan’s HEDIS results. It’s also essential to consider how much your efforts are yielding. For each initiative, how much of the data did you get from claims data or through a hybrid record review? Was a supplemental data source more valuable? Where are your time and resources best spent in the future?

Today, there are reliable tools that identify which strategies drive the greatest results. This enables you to create a road map of the best way to allocate resources. Moving forward, the tools will become even more sophisticated: increasing first-chase efficiency by evaluating records through natural language processing, as one example. You can look forward to even more targeting to reduce your effort while maintaining or measurably increasing your results.

Learn more with these resources.

Request a demonstration of HEDIS tools

Read a blog post on evaluating your HEDIS performance


Looking for proven answers to your HEDIS performance questions? Connect with Optum to talk with an expert.


About the Author:

Cybil Fry Headshot_Option 1.jpg

As director of Clinical and Quality Solutions at Optum, Cybil Fry partners with health plans to improve their HEDIS scores. Prior to joining Optum, Cybil spent significant time leading HEDIS efforts for health plans. She first worked in data analytics with a focus on accreditation. She later led HEDIS/Stars reporting and initiatives. She had the pleasure of conducting end-to-end HEDIS across all lines of business and accomplishing year-over-year improvements. Cybil also led a team that consistently met all Medicare Stars goals each year.

After achieving her HEDIS goals as a health plan employee, Cybil moved to Optum to help clients achieve their HEDIS and Stars goals. She recognizes “the purpose of quality reporting is quality improvement,” and focuses her sights on developing innovative means to project and improve HEDIS outcomes.

Cybil holds a BA in Information Systems and has an extensive background in trend analysis.

Healthcare Effectiveness Data and Information Set (HEDIS)
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