If you are a health care provider or plan with quality bonus payments, chances are you are familiar with HEDIS®. In many ways, HEDIS® a magic word that will either make health care professionals smile or cringe, depending on how well they are doing during their current reporting period. For those not familiar, HEDIS® (Healthcare Effectiveness Data and Information Set) is a set of quality metrics developed by NCQA (National Committee for Quality Assurance) to assess varying levels of quality care. NCQA’s mission is “To improve the quality of health care”. Today, these metrics are the most commonly used set of measures to grade the performance of healthcare organizations. CMS Stars, PCMH, ACO Quality Measures, and individual salaried physician bonuses are all at least partially derived from the HEDIS® measures. There is a significant amount of bonus at stake for high HEDIS® performance metrics. For example, a health plan with ~100,000 members, each quality metric would mean approximately $17M in reimbursements.
In January 2015, HHS announced that they aim to have >50% of all Medicare payments linked to quality. Having a trusted, reliable, and centralized source to evaluate the quality of care has been pivotal in enabling HHS to be nearly an entire year ahead of schedule at the beginning of of 2016 with an estimated 30% of all Medicare payments linked to quality. One can imagine the mayhem and misaligned incentives if different providers had different definitions of quality.
Put simply, think of HEDIS® as the rulebook for quality-based care. Just as all baseball players, coaches, and umpires play by the same rulebook, HEDIS® is the gold standard so everyone is playing by the same rules. Ask Chicago Cubs fans how the rules not being followed made them feel back in 2003.
How Epharmix can help
As Epharmix develops condition-specific interventions, our first goal is to improve morbidity and mortality. In order to increase the value to providers, each intervention is aligned with HEDIS® measures when possible. The best examples are for the EpxDiabetes and EpxHypertension interventions. In addition to controlling the appropriate biometrics, one of the more difficult HEDIS® metrics for providers to achieve is high ratings for eye exams. The EpxDiabetes intervention periodically asks the patient if they have had an eye exam. This alert can direct care coordinators to schedule appointments on behalf of the patients to improve the performance metric.
- CBP – Controlling High Blood Pressure
- BP Control
- CDC – Comprehensive Diabetes Care
- HbA1c control
- Eye exam
- BP Control
You can download the complete diabetes case study here.