Building a Foundation for HEDIS Success Amid Change

With Measurement Year (MY) 2024 complete, a new HEDIS season is now underway. The introduction of new measures, ongoing revisions to current measures, and regulatory updates create an ongoing need for adaptation and advancement to enhance quality. Plans must remain vigilant in reinforcing their data processes, encouraging provider feedback, enabling flexible retrieval strategies, and more to improve measure rates for MY 2025. These efforts are instrumental in closing care gaps and advancing the health outcomes of their population served.

One of the most significant changes ahead is the transition to digital reporting. Health plans should develop a comprehensive action plan to ensure preparedness for future requirements, as updates continue to move away from hybrid measures. Strategic planning for the upcoming measurement year should incorporate thorough communication between the health plan, its HEDIS vendor, and auditor.  

The move to digital reporting

One of the most substantial changes to HEDIS reporting is the transition to digital only reporting by 2030. Multiple measures are transitioning in MY 2025 to being reported exclusively through electronic clinical data systems (ECDS). These measures include cervical cancer screening, childhood immunization status, and immunizations for adolescents. Meanwhile, the eye exam for patients with diabetes is shifting to administrative-only reporting. Several new measures have also been introduced, including two mammogram-related measures and one blood pressure control for patients with hypertension, which changes the controlling high blood pressure measure into ECDS and expands the eligibility criteria. These updates will require careful planning and data readiness to ensure accurate reporting and compliance.   

Traditionally, measures have relied on logic coded by quality measurement vendors, with proprietary data models to match. Digital quality measures (dQMs), on the other hand, use standardized Clinical Quality Language (CQL) and the Fast Healthcare Interoperability Resources (FHIR) data model. The planned shift to dQMs by 2030 will therefore create better standardization, interoperability, and efficiency, but only with careful preparation to adjust for the speed that digital reporting will require. 

Health plans should proactively identify internal teams already working with FHIR, evaluate data deficiencies, and build strategic alignment. Plans must work to help ensure that they possess the necessary data not only to sustain current performance metrics but also to achieve future improvements. Consider the following strategies in both the short- and long-term.

• In the short term: Assess FHIR readiness and downstream needs. 

• Over the next 90 days: Attend a FHIR training session, foster cross-departmental collaboration, and allocate budget resources for infrastructure upgrades as needed. Establish a framework to support sustained success.
• Over the next year: Monitor state digital reporting needs, understand data gaps, strategize a plan for parallel reporting, engage with your HEDIS vendor, and initiate implementation of your plan, refining processes as appropriate. 

Improving retrieval results

Enhancing retrieval yield requires consistent year-round processes, robust data and analytics, and scalable infrastructure. Organizational success can be achieved by maintaining accurate provider information, streamlining outreach activities, and investing in digital connectivity, ultimately resulting in optimized retrieval processes. Establishing reliable, expert-driven practices throughout the year results in quantifiable improvements, including reduced retrieval times and superior data quality — particularly as operations transition towards digital reporting. Additionally, health plans are encouraged to assess charts retrieved for other functions, such as risk adjustment, to identify presence of supplemental data that can facilitate the closure of HEDIS gaps. Below are several strategies for improving retrieval yield:

• Provider data. A rich, curated provider dataset helps to gain insights into needs and to plan effective support and outreach. By leveraging a curated dataset — one that includes historical insights into provider locations and outreach preferences — plans can tailor engagement strategies, making them far more effective and efficient.
• Request optimization. Consolidate outreach by location and site, across use cases and health plans, streamlining efforts and reducing burden for both providers and payers. Streamlining the administrative side of retrieval — including grouping requests by location or use case — not only reduces provider abrasion but also improves overall operational efficiency. 
• Channel strategy. Invest in digital connectivity that drives value, while leveraging a range of diversified channels including automated retrieval tools and EMR integration to execute optimal strategy. Not all providers are digitally mature, so using a mix of digital and traditional communication methods ensures plans will be able to meet providers where they are. This flexibility directly translates to higher retrieval rates.
• Build strong relationships with high-volume provider groups. Foster strong communication with high-volume provider groups up front, clearly outlining the project, timeline, and expectations. This builds trust and sets the stage for smoother collaboration. 

These foundational strategies play a critical role in improving both the efficiency and effectiveness of quality and risk programs.

Closing care gaps proactively 

Another element for improving HEDIS scores includes closing gaps during and throughout the measurement year. This once more hinges on communication and strong member engagement. Starting early and working smarter sets the foundation for a more efficient and successful HEDIS season.

Prioritize high-impact measures by allocating more resources to complex (e.g. colorectal cancer screening, breast cancer screening) or heavily weighted measures (e.g., HbA1c control) that are also a part of Star Ratings calculations, since these can significantly influence your overall scores. 

View gaps at a member level across the population and measure sets then ensure you’re targeting the members that are most likely to engage. Strategically plan outreach to those members throughout the year, rather than just at key moments such as enrollment. Using these tools and others can help create smoother processes in the long run. 

Revving up for change in MY 2025

Here are three elements to keep in mind on the way to a higher HEDIS score: review, feedback, and collaboration. 

Target learnings from the previous year

Plans should consider what they learned from previous measure scores overall, paying attention to measures that switched from hybrid to ECDS reporting in the past, such as the colorectal cancer screening measure. For example, NCQA reported the colorectal cancer screening rate dropping for Medicare HMO from 68.6 in MY 2022 to 38.1 in MY 2023. 

Plans should conduct a thorough review of their own colorectal cancer screening measure data to identify opportunities. Analyze what worked, where there were delays, and identify any gaps in data or quality, leveraging available data for improvement. By digging into these insights, plans can start to develop targeted strategies to proactively engage members and optimize reporting for not only this measure, but applying those learnings across other measures moving to ECDS-only in the next measure year and beyond.

Initiate a provider feedback loop

HEDIS scores are reliant on concrete, accurate data. Part of getting that data together in a timely fashion is to establish solid relationships with providers. To optimize data capture, share outcomes and build relationships with providers, encouraging collaboration and transparency. Sharing high-level results not only builds trust but also opens the door for future collaboration. As digital measures become the norm, building up supplemental data will be crucial for accurate reporting. When providers see the impact of their efforts, they’re more likely to stay engaged and committed in upcoming cycles, contributing to better capture, faster.

Improve cross-departmental collaboration

Continuous communication eliminates the need for a last-minute scramble for data. Centralized communication leads to streamlined processes, enhancing overall productivity in an ongoing manner and with a continuous data flow. Reduce administrative workload by distributing tasks and fostering teamwork.

By sharing responsibility across teams such as Stars, population health, member marketing, and more, you can streamline communication, improve data capture, and ideally reduce the need for in-season chart retrieval.

All of these efforts work together to reduce administrative workload and enhance overall productivity, making the next HEDIS season even more efficient and successful.

Photo: Hollygraphic, Getty Images

Branka Sustic is vice president of risk adjustment and quality operations at Cotiviti. She provides leadership in product and business development, client program management, and strategy to assist health plans in meeting their quality goals, optimization of revenue, and risk mitigation. A leader with more than 20 years of healthcare experience, she is known for creating and establishing operational and support plans leading to increased client satisfaction and performance.

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