HEDIS and CMS Star Ratings – Optimizing Benefits

By Sandra Hewett, RN, BSN, CCM

Quality healthcare belongs to the entire health care team, including the patients. Health plans play a significant role in ensuring that patient treatments, drug therapies and preventative care measures are handled in a timely, thorough, efficient and attentive manner. A health plan’s ability to deliver a high level of service not only impacts its reputation in a very competitive industry, it determines the level of performance incentives the plan will receive from the Centers for Medicare and Medicaid Services (CMS). Patients also have a significant role in the perceived reputation of the health plan.

Sandra Hewett

Sandra Hewett, RN, BSN, CCM is Director of Clinical Content for ZeOmega

Health insurers are held responsible for service levels to their members through the National Committee for Quality Assurance’s (NCQA’s) Healthcare Effectiveness Data and Information Set (HEDIS) quality measures. HEDIS is a tool used by health plans to evaluate their performance on many aspects of their service. HEDIS consists of 75 measures across 8 domains of care (see official NCQA Listing), whereby health plans are able to determine the percentage of their member populations that are compliant with specific treatment protocols, such as ongoing activities to manage diabetes or other chronic conditions. The HEDIS measures also guide health plans in the adoption of best practices for preventative care, such as ensuring that children are receiving recommended immunizations at the proper age.

Stemming from the measures set forth by HEDIS, the CMS deployed its Star rating system that effectively rates a health plan’s Medicare Advantage programs. The Star ratings are awarded based on 53 quality measures within eight topics. Each measure falls into member-centric categories that include a focus on areas such as managing long term conditions, preventative care, member experiences with drug plans and customer service/plan responsiveness. Health plans are awarded a number of stars ranging from 1 (poor compliance) to 5 (excellent compliance), which are congruent with their achievements within the categories evaluated.

To encourage Medicare Advantage plans to provide quality care, the 2010 health reform law¹ authorized Medicare to pay plans bonuses beginning in 2012 if they receive 4 or 5 stars on the program’s 5-star quality rating system. Building on that provision, the Centers for Medicare and Medicaid Services subsequently launched a demonstration that allowed more plans to receive bonuses and increased the size of the bonuses to encourage plans to maintain or improve their ratings. Health plans, of course, desire the highest possible rating to be more attractive to consumers and there are incentives to the star ratings. Additionally, health plans receiving 5 stars in 2012 will be able to enroll and market to Medicare beneficiaries throughout 2012. About one third of the bonus payments will be made to plans with 4 or more stars with the other two-thirds for plans with 3 or more stars. Without the proper intelligence (data), health plans are unlikely to effectively and efficiently evaluate their populations and the efficacy of member programs to improve upon their identified service quality scores. Enter health care technology solutions.

A handful of software service providers are deploying various care/population management software solutions to help health plans automate workflow processes and gather critical data elements. Superior technology platforms typically incorporate a sophisticated rules engine that automates the process of interrogating claims and other clinical data elements. In response to recent government legislation that concentrates the overall focus on achieving healthier populations, these software solutions are helping health plans better manage entire populations of members through periodic evaluation of populations for specific clinical elements. For example, technology can be configured to identify women over the age of 50 to determine if they have or have not met a certain HEDIS measure, such as receiving regular mammograms.

Traditionally, this identification has been accomplished through a time-consuming manual analysis of claims data, complex report writing and manual assessment for various health care management programs. A software solution that integrates not only claims or encounter data, but clinical and operational data of a health plan’s membership has become a necessity in allowing the health plan to capture pertinent data for accurate and thorough HEDIS reporting. Add to the software solution the ability to generate robust algorithms to present the end user with real-time, actionable data is one of the key answers to managing and using gained intelligence.

Leveraging automated business logic processes, care/population management software applications also allow health plans to more effectively report HEDIS-like measures as a means for continuous quality improvement; it will also give health plans closer to real-time assessment of where the plan will fall in CMS’ star ratings. The ongoing challenge for application developers is to leverage additional abstract quality metrics that aren’t easily captured in a software platform, such as a health plans’ customer service performance. The most effective solutions are breaking down these barriers by, for example, accommodating, integrating and aggregating data that health plans generate from customer surveys.

Superior care/population management software programs must be designed to help provide actionable data, near real-time to the health plans to help lower healthcare costs and elevate healthcare quality. Innovative care management automation solutions are assisting health plans in achieving these two important measures, not only to attain higher star ratings or CMS bonuses, but also to ensure their plan participants achieve the best possible quality outcomes. As policymakers continue to focus on strategies to encourage high-performing plans and providers, it will be important to monitor whether quality ratings and bonus payments are associated with better care and improved health outcomes for Medicare Advantage enrollees.

Sandra Hewett, RN – Sandra Hewett is is Director of Clinical Content for ZeOmega, a leading provider of population healthcare management software.   She directs and manages the development and implementation of the clinical protocols and assessments for ZeOmega products. Ms. Hewett also provides leadership and strategic direction for the Clinical Content Department for product development, implementation, and client support.  A veteran in care management, Ms. Hewett brings more than 20 years of clinical expertise. Among her successes, she served at Community Health Plan of Washington, where she was responsible for designing, developing, implementing and directing the Care Management Services Program. She has also served to influence care across the continuum for a hospital-provider system.  Ms. Hewett earned her Bachelor of Science in Nursing from Rutgers University.

¹Hereinafter, the health reform law refers to the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148; PPACA) as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152).

Posted in: CMS, HEDIS, Population Healthcare Management

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