Author: LBodnarchuk

The Healthcare Effectiveness Data and Information Set (HEDIS), a set of performance indicators, is required by the Centers for Medicare and Medicaid Services (CMS) for all Medicare Advantage plans. It is a tool utilized to monitor outcomes related to clinical quality and preventative care across health plans and has significant impact on Medicare Stars. HEDIS data can be calculated either utilizing administrative data within the claim or encounter, supplemental data, or hybrid data review. Hybrid data requires additional information through medical record review to provide the full picture of the care provided. HEDIS season is the last opportunity to focus on HEDIS measure improvement efforts for Star Year 2023.

Maximizing your Chart Retrieval Process for HEDIS

Performing a review and analysis of the medical records is critical to the success of HEDIS/Hybrid season and maximizing abstraction efforts. Medical record outreach to providers can be completed in multiple ways, such as fax, mail, on-site collection, electronic medical record (EMR) access, etc. From HEDIS pre-planning efforts to the pull of the initial rates, health plans need to be focused and have strategies in place for early and often outreach.

Below we discuss three key themes outlining a successful HEDIS/Hybrid strategy.

Advanced Analytics Support

• Completing an initial assessment/impact analysis of the HEDIS data as your initial rates/sample is pulled gives your team a great perspective on the season ahead and allows for strategy development. This enables your team to have a clear understanding of opportunities and strategies to pursue throughout the season.
• Plans are encouraged to have reporting to allow leadership insight into performance as the season progresses. This includes chart retrieval goals, forecasting and provider location opportunity analysis, which allows for better communication and more informed decision-making.

Enhance Provider Partnerships

• Optimizing relationships with provider partners is extremely important to the success of HEDIS season. Plans typically have internal communications, tools, trainings and resources available to better assist provider partnership.
• Continuously updated provider data enables a strong start to the HEDIS season and in turn will help reduce provider abrasion and ensure your requests are ‘first in the door’ with providers.
• Plans should also consider creating strong and up-to-date provider repositories. This repository/database will go a long way to help ensure the information is passed from season to season such as a list of providers that require on-site retrieval or providers with EMR access.

Clinical Approach and Review

• Having the right clinical abstraction team in place to support HEDIS season is imperative. Ensuring the team is established in prior to the new year, allows for trainings and educations to be completed ahead of the start of the season. This clinical abstraction team will make the clinical connections that can improve HEDIS outcomes.
• Performing a second review (over-read) of the medical records at 100% ensures accurate and consistent abstraction with every medical record retrieved.

At ProspHire, we continue to partner with Health Plans, to offer insights, analysis and execution strategies to improve Star ratings. Do you need support to optimize your HEDIS season? Let’s have a conversation.

With the shift in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) and other operational measures weighted from 2x to 4x, a positive Member Experience with the plan is now critical to succeed in Stars. Understanding member’s journey with the plan, end to end, is paramount. In our experience, health plans that listen to the member and proactively react to their feedback often will achieve their performance goals and reach 4.0+ Stars for their contract.

Creating a Culture of Positive Member Engagement – Strategic Approach

Individuals are most dissatisfied when their expectations are not met. The Medicare Program and the Medicare Stars team need to work collaboratively across the organization to ensure that members’ expectations are clearly set, defined, and ultimately exceeded. Mature Health Plans have strong alignment between the management of their products and the management of the Member Experience. From the pre-sales process to acquisition to onboarding and throughout the life cycle of the membership, health plans need to be cognizant of every member interaction to make each touch meaningful and impactful.

Below we discuss four key themes outlining a successful member engagement strategy.

Predictive Analytics and Centralized Data

• You cannot fix what you don’t understand and measure. Health plans need to think more creatively about the ways they understand Member Experience at the health plan. Centralizing Member Experience metrics in a database will go a long way to help enable better, more informed decision making.
• Understanding your membership – Plans need to consider deployment of micro-surveys, pulse checks, and off-cycle surveys in order to gather key member insights which will inevitably inform your ongoing strategy.
• Predictive Analytics – predicting future member dissatisfaction will help mitigate downstream risk. Analysis of member-level predictions can identify opportunities for targeted messaging.

Alignment of Messaging and Synergy Identification

• Plans typically have the internal capabilities, tools, and resources necessary to optimize member communications. Internalizing multichannel engagement strategies and leveraging those capabilities and expertise reduce reliance on external solutions and ensure greater governance, data management, and program management.
• In heavily siloed organizations, members are often victims of ‘information overload’ due to numerous member outreach campaigns throughout the year. Within these campaigns, there are several opportunities to combine efforts among plan operations that should be considered to reduce member abrasion.

Enhance the Payer – Provider Relationship Potential

• Providers are typically a member’s primary point of care, not the plan. Plans should optimize their provider relationships as it can have deep downstream impacts on CAHPS and satisfaction. This includes understanding a member’s care journey, medication history and other relevant experience information.
• Positive Feedback Loop – keeping providers informed and engaged is key. Plans need to educate providers about what you are asking your members to do in addition to the incentive opportunities they may have. Lastly, plan product design changes can impact providers, and proactively informing providers of changes and their impacts can improve engagement.

Benefit and Resource Optimization

• In a highly competitive Medicare landscape, optimized benefit design and reward or incentive programs can significantly impact Member Experience while also impacting other domains (i.e., HEDIS, HOS, PDE, etc.). Plans can also empower their supplemental benefit providers to bolster the member experience across existing touchpoints (and therefore avoid the need for additional outreach).
• Health plans invest a lot of money into programs and resources that members either are not aware of, or not capable of connecting with. It is the health plan’s job to proactively form those connections, to improve satisfaction and engagement.

At ProspHire, we continue to partner with Health Plans, to offer insights, analysis, and execution strategies to improve Star ratings. Have you considered your own health plan’s member engagement strategy? We would love to have a conversation. Feel free to reach out to me, Andrew Bell, at [email protected]. Let’s prosper together.

On Thursday, January 6, 2022, the Centers for Medicare and Medicaid Services (CMS) issued their annual proposed rule, aimed at informing health plans and stakeholders of potential changes to the Medicare Advantage and Part D programs. Many of the underlying proposed changes are aimed at improving health equity in the programs. These proposals, if adopted, will impact health plans, the DSNP product, marketing and communications to members, network adequacy, and many other key facets of health plan operations.

A few of the significant changes proposed by CMS are outlined below.

1. Network Adequacy Requirements
   1. CMS is proposing that plan applicants must demonstrate they have a sufficient network of contracted providers prior to agency approval of an application for a new or expanded MA plan

• Marketing Oversight and Communication Enhancements
  • CMS is seeking to increase oversight of third-party marketing organizations to identify and prevent potential deceptive marketing tactics, particularly around enrollment of members
  • CMS is also proposing the reinstatement of a multi-language insert in specified materials to inform beneficiaries of the availability of free language and translation services

• D-SNP Plan Operational Enhancement
  • CMS is proposing that all D-SNP plans establish and maintain at least one enrollee advisory committee in order to hear from the members in order to improve health equity
  • Special Needs Plans, under the following proposed changes, would also be required to add to the current Health Risk Assessment (HRA) questions regarding a member’s housing stability, food security, and access to transportation status

• Enhanced Transparency in Medical Loss Ratio (MLR) Reporting
  • The proposal would reinstate MLR reporting requirements that were already in effect from 2014-2017

• Star Rating Calculation Adjustment (HOS Measure Inclusion)
  • The adjustment would make the calculation for three HOS measures (Improving Bladder Control, Monitoring Physical Activity, and Reducing the Risk of Falling) possible until PHE guidance

In summary, CMS continues to highlight and emphasize the importance of Health Equity in its latest proposed ruling through tightening marketing and communication guidelines to alterations in DSNP plan operations. The potential regulatory changes would once again signal to health plans that a robust and thoughtful health equity strategy is no longer nice to have, but a must.

In 2021, 219 contracts saw improvements in ratings, compared to only 63 last year. In partnership with Hyperlift, the ProspHire team has put together a look back at Star Year 2022, complete with an analysis about the performance of all contracts industry wide. The industry experienced an unprecedented increase in performance (due primarily to the impact of CMS’ Better-Of guidance) and we want to make sure you’re planning to sustain your success next year.

Looking ahead to Star Year 2023, there are several critical considerations for Stars leaders to embrace to maintain or improve their Star Score.

1. Managing Expectations with Senior Leadership: As you close out Q4 efforts and move into medical record review and CAHPS season, it’s imperative that Stars leaders appropriately set the right expectations with Leadership moving into SY2023. With the emphasis in Member Experience and CAHPS (and the shift in measure weighting from 2x to 4x) paired with the probable drop in overall Star Ratings, Senior Leadership needs to be aware of potential downside risk to Stars contract scores.
2. Lesson’s Learned and Strategy Sessions: It’s always helpful for teams and leaders to step away from their day-to-day work and observe progress, risks, and issues from a high level. At ProspHire, we have partnered with Hyperlift to facilitate and lead several successful Program Strategy sessions. Teams need to rigorously evaluate not only measure performance, but also intervention and initiative effectiveness to stay ahead of risks and make data-backed decisions that drive positive results.

There is no singular success model for Stars. Each plan has their own unique set of challenges which require their own unique solutions. Successful Stars Programs share similar characteristics including governance and accountability models, analytics insights into both measures and interventions, as well as support from Senior Leadership.

If you’d like to talk more, please contact Andrew Bell, Manager and Stars Leader, [email protected]