I think I'm going to talk a bit about stratification and HEDIS. NCQA requires that members are stratified according to risk levels(HIGH, and other(Medium and Low depending on how you assess risk) for Health Plans and DM companies. Now you are suppose to outreach to these members based on their stratification. Common sense says you outreach to those High members based on the fact that they are usually the most unhealthy of your population. The conundrum is with HEDIS that stratification isn't a concern most of the time. It looks at chronic high risk members the same as low risk chronic members for a significant number of HEDIS measures. You could be diabetic or asthmnatic in very good health but still have considerable gaps. Take me for example I have asthma, I use an inhaler as needed but hate taking a controller. I also usually forget my flu shot. But otherwise I'm in good health(my wife thinks I could lose a few). I'd be showing as having a few gaps much to Cigna's chagrin. How do you convince me to close those gaps? With a lot of HMO's since I'm low risk I probably wouldn't get much attention. But with HEDIS measures now the challenge is how to get me to change behaviors and close those gaps??? It's a challenge because if I'm not living at PCP practice who is going to remind and should they? The way the market is appearing to move its looking at more preventative and screening as a way to get people healthier. Makes sense to be honest you want to catch things before they get worse. Is it ideal?? In my opinion not really I don't think the standards really take into account how good your doctor is and how well they treat you. I think some good practitioners out there may feel handicapped because of what they may be forced to do to get good ratings. The system isn't perfect and it is involving. Wellness is going to be a factor down the road... prepare for it....
Imported/Syndicated Blog Original Publish Date : Sun, May 6, 2012