Improve Your HEDIS and Star Ratings by Closing Patient Care Gaps

HEDIS and Star ratings play an important role in ensuring the success of healthcare organizations as both businesses and purveyors of excellent patient care. This blog will cover the basics of HEDIS and Star ratings, as well as ways to improve your scores by closing care gaps.

What is HEDIS?

HEDIS stands for Healthcare Effectiveness Data and Information Set. It was created by the NCQA in order to routinely check and ensure that healthcare programs, systems, and Health Risk Assessment organizations (HRAs) were adequately serving patient populations based on predetermined measures.

What are Star Ratings?

Star ratings are another way healthcare systems and HRAs are monitored and rated for their efficacy. Instead of applying to all health organizations, they apply mostly to Medicare Advantage plans.

HEDIS Ratings vs Star Ratings

The goals of HEDIS and Star are almost identical in their objectives, but the methods they use and their managing organizations differ. 

HEDIS is managed and defined by the NCQA and applies to essentially everyone in the healthcare space. Star ratings are more unique, since they’re managed by CMS and apply only to Medicare Advantage plans.

HEDIS Compliance Incentives

For healthcare providers considering an effort toward maximizing HEDIS compliance, there really is no downside. Ensuring HEDIS measures are met appropriately can require additional systems and processes to be established, but the payoff greatly outweighs the initial effort. Maximizing HEDIS compliance ratings benefits patients by providing increased access to necessary care, and benefits your providers with rewards incentivized by a higher level of care.

HEDIS and Diabetes

HEDIS has a specific measure for diabetic patients called “comprehensive diabetes care,” which covers the most essential medical attention needed for diabetic patient plans.

Those measures consist of:

• Hemoglobin A1c testing (HbA1c poor control >9, HbA1c control <8)
• Blood pressure control (<140/90 mmHg)
• Eye exam (retinal) performed
• Medical attention for nephropathy

Since a retinal exam is an integral part of meeting these measures, proper eye care is essential for closing gaps in care. HEDIS ratings can be boosted by investing in technologies that make these preventative diabetic exams more accessible and easily administered by health systems and HRAs.

How Access to Retinal Exams Can Improve HEDIS Ratings 

Anyone with diabetes is at risk of diabetic retinopathy, and the risk increases with every year that an individual has diabetes. Diabetic retinopathy is one of the leading causes of vision loss and blindness in the United States. Early detection of the condition can be simple and cost-effective and can be done with non-invasive retinal screenings. These tests allow individuals and their healthcare providers to take steps to slow the progression of the condition. 

Eye exams are considered performance measures for diabetic care under both HEDIS and Star rating systems because they can improve outcomes for diabetic retinopathy. Improving access to retinal screenings can increase the number of patients who receive these exams. As a result, providers and payors can report those increases and improve their ratings for diabetic care. 

Why HEDIS and Star Ratings Matter

HEDIS and Star ratings matter because they indicate the efficacy of a healthcare organization’s patient care and a payor’s preventative healthcare measures. If you have gaps in care, HEDIS ratings will drop. Closing those patient care gaps and boosting the frequency of preventative screenings will help you improve your HEDIS score.

Another reason healthcare organizations and insurance payors should focus on keeping their HEDIS and CMS Star ratings up is because of their effect on potential funding. If an organization has high healthcare Star ratings or HEDIS ratings, it could see a boost in funding. But if an organization or has low ratings, it could struggle to qualify for reimbursement and face financial penalties. For example, organizations with less than four stars do not qualify for bonus payments. Low ratings can also cause third-party entities to be less likely to renew contracts or partnerships with these healthcare organizations.

To give an idea of how much a health system or HRA organization has to gain from a high HEDIS or CMS Star rating, a health plan with 100,000 members would qualify for $17 million in reimbursement for each quality measure taken.

So what’s the best way to close HEDIS gaps and boost HEDIS and CMS Star ratings?

How HRAs are Improving NCQA HEDIS and CMS Star Ratings with IRIS

To close gaps in care, HEDIS-based organizations and HRAs are starting to administer preventative screenings through at-home test kits, home health visits, and screening events. This makes it easier to ensure the closure of care gaps because it removes the need for patients to make it to an in-person doctor’s appointment. Patients benefit because they can receive screenings in a convenient manner, providers benefit because their HEDIS ratings go up with every screening performed, and insurers benefit because the chances of catching the development of a more serious condition are higher.

The IRIS solution helps healthcare systems and HRAs close gaps in patient care through at-home screenings because it allows for the portability of the diabetic retinal exam (DRE), with no ophthalmology appointment required.

It all starts with a portable fundus camera used by an IRIS-trained HRA employee. Once the fundus image is captured, it is sent to the IRIS cloud, enhanced by our proprietary algorithm, and delivered to the IRIS Reading Center (IRC), where the image is interpreted by one of the IRC’s licensed eye care providers. The results are then available to the healthcare organization, who returns comprehensive results to the patient, the patient’s health plan, and the patient’s primary care provider.

Improve Your Preventative Screenings with IRIS Today

For years, IRIS has been working with in-home health evaluation organizations, HRAs, and HCPs to improve HEDIS and STAR ratings by making it easier for patients to receive eyesight-saving examinations. Our image-enhancing technology, paired with portable fundus cameras, makes diabetic HEDIS measures easier to reach by helping providers meet diabetic patients wherever they are in their health journey.

Our solution is used by organizations such as Prisma Health and St. Elizabeth’s Healthcare. If you’re interested in trying IRIS yourself to close HEDIS gaps and improve CMS Star ratings, reach out to us today to schedule a demo.

 

Frequently Asked Questions

What is the star rating?

Star Ratings are methods of evaluating and distributing information related to Medicare Parts C and D health plan quality and performance. They provide insights into how well the health plans are currently performing in terms of adherence to established quality measures. 

What are HEDIS measures?

The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures applied to healthcare providers, facilities, and health insurance plans on important dimensions of care and services.

What is a HEDIS score?

NCQA conducts surveys of health plans and Preferred Provider Organizations (PPOs) using the Healthcare Organization Questionnaire. In addition, NCQA collects non-survey data via the Interactive Data Submission System. NCQA assesses the data to determine how well plans are meeting HEDIS measures and assigns a score based on the results. 

What are the main categories of Star rating measures?

Star Ratings measure plans across five categories:

• Health outcomes: Measures of improvements to a beneficiary’s health based on the care provided
• Intermediate outcomes: Measures that contribute to health outcome measures
• Patient experience: Measures of beneficiaries’ opinions about the care they’ve received
• Access to care: Measures of issues that may result in barriers to receiving care
• Process measures: Capture the ways health care is provided

How are CMS star ratings calculated?

Star Ratings are based on performance measures and surveys, including the CMS Health Outcomes Survey (HOS) and The Medicare Advantage and Prescription Drug Plan Consumer Assessment of Healthcare Providers and Systems (MA and PDP CAHPS). The performance measures are developed by the National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), and the Pharmacy Quality Alliance (PQA). 

How to improve Medicare star ratings?

Healthcare providers and health insurance plans can improve their star ratings by enhancing their performance on key measures. Increasing access to care and ensuring more patients receive high-priority preventive screenings is one strategy for increasing star ratings. 

 

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