Measuring Quality in Healthcare

The Challenge

Every healthcare organization’s quality ratings tell a story. They reflect how well you know your patients and members, how effectively you reach them and whether the care you deliver truly meets current quality standards. That story has real financial and reputational consequences. A half-star drop in Centers for Medicare & Medicaid (CMS) Star Ratings can translate to millions in lost revenue and incentive payments.  Equally important, poor-quality scores can erode trust with members and jeopardize plan selection during open enrollment.  

In our new guide, Why Knowing Your Patients and Members Can Improve Quality Ratings, learn what it takes to build stronger, more connected relationships with your patients and members. Discover how investing in this work can boost health outcomes, equity and satisfaction and improve your bottom line. 

The Stakes Have Never Been Higher

Medicare Star Ratings and the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) are used for measuring quality in healthcare. These measures now influence nearly every aspect of healthcare operations. These measures of healthcare quality are used to:

• Assess the quality of health and drug plans
• Identify and close gaps in patient care
• Inform employer and employee choice of plans during benefits decision-making
• Improve reimbursements and monitor compliance for value-based incentive programs

An increasing focus on health outcomes and equity is further intensifying the pressure to achieve strong performance on measures of healthcare quality. The CMS Excellent Health Outcomes for All (EHO4all) reward factor will further raise the bar. EHO4all incorporates social determinants of health (SDOH) data, such as dual-eligible status, low-income subsidy (LIS), disability and geographic location, as key factors in adjusting CMS Star Ratings and determining incentive payments.

At the same time, members are increasingly savvy healthcare consumers. They expect personalized, seamless experiences. These expectations are shaping how—and whether—they respond to patient experience surveys, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey. 

With more than 68 million people enrolled in Medicare, and over 200 million lives tracked through HEDIS measures, the pressure to perform is high.  That is why achieving better scores on HEDIS measures and CMS Star Ratings requires stronger relationships with your members. And that begins with accurate, comprehensive member data.

The Hidden Barriers to Member Engagement

If your healthcare organization is struggling to connect with members or better understand their unique needs, it may not be a communication problem. It’s often a data problem.

Millions of members change addresses, jobs, phone numbers and health plans each year. New health plan members often arrive with incomplete or outdated personal information and medical histories. With inaccurate, out-of-date data, health plans can’t conduct outreach about preventive screenings, close care gaps or boost patient experience survey response rates.

Some of the people most in need of support, such as those facing housing instability or lack of transportation, are often more likely to fall through the cracks. These gaps in social determinants of health data make it harder to address healthcare disparities, reduce hospital readmissions and emergency department use, and improve medication adherence. 

These engagement barriers also hinder performance on patient experience measures. Surveys like CAHPS provide a key opportunity to improve HEDIS scores and Star Ratings, but only if a sufficient number of members complete the survey. With average response rates hovering around 33%, plans need comprehensive data and thoughtful outreach strategies to ensure members not only receive the survey but also feel motivated to participate.

Ultimately, these data gaps put your HEDIS scores and Star Ratings—and your members — at risk.

The Cost of Not Knowing

When data is incomplete or inaccurate:

• Preventive screenings go unscheduled
• Hospital readmissions rise due to unidentified social risk factors
• Medication adherence drops
• CAHPS surveys are ignored or generate negative feedback

These issues have a direct impact on your HEDIS scores and Star Ratings. And with an increasing industry focus on reducing disparities in healthcare access, quality and outcomes, the financial consequences of poor quality ratings will only intensify.

The Solution

Although there is more pressure than ever, the way to better quality scores hasn’t changed over time: 

• Optimize engagement with a whole person perspective to help improve HEDIS scores.
• Improve patient experience to improve CAHPS (Consumer Assessment of Healthcare Providers and Systems) scores for provider organizations.
• Reduce hospital readmissions to lower costs and improve CMS Star Ratings.
• Ensure partner pharmacies are taking measures to support better CMS Star Ratings.

Having the right and up-to-date data is a must to help manage quality scores effectively. Especially since the EHO4All is requiring identification of certain populations.

• Remove the first barrier to engagement, out of date contact information, by correcting and enriching your own data.
• Gain a whole-person view of your patients or members with social determinants of health data. This allows you to address special risks and engage with relevant, targeted messaging.
• Improve patient experience through industry-leading identity verification and authentication solutions that work together to address digital experience and risk-appropriate security.

The goal is to help members live healthier lives. Supporting better health outcomes is clearly better for members, but good for payers too. According to an EY survey, 85% of healthcare organizations report better health outcomes and 75% of them reported financial savings specifically based on efforts to identify and close care gaps.*

*Optimizing Health Outcomes for All, https://www.ey.com/content/dam/ey-unified-site/ey-com/en-us/campaigns/health/documents/ey-final-optimizing-health-outcomes-for-all-report.pdf

Key Takeaways 

1. The pressure to perform on HEDIS measures has increased, making it necessary to find new ways to improve HEDIS scores.
2. Engaging patients and members is necessary to receive survey responses and create a relationship that encourages positive reporting. 
3. A strategic communication plan is needed to reach the right people with relevant messaging about the right care. This requires a panoramic view of your patients and members.