The Road to Five Star - HEDIS 2017

Every Managed Care Organization (MCO) aspires to be a FIVE STAR PLAN. Star ratings are devised from quality reporting initiatives that include - Health Effectiveness Data Information Set (HEDIS), the Health Outcomes Survey (HOS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS). I will reserve HOS and CAHPS for another discussion. Today, I am concerned with HEDIS since HEDIS season is quickly approaching. The better your Star Score is – the better your financial incentives, member enrollment advantages and, of course, BRAGGING RIGHTS.  

There are three elements essential to great HEDIS scores - your staff, the members, and the providers. 

1.  Your MANAGED CARE STAFF - Quality reporting requires specially trained managed care employees. Departments include legal, contracting, marketing, member services, customer services, claims, provider services, quality management, analytics, finance...  there are so many - but you get the idea. The goal is to provide exceptional care in the most cost-effective manner available and meet quality reporting thresholds.  

Having properly informed staff in place is crucial to meet this goal. I was in managed care collecting HEDIS data for months before I learned the benefits of being a FIVE STAR PLAN.  I recommend keeping your HEDIS reviewers informed all through HEDIS season about where the numbers are. Do they know you only need another 50 Care of Older Adult – Medication Reviews or ONLY 4 - Osteoporosis Management in Women - bone density screenings. Knowing this information could motivate (or challenge) them to meet goals, thus boosting your STAR score. 

An often forgotten aspect of HEDIS scores is member and provider satisfaction.  Ultimately, the VERY UNHAPPY member will have a chance to vent their feelings if they had to pay an extra $20, they felt the person on the phone was rude, or they got lost in the “phone tree”. Any potential problem needs to be addressed because their answers to the Satisfaction Survey will directly affect your STAR scores. A VERY UNHAPPY provider who didn’t get paid for that claim or had to file it three times, or still doesn’t have a signed contract with an effective date will receive a survey they will be more than happy to fill out and their feedback will directly affect your STAR scores. Your staff needs to understand the potential fall-out from a disgruntled member or provider.

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