Achieving success in these three key measures requires a holistic and continuous approach to quality improvement that incorporates digital tools, a silo-free data landscape and close collaboration with providers.
Plans with four stars and above outperformed the other contracts across measures that are affected by providers and members as well as a payer’s internal systems and processes. The “Provider-focused medical record” metric involves clinical data acquisition by payers from medical records held by providers. The “Medication” metric is based on provider medication management. The “Member-focused satisfaction” measure is based on members’ perceptions of a plan as reflected in a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
In our experience, plans that perform well in these three categories have cross-functional collaboration, few data silos and strong data governance. Clinical, pharmacy, member experience, appeals and grievance, care coordination and encounter data analytics all are incorporated into quality efforts.
Sustaining success, and four-star ratings, also requires a commitment to process improvement across the value chain. To wit: a high score for the medical-record metric indicates a plan can efficiently retrieve medical records from provider offices. This requires medical record chase analytics for higher yields and good provider relationships and contacts.
Digitally driven tools and strategies can help payers achieve these capabilities. Here are five key steps that payers can take to improve performance under the Medicare star ratings program.
1 Incorporate artificial intelligence (AI) and natural language approaches to enhance a 360-degree view of members.
Machine learning and natural language processing (NLP) can help streamline investigations into electronic health record (EHR) progress notes and discharge summaries, which are important sources of social determinants of health (SDoH) data. SDoH information is becoming a key driver in closing gaps in and improving quality of care. In our experience, machine learning and NLP tools can cost-effectively and efficiently extract this data.
2 Integrate HEDIS and star analytics with contact center operations and CRM systems.
Empower member service representatives by incorporating care gap insights and comprehensive member views from HEDIS® and star systems with customer relationship management (CRM) systems such as Salesforce. The goal is to provide a holistic view of the member. That enables plans to provide members with information about recommended screenings, interventions and medication refills in fewer contacts by using a member’s preferred channels. This will help improve member satisfaction while also closing care gaps to improve HEDIS and star ratings.
3 Create a multidisciplinary data science team.
Pair subject matter experts with data analytics tools. Create a team with members who are experts in statistics, HEDIS analytics, clinician analytics, R and SQL. Include associates with strong client relationship experience to ensure the project remains focused on achieving practical results.
4 Share provider quality-incentive programs and collaborative scorecards.
Provider contracts that incent better performance in HEDIS measures, better coding (use of CPT Category II codes) and sharing of data and medical records will lead to higher star ratings.
Payers could choose to emulate value-based traditional Medicare programs like the Merit-based Incentive Payment System and Advanced Alternative Payment Models with their provider groups. Star rating measures also are good starting points. In addition, we have seen payers proactively address newly introduced HEDIS measures such as “transitions in care” that require providers to render and document care within a narrow timeframe.
These programs would require a provider scorecard that enables payers to collaborate with providers by sharing gaps in care intelligence. Scores would also tap into the often-competitive nature of providers by showing them their performance vis-a-vis peers. This scorecard could be a widget in an existing provider portal or embedded in the existing EHR workflows as new CMS rules improve system interoperability.
5 Leverage supplemental data acquisition and interoperability standards.
As CMS interoperability rules go into effect, payers should consider implementing a year-round supplemental data acquisition strategy. Supplemental data from provider files is increasingly critical and aligned with electronic clinical data systems and the future of quality reporting. Interoperability standards like HL7 FHIR will enable payers to retrieve data from EHRs in real time. That should lead to faster identification and closure of care gaps. It also should improve ratings and reduce the medical-record retrieval burden during the HEDIS hybrid season.