An expert viewpoint: Five questions to evaluate your HEDIS performance

If you are feeling relieved (and perhaps somewhat exhausted) now that your HEDIS submissions are in for the year, you are not alone. But if you want to be even more successful with your HEDIS effort next year, take action now to evaluate what went well, what didn’t, and how you can improve moving forward.

 How did you perform based on your goal?

If there was a significant miss, perhaps you set unrealistic expectations. Considering the volume of HEDIS measures it’s idealistic to try and address all of them within a single season.  Prioritization is essential.  You must determine the high priority measures, determine your best opportunities for improvement, and define a means to set your goals accordingly.

Before you examine what went wrong, take a real look at what success can and should look like for your health plan. It can be useful to look at how you are performing against your peers. But if the Stars thresholds say that you have to achieve a 10-point jump to get to four Stars, is that reasonable to expect?

Alternatively, did you significantly overachieve? Perhaps you underestimated a member engagement and didn’t set goals high enough.  Consider your improvement programs and set goals to reflect them.  Ideally, you are defining appropriate goals.  This way your goals are basically projections to leadership.

What is your year-over-year trend?

Many measures have trends.  If you have been ranging between 70-73% consider those trends when setting your goal.  Likewise, if you see that you are achieving a two percent bump each year tied to a specific initiative, consider if you are continuing that initiative and/or introducing others.

How are measure trends affecting your results?

Leverage published data or conduct analyses on measure trends.  Some measures see incremental improvements while others dip and spike.  Evaluate these trends and determine where you are on measure trend cycles to more accurately set next year’s goals.

How did your individual work streams perform?

Retrieval. Abstraction. Medical Record Retrieval Validation (MRRV). Each of these can have a significant effect on whether or not you hit your goals. For retrieval, are there opportunities to improve the chase file drop and start your season earlier? Perhaps certain offices are always late or frequently rescheduled. Consider ways to address these earlier next year. To find your optimal time for the chase file drop, look at the dates for past years. Were your resources on hold waiting for files? Or was there too much too fast for them to handle? When is your data mart available to run vendor files?

With regard to abstraction, what areas did the team struggle with or underperform? Would the team benefit from a training deep-dive on a given measure? Was the person responsible for receiving clarifications and auditor escalation during the season clearly defined? Did the means of sharing findings with the team work efficiently? This kind of workstream detail is easy to overlook but can have far-reaching implications for the final results.

For MRRV, what were your milestones – both the internal and external dates? Do you have a subject matter expert for each hybrid grouping?

Did you have the reporting insights you need to identify opportunities in real time?

What can your data tell you along the way that can help fuel (or course correct) your season? Those pain points from the past year are your key indicators for next. Identify and monitor them carefully, ensuring you are ready to escalate before they become barriers to greater success.

Your health plan (and your leadership) is counting on you to set realistic HEDIS goals and achieve them. These five considerations can help you set a course for continuous improvement.

Learn more with these resources:
Read a blog post on improvements beyond workstream analysis

Request a demonstration of HEDIS tools


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

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