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Season 1, Episode 9




“The goal is to support consumers in making informed decisions about which plan to choose”

HEDIS hones in on 5 domains of care and measures whether the healthcare services rendered are actually improving conditions. The domains include effectiveness of care, access or availability of care, experience of care, utilization and resource use, and information about the health plan.

In the domain of access or availability of care, advancing health equity and improving quality of care for underserved populations is an up and coming topic that the NCQA is focusing on. There will be a requirement, tentatively set for 2024, for health plans to have race and ethnicity data on 80% of a health plan’s population. Health plans should be auditing their member information now to identify incomplete information sets and develop a plan for incorporating the right data into race and ethnicity stratifications. This data can be sourced directly or indirectly. Direct data comes directly from the member. For example, from a survey, enrollment information, or even requested from provider’s EMRs. Indirect data is the practice of using data for a purpose other than the reason it was originally collected, such as census data.

Another change we can expect from the NCQA is the shift to acquire more electronic sources for data collection. They’ve started to develop specific measures, Electronic Clinical Data System sets, ECDS. It’s not required today for the Medicare Advantage population, but this should be on every health plan’s radar because it will be a NCQA requirement in the future.

HEDIS data is valuable beyond HEDIS. Forward-thinking plans can leverage the output of HEDIS data to support CAHPS and HOS. The data can be pushed downstream to other areas of the business to provide member-level insights like member compliance for care management teams or member communications. This is where risk adjustment—closing gaps, health management, communications, and member experience intersect. This should be each health plan’s future goal—to have a holistic model where all business units are on the same page, fueled by the same data and working together towards the same goal. 

In this episode we'll discuss:

1:28 Contributions to overall Star Rating
2:30 New measures to keep an eye on
3:14 Health equity: race & ethnicity data requirements
5:35 HEDIS data sources
7:02 Provider mapping logic, ECDS, and HEDIS vendors
8:39 The value of HEDIS data beyond HEDIS

About Our Guest: Alyse Schwartz is the Director of HEDIS Analytics for Advantasure. Alyse holds a Master of Science degree in public health with a focus on epidemiology. She’s an experienced researcher and has been in the quality improvement space for over 10 years. 

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This podcast is sponsored by Advantasure—managed service and technology solutions for government-sponsored health plans.