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A Better Engagement Approach Can Close HEDIS Gaps


Medicare Advantage plans are facing a problem—high rates of gaps in care that affect HEDIS® (Healthcare Effectiveness Data and Information Set) quality measures … and ultimately revenue. The solution? Not just member engagement, but a strategic and multi-faceted approach to member engagement.

First, let’s talk about the HEDIS gaps problem

There is a huge amount of money at stake when HEDIS scores and CMS Star ratings for Medicare plans are low. In fact, a half-Star increase (for example, from 3.5 to 4 Stars), is valued at an estimated $500 per member. That means if a plan has 75,000 members, a projected $37.5 million in additional funding could be realized.

Unfortunately, when formulating a strategy for closing care gaps and raising HEDIS and Star scores, a few challenges quickly present themselves:

  1. Determining the right quality measures to target
  2. Formulating the right strategy that will achieve member buy-in and hit necessary ROI targets
  3. Encouraging feedback and cooperation among all engagement team members and partners
  4. Choosing the right team of people to lead the movement and the best tools for reporting on success
  5. Evaluating performance in an agile manner and adjusting quickly as necessary

This is a lot for any organization to take on, and missing the mark on any of these challenges can have serious consequences.

Why strategic healthcare outreach is the answer

At Carenet Health, we’re leading a healthcare engagement movement. Part of our methodology to do that includes offering a multi-channel, interactive, outcomes-based solution to closing gaps in care. This engagement approach is designed to deliver personalized and convenient experiences for consumers, which is exactly the approach Medicare Advantage health plans need to succeed.

A holistic, hyper-personal engagement approach at every member touchpoint has been proven to close critical gaps in HEDIS measures such as:

  • Annual wellness visits
  • Cholesterol, diabetes, and cancer screenings
  • Disease monitoring
  • And more

Simple approaches like reaching out to plan members with one phone call or one text reminder  aren’t typically enough to encourage healthcare consumers to make and keep appointments, especially when there are barriers to access, time constraints or patient fears. Even emailing or mailing comprehensive education materials to patients on the benefits of screenings often doesn’t work either. In fact, any piecemeal plan has a good chance of failing.

What closing gaps in care requires is an intelligent, data-driven strategy with multiple touchpoints and skilled engagement teams. When combined, those elements can produce substantial outreach ROI for health plans, while helping their members take the next evidence-based steps for optimal health and wellness.

A HEDIS case in point

Carenet Health has dedicated extensive time to solving this problem for health plans and other partners. In one instance, Carenet Health worked with a Medicare Advantage plan partner to close HEDIS gaps and the results speak for themselves, including closing 88,000 gaps in care and a 76% overall activation rate. To learn the details about how these results were achieved, download the full case study now.

If you’d like to find out more about our engagement solutions for Medicare, Medicaid and other populations, please reach out for a brief conversation to get started.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).