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.
HEDIS and effective outreach Part 1
How do you close those pesky HEDIS Gaps??? Like the rest of the Health
Care Market there isn't a perfect solution. However with a little
persistence, a really good outreach program and some decent analytics
you can get yourself in good shape. However HEDIS changed all that when
they looked at populations and chronics as a whole. Population
stratification while important isn't a big factor when it comes to
HEDIS. For most of the screening and preventive gaps stratification
doesn't count but age might buts its not consistent. So what do you?
Start sending out reminders? Computer Calls? Health Coach Calls? What
time? What day? As a HMO you might want to start hiring a staff to do
this.... Or you could outsource it.. You could ignore the issue and
blame the provider that will only get you so far and then the providers
will start refusing your insurance. Just the start of my thoughts on
this... More to come
Why is HEDIS so hard for many organizations?
I think many companies are having a rough time coping to the changes in
the market. Change is slow especially in Health Care and with
Affordable Care Act passing a few years back changes hit the market at
lightning speed(for Health Care). Everybody knew it was coming but I
don't think companies understood how important HEDIS was to
become. These numbers are now how many HMO's live and die by. So much
emphasis has been put on these by HHS and CMS that now all companies
talk about is this and how to make numbers better. The problem is there
is no easy silver bullet to good HEDIS numbers. A lot of HMO I think
shot themselves in the foot when they scaled by on outreach services in
order to cut costs. Then they turned around and dumped the
responsibility onto the provider practice to move the scores. While it
made sense in the short term for costs in the long run it will cost
them. You won't be able to move those numbers and get better ratings
unless you invest in outreach and analytics. You need to attack the
problem from multiple angles of intervention and have different programs
based on your populations