Establishing your Medicare Advantage HEDIS strategy for the year 

By DataLink’s value-based care team

What is HEDIS and why does it matter?

The Healthcare Effectiveness Data and Information Set, or HEDIS, is a standardized set of performance measures developed by the National Committee for Quality Assurance. It’s used by more than 90% of America’s health plans, making it possible to compare the performance of health plans on an “apples-to-apples” basis. 

Measures are continuously revised based on published guidelines and scientific evidence, assisting in identifying gaps in care, helping improve patient outcomes, and reducing care costs. 

So why does it matter? HEDIS measures address a broad range of important health issues, such as cancer, care for older adults, diabetes, heart disease, medication management, and transitions of care. 

The power of a team-based approach

A team-based approach is a great way to incorporate processes that capture everything you need to provide the best possible care for your patients. Research has shown that a team-based approach between clinical and non-clinical staff can improve patient outcomes, prevent medical errors, increase efficiency, and improve patient satisfaction. 

To get started, we recommend focusing on teamwork, creating templates, developing screening / standing order policies, identifying and addressing SDoH barriers, prioritizing patient education and outreach, and sending out persistent reminders. 

Building your HEDIS strategy

To build your HEDIS strategy, you must first understand the Medicare Advantage measures. Every measure has four parts: 

  1. Eligibility (who qualifies?) 
  2. Requirements of that measure (what needs to happen to close that gap?) 
  3. Exclusions (who and how can a patient be excluded from the measure?) 
  4. Submission (once gap closure activity is complete; how do you report it to the payer?) 

Education and communication

Knowing the information above is imperative to ensuring that you’re optimizing your strategy, and to do that you have to focus on education and communication within your organization. Here’s how you can do that: 

  • Payer: Create a comprehensive resource guide and host quarterly webinars. 
  • Engagement manager: Discuss a measure on each monthly call and/or provide printed resource guides. 
  • Practice administrator: Educate during staff meetings and have a monthly or quarterly themed focus. 
  • Vendor: Help by supplying blogs, sending out newsletters, and hosting webinars. 

Building your HEDIS strategy

Effective HEDIS planning requires a consistent cycle that’s based on proactive versus reactive planning. 

  • Review contract 
  • Assess past performance 
  • Identify areas of opportunity 
  • Set goals 
  • Strategize 
  • Implement processes 
  • Examine results 

Tip: It can be valuable to use a data-driven population health tool to assess past performance, help identify areas of opportunity, and set goals. 

Quarter 1 proactive strategies

Quarter 1 is the optimal quarter for planning because a productive first quarter ramps you up for a successful year. 

  • Review performance Identify opportunities 
    • Review best practices 
    • Implement new workflows 
    • Order early 
    • Review for exclusions 
    • Schedule appointments 
    • Resources 
    • Education 
    • Call the office prior to and post-event 
    • Outreach plan 
    • Assess barriers 
    • Provide resources 
  • Open gaps (BCS, COL, EED, GSD*, KED) 
  • Out of control (GSD, CBP) 
  • Patient education 
  • Medication adherence 

Measure gap closures

The perfect scenario is that a test is ordered, the a screening exam or lab is completed, documented, and then it’s reported. However, we know that the process can break at any time. For example, we may forget to order the test, the patient doesn’t complete it, etc. 

Here are a few tips: 

  • Patient reported measures: Remember that some measures can be patient-reported, so ask them about these in the questionnaires. Also be sure to know the documentation requirements. 
  • Questionnaires: Make sure that you ask about previous tests done in your new patient and annual wellness questionnaires, for example, breast cancer screening, colorectal, or eye exams.
  • EMRs: Put a dedicated area for this information in your EMR templates. 
  • Declined tests: If a member declined a test, review the chart for any advanced illness, frailty, or other exclusions. 
  • For measures where the results matter, be sure to document the result’s value and know what the acceptable values are. 
  • Timeframes: Some tests might only be acceptable during certain timeframes, so make sure that you are aware of them, and document appropriately.