Insight
Maximize Your Investment in Value-Based Care: Top 10 Annual HEDIS Tasks
For healthcare providers, transitioning to value-based care requires substantial time, money, and resources, along with a substantial commitment to partnership and collaboration with payers.
The Healthcare Effectiveness Data and Information Set (HEDIS) is a valuable tool for aligning payers and providers with their value-based care initiatives. By tracking key performance metrics across a broad range of clinical and service measures, HEDIS enables healthcare organizations to benchmark their performance, improve patient outcomes, and enhance payer-provider collaboration.
Most payers have already adopted HEDIS to monitor and report on care outcomes and standardized quality measures. Provider organizations have followed suit, increasingly using HEDIS to identify areas for improvement and as a foundation for payer contracts.
However, a commitment to regular maintenance is essential from both parties to unlock HEDIS’ true value and maximize an investment in value-based care.
This article aims to help provider organizations better understand how to successfully use HEDIS and the level of effort required for important annual updates.
Why Is Annual Maintenance Important for HEDIS?
Annual HEDIS maintenance is essential for maintaining compliance with evolving quality standards set by the National Committee for Quality Assurance (NCQA).
Planned maintenance provides a valuable opportunity to track and improve key performance indicators related to preventive care, chronic disease management, and patient outcomes. This includes identifying gaps in care that require member outreach and intervention.
Additionally, annual maintenance helps ensure the accuracy and integrity of data to prevent errors impacting quality scores and reimbursement. When done properly, these quality checks help providers earn HEDIS scores that improve payer relationships and attract more patients.
Problems That Can Occur When HEDIS Is Not Maintained
Failure to maintain HEDIS can lead to delayed reimbursements for providers. Many payer contracts, especially those tied to value-based care models, incorporate HEDIS performance measures as a factor in determining reimbursement rates.
If a provider organization does not keep up with annual HEDIS updates, data submissions, and quality checks, the following issues may arise:
- Incomplete or inaccurate reporting: Missing or incorrect HEDIS data can result in lower quality scores, which may delay or reduce incentive payments from payers.
- Failure to meet payer contract requirements: Many value-based contracts tie payments to HEDIS compliance and performance benchmarks. Non-compliance can lead to payment disputes or delays in reimbursement.
- Audits and additional review processes: If payers identify discrepancies or gaps in HEDIS data, they may withhold payments until the provider resolves issues, leading to cash flow disruptions.
To avoid these risks and ensure seamless compliance, provider organizations should implement a structured approach to HEDIS maintenance, starting with these key annual tasks.
Checklist: 10 Annual HEDIS Maintenance Tasks
- Update Performance Periods: Ensure new measure versions are applied annually. Measures should reflect the latest clinical evidence and align with evolving healthcare needs and priorities. Examples include new guidelines for breast and colon cancers, high blood pressure, and vaccination frequency.
- Identify Training Gaps: Evaluate the need for training on existing or new measures. This can be done by performing a gap analysis of performance measures as compared to NCQA benchmarks. We recommend communication with HEDIS clinical teams, patients, and payer organizations to gather feedback on barriers to care and training opportunities.
- Validate Claim Mappings: Check for payer-specific updates impacting reporting. It's critical for providers to stay in communication with payers, regularly review updates, and ensure their staff are well-trained on any new or revised reporting guidelines.
- Optimize Patient Attribution: Adjust provider-patient assignments to reflect accurate care responsibility and maintain HEDIS compliance for performance tracking. Optimizing provider-patient assignments for HEDIS is essential to improving both the quality of care and reporting accuracy.
- Clear Care Gap Data: Reset outdated patient statuses to align with current-year reporting. HEDIS measures are designed to track the quality of care provided to patients across various domains, and accurate, up-to-date data is crucial to avoid misreporting and ensure compliance with current guidelines.
- Evaluate External Data Sources: Assess how external claims and supplemental data contribute to measure performance and risk scores. This process supports the identification of care gaps, enhances care coordination, facilitates benchmarking, and ultimately drives better patient outcomes. By integrating external data into their quality improvement strategies, providers can ensure more accurate reporting, optimize care delivery, and achieve better performance on HEDIS measures.
- Analyze Annual HEDIS Results: Conduct a comprehensive review to identify trends, gap areas, and success factors for future performance improvements. Regularly reviewing these results supports continuous quality improvement efforts, enhances patient engagement, and ensures alignment with evolving healthcare standards and value-based care models.
- Share Performance Feedback: Share performance reports with providers to promote accountability and improvement. This helps identify areas for improvement, encourages continuous professional development, and fosters collaboration between providers, payers, and healthcare organizations.
- Benchmark Performance: Compare your performance against industry standards and peers. Benchmarking HEDIS performance is a valuable practice for providers looking to improve patient care, stay competitive, and meet the evolving demands of value-based care. By comparing their performance, providers can identify gaps, adopt best practices, and take action to optimize their care delivery.
- Plan for Future HEDIS Success: Use the results of your annual review to plan for continuous strategic improvement. Engaging staff, collaborating with external partners, and fostering a culture of ongoing learning helps drive meaningful improvements in patient care. By consistently focusing on these areas, providers can continuously enhance their performance on HEDIS measures, leading to better patient outcomes, improved quality of care, and long-term success in value-based care models.
Interested in learning more about HEDIS, or planning an implementation? Explore Tegria’s whitepaper for key insights and strategies. Our data and analytics experts are available to help at any stage to ensure peak performance.