With the completion of Measurement Year (MY) 2024, the new HEDIS The season is underway now. The introduction of new measures, ongoing revisions to existing measures and regulatory updates create a constant need to adapt and progress to improve quality. Programs must remain vigilant to enhance data processes, encourage provider feedback, enable flexible search strategies, and more to increase measurement rates by 2025. These efforts help close gaps in care and improve health outcomes for the populations served.
One of the most important changes ahead is the transition to digital reporting. As updates continue to move away from hybrid measures, health plans should develop comprehensive action plans to ensure they are prepared for future needs. Strategic planning for the upcoming measurement year should incorporate adequate communication between health plans, their HEDIS vendors, and auditors.
Shift to digital reporting
One of the most significant changes to HEDIS reporting is the transition to digital-only reporting by 2030. Several measures will transition to reporting exclusively through the Electronic Clinical Data System (ECDS) in 2025. These include cervical cancer screening, childhood immunization status, and adolescent immunization. Meanwhile, eye exams for patients with diabetes are moving toward administrative reporting only. Several new measures were also introduced, including two related to mammography and one on blood pressure control in patients with hypertension, changing the measure to control hypertension to ECDS and broadening the eligibility criteria. These updates require careful planning and data preparation to ensure accurate reporting and compliance.
Traditionally, measurements have relied on logic coded by the quality measurement vendor, and a proprietary data model to match. Digital quality measurement (dQM), on the other hand, uses the standardized Clinical Quality Language (CQL) and Fast Healthcare Interoperability Resources (FHIR) data models. Therefore, the planned move to dQM in 2030 will create greater standardization, interoperability and efficiency, but only with careful preparation to accommodate the speed required for digital reporting.
Health plans should proactively identify internal teams already working with FHIR, assess data deficiencies, and build strategic alignment. Programs must work to help ensure they have the necessary data to not only maintain current performance metrics but also enable future improvements. Consider the following short-term and long-term strategies.
- short term: Assess FHIR readiness and downstream needs.
- within the next 90 days: Attend FHIR training sessions, promote cross-departmental collaboration, and allocate budget resources for infrastructure upgrades as needed. Establish a framework that supports ongoing success.
- in the next year: Monitor state digital reporting needs, understand data gaps, develop a parallel reporting plan, work with your HEDIS provider, and begin implementing your plan and improving processes as appropriate.
Improve search results
Improving retrieval rates requires consistent processes year-round, robust data and analytics, and scalable infrastructure. Organizational success can be achieved by maintaining accurate provider information, streamlining outreach, and investing in digital connectivity to ultimately optimize the retrieval process. Establishing reliable, expert-driven practices throughout the year will lead to quantifiable improvements, including reduced retrieval times and improved data quality, especially as operations transition to digital reporting. Additionally, health plans are encouraged to evaluate charts retrieved for other functions, such as risk adjustment, to determine whether supplemental data exist that would help close HEDIS gaps. Here are a few strategies to improve your search rates:
- Provider data. Rich, curated provider data sets help gain insights into needs and plan effective support and outreach. By leveraging curated data sets that include historical insights into provider locations and outreach preferences, programs can tailor engagement strategies to make them more effective and efficient.
- Request optimization. Consolidate outreach by site and setting, across use cases and health plans, streamlining efforts and reducing burden on providers and payers. Simplifying the administrative aspects of retrieval, including grouping requests by location or use case, not only reduces provider wear and tear, but also improves overall operational efficiency.
- channel strategy. Invest in digital connections that drive value while leveraging a diverse set of channels, including automated retrieval tools and EMR integrations, to execute your best strategies. Not all providers are digitally mature, so using a combination of digital and traditional communication methods ensures plans meet provider needs. This flexibility translates directly into higher retrieval rates.
- Build strong relationships with a high-volume provider base. Establish strong communications up front with a large supplier base, clearly outlining projects, timelines, and expectations. This builds trust and sets the stage for smoother collaboration.
These basic strategies play a key role in improving the efficiency and effectiveness of quality and risk programs.
Actively closing care gaps
Another factor in improving your HEDIS score includes closing the gap during and throughout Year of measurement. This again depends on communication and strong member engagement. Starting early and working smarter sets the stage for a more efficient, successful HEDIS season.
Prioritize high-impact measures by allocating more resources to complex (e.g., colorectal cancer screening, breast cancer screening) or higher-weighted measures (e.g., HbA1c control) that are also part of the star calculation because these measures can significantly impact your overall score.
Look at the gap at the membership level across the entire cohort and within the metric set, then make sure you're targeting the members most likely to engage. Strategically plan outreach to these members throughout the year, not just during key moments like registration. Using these and other tools can help create a smoother process in the long run.
Prepare for change in 2025
There are three elements to keep in mind on the way to achieving a higher HEDIS score: review, feedback, and collaboration.
Previous year’s target learning
Plans should holistically consider learnings from previous measurement scores and be mindful of past measures that have moved from hybrid reporting to ECDS reporting, such as the colorectal cancer screening measure. For example, NCQA reports that colorectal cancer screening rates among Medicare HMOs will drop from 68.6 in 2022 to 38.1 in 2023.
Programs should conduct a thorough review of their own colorectal cancer screening measurement data to identify opportunities. Analyze what works, where delays exist, and identify any gaps in data or quality to make improvements using available data. By delving into these insights, programs can begin to develop targeted strategies to proactively engage members and optimize reporting, not only for this measure, but also apply this knowledge to other measures and move to ECDS-only use in the next measure year and beyond.
Start a provider feedback loop
HEDIS scores rely on specific, accurate data. Part of collecting this data in a timely manner is building strong relationships with providers. Optimize data capture, share results and build relationships with providers to encourage collaboration and transparency. Sharing high-level results not only builds trust but also opens the door to future collaborations. As digital measurements become the norm, establishing supplementary data is critical for accurate reporting. When providers see the impact of their efforts, they are more likely to stay engaged and committed in upcoming cycles, thereby contributing to better, faster capture.
Improve cross-department collaboration
Continuous communication eliminates last-minute scrambles for data. Centralized communications streamline processes and increase overall productivity through an ongoing approach and continuous data flow. Reduce administrative workload by delegating tasks and fostering teamwork.
By sharing responsibilities among teams such as Stars, Population Health, Membership Marketing, and more, you can streamline communications, improve data capture, and ideally reduce the need for current-quarter chart retrievals.
All these efforts combine to reduce administrative workload and increase overall productivity, making the next HEDIS season more efficient and successful.
Photo: Hollygraphic, Getty Images
Branka Sustic is Vice President of Risk Adjustment and Quality Operations at Cotiviti. She provides leadership in product and business development, client project management, and strategies to assist health plans in achieving quality goals, optimizing revenue, and mitigating risk. She is a leader with over 20 years of healthcare experience known for developing and building operational and support programs that improve customer satisfaction and performance.
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