Improving HEDIS Quality Measures: Best Practices for Healthcare Administrators

What separates one healthcare provider from another? In 1991, the National Committee for Quality Assurance (NCQA), a private nonprofit organization committed to improving healthcare quality, sought to answer that question with the HMO Employer Data and Information Set (HEDIS). It is an auditing tool designed to inform healthcare payers and consumers about providers’ performance-related benchmarks. In 2007, HEDIS became known as the Healthcare Effectiveness Data and Information Set.

Today, more than 90% of health plans use HEDIS to evaluate provider care and collect performance data so that payers can make informed choices about healthcare coverage. As the healthcare landscape continues its shift toward value-based care, HEDIS audits are invaluable for quantifying what payers want. That means healthcare administrators have many opportunities to differentiate their organizations from their competitors. It all starts with the right talent who can ensure quality data abstraction and help you secure higher Star Ratings without the hiring headache.

Understanding HEDIS Quality Measures

HEDIS consists of more than 90 measures across six domains of healthcare quality — effectiveness, access, experience, utilization, descriptive information, and clinical data systems — used to evaluate hundreds of Medicare Advantage, Medicaid, and commercial health plans. Using HEDIS to measure the clinical quality of a health plan offers insight into the caliber of the healthcare services a consumer can access through it.

The NCQA uses HEDIS measures along with data derived from the Health Outcomes Survey and the Consumer Assessment of Healthcare Providers and Systems program to assign a weighted average Health Plan Rating (HPR) to every eligible participating health plan. The star-rating scale ranges from 0 to 5 and increases in half-point increments, with specific ratings based on a plan’s performance in three subcategories:

• Patient experience: patient-reported experiences relating to providers, plan services, and customer service
• Prevention: the proportion of care recipients who received prevention measures, such as immunizations, screenings, and health advice
• Treatment: the proportion of care recipients who received appropriate treatment measures — direct actions to resolve acute or chronic conditions — such as providing the correct ratio of medications to a patient with asthma

The broad objective of HEDIS and the associated HPRs is to evaluate whether healthcare providers and insurers are optimizing their resources to deliver high-quality care, information that can benefit players on all sides of the healthcare market. For consumers, HEDIS data and a high rating point to the likelihood of receiving top-notch care. For healthcare providers and health plan administrators, the measures can help with identifying performance gaps, realizing improved outcomes, and encouraging consumers to choose one health plan over another. There’s also a financial incentive, as highly rated health plans have better chances of boosting their funding.

How to Improve HEDIS Quality Measures with Staffing and Technology

As you oversee operations in your role as a healthcare administrator, consider these best practices to improve your organization’s HEDIS quality measures.

1. Hire for and foster a culture of collaboration and communication. Interdepartmental coordination is a common challenge among health plans, as pertinent data often becomes isolated in individual team silos. The solution to these departmental barriers is fostering a culture of collaboration and communication and hiring individuals with strong communication skills to promote it. Key member data should be accessible and shared across teams so the entire organization can work toward meeting consumers’ needs. The consumer, too, should feel welcome to take part in the collaboration, triggered by proactive communication from staff. From the consumer’s point of view, a concerted and proactively communicative effort by their health plan demonstrates prioritization of health outcomes, improves engagement, and offers superior levels of customer support, thereby improving HEDIS scores.
2. Leverage technology for data collection, analysis, and reporting. Technology may prove integral to your organization’s endeavor to improve HEDIS quality measures. Electronic health records, for example, are essential for centralizing and sharing access to important patient health data. Bear in mind, also, that reporting and data analysis are mainstays of HEDIS compliance that can be both time-consuming and capable of causing delays if poorly executed. Leveraging advanced tech tools such as automation, artificial intelligence, and natural language processing — and building a team familiar with these technologies — can not only expedite these processes but also help to ensure accuracy.
3. Ensure you have the right staff in place to support tech initiatives. Tech is only as good as the people who use it, and a health plan needs sufficient staff to satisfy the high level of administrative work required for data collection, analysis, and reporting. Identifying experienced and capable talent is a labor-intensive process, but you can overcome these challenges by partnering with a dedicated staffing agency like Medix with the tools and screening processes to vet candidates’ soft skills and hard skills. With our care management experience, you can be confident that you have an ally that knows what you need and how to get it for you, including communicative, technologically savvy clinical and non-clinical healthcare talent. We provide pre-vetted, HEDIS-experienced clinical and clerical staff ready for immediate deployment, reducing the hiring burden and ensuring high-quality, compliant data abstraction to boost HEDIS scores.

Your Partner in Improving HEDIS Quality Measures

Medix is a staffing partner that specializes in healthcare and healthcare technology. To ensure your HEDIS staffing success, we find the specialized talent you need, exactly when you need it, ensuring compliance, quality, and proven results for your most critical HEDIS initiatives.

Healthcare admins have been partnering with us for over 20 years to find trained, highly capable talent who can seamlessly integrate with HEDIS teams, ensuring timely and accurate data submission. In the past five years, Medix has provided more than 700 skilled professionals to support HEDIS-related functions.

• RN case managers: 202
• RN quality management: 33
• Utilization review: 6
• Care coordinators: 497

Get in touch with us to learn how we can help you build a flexible, skilled team.