Risk Adjustment

Four Steps to Improve Your Health Plan’s Quality Performance

It takes effective and targeted interventions at the member and provider level. It takes efficient processes. And it takes a strategy to close care gaps. It’s not a process that happens overnight, but with these four steps and the help of Analytics, a health plan can boost its Quality performance.

Know Your Current Quality Rating and Set Next Steps

First, payers and providers must know their current Quality performance. Once that’s established, they’ll need to set goals. Where do they want their scores and ratings to be? And furthermore, what’s the best way to get there?

Start by evaluating Quality programs from a high level. Identify any overlaps that exist among the various HEDIS, STARS or state-specific data sets. These overlaps will provide an opportunity to improve efficiency and determine how best to use finite resources for the strongest Quality outcomes.

Target Providers and Members Who Need the Most Help

With finite resources, health plans need to know where to devote them. When it comes to improving Quality, health plans should strategically target providers and members who need the most help. Those that need the most help are those with the most Quality gaps in delivered or received care. Health plans need to know which members and providers to intervene with and what to ask. With powerful targeting capabilities, Analytics can help create a data-driven action plan that addresses the members and providers most in need by tailoring effective interventions.

Identify the Right Providers for the Right Interventions

Communicating provider-specific rates is the first step to improving collaboration with providers. Sharing data such as HEDIS or prospective HEDIS rates with providers can help them monitor progress and target patients proactively. Using Analytics, payers can determine the combination(s) of measures that must be improved to achieve an overall HEDIS, Star Ratings or other state-specific goal.

Payers can also use Analytics to drill down to determine which providers are underperforming and develop a strategy to address the issue. Through internal benchmarking, plans can compare and rank providers within peer groups to help highlight provider practices with low measure compliance. In addition, health plans can leverage risk profiles to identify differences in member health status across practices.

Identify the Right Members for the Right Interventions

With Analytics, payers can also focus in to the member level and identify who meets numerator and denominator criteria as well as who doesn’t. Once a plan determines which members are non-compliant on which measures, Analytics can pinpoint beneficial interventions. Analytics can also help plans identify any connections between underperforming providers and members with gaps, which may indicate deeper root causes. If so, provider interventions may lead to process improvements.

Following these four steps will lead a health plan to increased Quality performance. With the help of Analytics, a health plan can more easily determine the best strategy to close care gaps at the member and provider level. Not only that, Analytics will help identify better processes. Armed with effective and targeted interventions and more efficient processes, a Health plan’s Quality performance is well on its way to improvement.



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Presentation @ RISE VBC: Effective Collaboration Strategies Between Payer & Provider