NCQA’s Future of HEDIS® – How to align your health plan to follow this direction

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Starting 2022, NCQA plans to rope in multiple changes and bring a change in the payer perspective on how they look at HEDIS reporting. The emphasis is on consumers (member experience) and the shift from volume to value is creating a turnaround across key areas of payer enterprises such as clinical guidelines, digitization of member records, electronic exchange of data, adoption of FHIR standards, provider value-based contracting, and multi-level care coordination. We believe that quality management should be the foundation necessary to execute a number of the aforementioned initiatives. Health plans can expertly manage next generation processes and technologies that focus around adopting FHIR, enabling enterprise collaboration and improving quality of care delivered.

We closely follow the changes in regulatory reporting and quality measurement to help clients ride the curve. Our assessment of the upcoming changes has led to identifying 7 key areas of impact and that will drive the preparedness required for health plans in near term. In the upcoming series of blogs, we will analyze each impact area in detail along with recommendations for success.

1. Rising Demand of Electronic Data Sources

NCQA plans to have over forty ECDS measures by 2022. With the annual rise of electronic measures rolling over in the effectiveness of care domain, there is a steady need to acquire electronic data sources like CCDA, HL7® FHIR®, etc. from various providers. CMS’ New Interoperability and Patient Access rule is also pushing providers to share clinical data in response to health plan inquiries.

Payers will need an enterprise clinical data repository for seamless acquisition and integration of clinical data from various provider sources. The new CMS’ rule is urging payers for a stand up FHIR server to acquire clinical resources from provider site which can be another alternative channel for aggregating member clinical data.

2. FHIR for HEDIS Reporting

NCQA plans to alter the HEDIS landscape in next 2-3 years by transitioning to true end-to-end electronic measure management. In its current roadmap, NCQA has laid out three critical future components – FHIR based data input specification, FHIR compliant ECDS measures scripted in ‘Clinical Quality Language’ (CQL), and FHIR based measure reports for collaboration.

Payers will need to scale-up their FHIR capabilities by building a bi-directional inquiry and response mechanism with providers to align with CMS’ & ONC’s interoperability guiding principles. This will be an essential technology investment through 2020-2021.

3. Focused intervention through Micro-segmentation

To drive campaigns around compliance improvement and optimized ROI, payers will need to segment member population on multiple factors such as family history, prior year compliance trend, current year compliance trend, comorbid conditions, socio-economic factors, etc.

Analytics users need to study the population flow-down and identify top contributing factors for non-compliance will be crucial. Such non-compliant population uncovered through descriptive analytics need to be further complemented with prescriptive analytics by data science professionals to gauge member propensity to turn compliant while considering multitude of predictive markers, including socio-economic factors.

Member level predictive scores should be analyzed to prioritize and micro-segment the population cohorts for outreach and intervention. Predictive models should be leveraged to forecast aggressive and optimistic performance targets, CMS Medicare Advantage Star cut points and contract/plan Star ratings.

4. Value driven analytics for Provider Incentivization

Regular acquisition of clinical data from provider sources throughout the year can significantly improve the quality of care and compliance. Goal-based tracking of affiliated provider groups and individual provider performance for their attributed panel across a preferred list of KPIs becomes essential. This will help payers to demonstrate a risk-based provider incentive program for rewarding high performers while penalizing the low performers.

Payers will need to visualize provider performance across attributed panels and roll up over the provider hierarchy to stratify high and low performers within their provider database. Establishing a comprehensive measure library that also supports custom measures will allow for the desired configuration flexibility. Value-based quality programs will need to be configured based on choice of KPIs, member population, provider affiliation and performance benchmark set-up.

5. Digital Strategy and Automation for Margin Optimization

Medical record review is one of the key cost drivers round the year for both risk and regulatory quality measures like HEDIS, QARR, etc. Highly resource intensive areas involving several manual processes and acute shortage of skilled medical coders, especially during peak hours of the HEDIS MRR season is crucial.

To attain certainty, payers should enhance efficiency and accuracy in high resource intensive areas through NLP-based automated abstraction and coding. This can be complemented with Machine Learning driven work prioritization insights while maturing the cycle over-time.

6. Prolonged timeline for focused performance improvement

Annual changes to measure specifications with limited time for adjustments has been a conventional challenge for most stakeholders including health plans, providers, HEDIS vendors, CAHPS vendors, and HEDIS auditors. NCQA’s more holistic and stable approach for measure specification change will help in orchestrating a more meaningful quality program management. Additionally, a two-year strategy, process stability, longer vendor engagement, collaborative relationship, and improved provider relationships will truly embark next generation HEDIS management.

NCQA has communicated that 2023 HEDIS specifications are planned to be made available 11 months in advance. This change calls for prevailing planning and analytics remediation for a long-term approach over the traditional short-term approach.

7. Unified tracking of MLR compliance

Tighter MLR margin compliance, especially in government line of business, requires an integrated view of member-based revenues and expenses. With quality being the focus, health plans will see increased resource usage per member in terms of outreach expenses, provider incentives, member education, etc. to drive the compliance needle. All of these factors need to be holistically quantified and monitored closely against earnings (member premiums and quality incentives).

Payers today need a single unified platform for clinical quality, financial and utilization KPIs to chart overall performance. A single platform with benchmarking, trending, and drill through capabilities to identify and isolate low performing areas along with deeper analysis and actionable insights for continuous improvement will help payers achieve their performance goals.

To Summarize, the aforementioned seven key strategies account for the near-term future changes in payer quality improvement and regulatory compliance functions across all facets – data acquisition, measure processing, performance collaboration and advanced analytics – for continuous improvement. The outlined strategies are directed to build a strong quality management foundation that seamlessly weaves enterprise goals with regulatory compliance and care quality improvement.

Keep watching this space for detailed analysis of each of the above mentioned impact areas

Next Topic: COVID19 Impact on Payer Quality Improvement for 2020-21

NCQA does not endorse any CitiusTech programs or products; HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)


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