Succeeding with your MY25 Prospective HEDIS Programs

Clock Management

Just like football, success at Prospective HEDIS is all about clock management. Except your clock is measured in measurement years instead of 15-minute quarters. And to make it even harder, until hybrid season goes away, you are really being asked to manage two clocks at the same time – one for your backward-looking reporting year, and one for your forward-looking prospective year. The first thing to understand is how these clocks interact, and what new responsibilities you are adding as you take on the prospective clock.

Of course, we are all well aware of the hybrid season clock, with its complex set of timelines and deliverables – from auditor timelines to staffing up to supplemental deadlines. That’s the devil you know! Now what about the devil you don’t know? How do you manage your prospective clock even as you ramp up your first prospective year or expand your subsequent years?

As usual, it’s best to work backwards.

Most prospective programs are focused on finding out as quickly as possible who your truly non-compliant members are during the MY, so that you focus your valuable resources on closing these gaps. That’s why forward-thinking health plans are trying to maximize the amount of time they have for prospective review. Practically speaking, certain things have to happen before you can start your prospective season: (1) you need a team which generally means waiting until your hybrid season is complete, (2) you need to be able to generate gaps for the current MY (regardless of when your actual HEDIS engine turnover occurs), and (3) you need your prospective review software to be ready with new measures and deployed on your data. Best case scenario, you could be starting prospective review in the Spring and finishing up by December or January. Achieving at least a 6-month prospective HEDIS season puts you in excellent shape to see solid impact.

If you’re starting prospective HEDIS abstraction in June, you’ll need to expect at least 6-8 weeks for technology deployment. Ideally, that means you’ll want to have implementation beginning in April. Many plans are finding that scaling prospective HEDIS is almost impossible without NLP technology, like Astrata’s innovative Chart Review software. That implementation period includes tuning to customer data, mapping to your HEDIS engine codes, and training your staff.

To get your tech deployed in time, the optimal prospective planning time is from January – April, which of course is exactly when the chaos of hybrid season is landing on your desk. How do you manage? This is one of the hardest aspects of this transition. If you’re a quality director or above, it means you need to reserve some of your time to manage the major aspects of prospective planning while simultaneously helping your team manage the chaos of chart chase and hybrid review. The good news is that as hybrid measurement fades away, you will eventually be able to focus all of your time on the prospective clock.

Now let’s unpack the key decisions to make and actions to take during that all important Q1 of the prospective year.

Q1 Planning Essentials

If this is your first year doing prospective review, we hope you actually started planning last year. But if not, contact us to learn more about Astrata’s quick start plan. I’m going to assume that everyone else has already got the basics in place. In Q1, the most important steps are

• Review last year’s results. You should expect your NLP vendor to provide a summary of last year’s results including NLP accuracy, abstractor agreement, and data issues encountered. Add this to the data you’ve got on source impact to determine what improvements you want to make and where you saw the most value. And be sure to set aside time to review with your key quality and technical leaders.
• Plan new data sources. Adding new data sources takes time. Whether it’s coming from an internal source, HIE, payer provider platform, chart chaser, or as a direct feed from one or more provider groups, you should expect a lag of several months. Make sure you to prioritize new data sources and get them into the integration queue way in advance of your prospective year start date. You can learn a lot more about how to manage the data aggregation aspects of prospective review with Astrata’s clinical data toolkit.
• Select highest priority measures. Your measure priorities change yearly, and you should expect that to impact your measure selection for Prospective HEDIS too. Which measures are next to come out of the hybrid method? Where did you narrowly miss or hit your thresholds from last year? What measure spec changes put you most at risk? Where could new data sources have meaningful impact on specific measures? Work with colleagues from business lines and your NLP vendor to determine the right mix of measures for the coming year.
• Complete contracting with your prospective HEDIS tech vendor. If you’re already partnered with a prospective review tech vendor, be sure to get your next MY measures ordered and communicate your expectations for new data sources. Determine what contractual additions or changes are needed. This should not be a difficult process, but it’s key to ensuring you can hit the ground running when it’s time to start your prospective HEDIS season.

Getting to 2030

This is a complex transition and it’s easy to get lost in the trees and not see the forest. Success at Prospective HEDIS is just part of a larger transition to fully digital HEDIS measurement. Four key areas of focus should guide your long-term planning

• Keep adding data. The value of prospective review is tightly tied to the chart volumes you can process. You should track the volume of data you are processing over time, and set yearly targets for volume expansion.
• Stay up-to-date on hybrid retirement. NCQA recently published their timeline for hybrid measure retirement. It’s critical to keep up with any changes and plan a set of efforts (including other supplemental data sources) to meet these timelines.
• Start planning your road to digital. Remember that ECDS is just the first step in a longer journey to fully digital measurement. As HEDIS moves to FHIR and CQL, we see major upsides for health plans including more rapid deployment of new measures, faster and more accurate HEDIS measurement, and likely higher rates. But this is a big tech change too. What will these new-fangled HEDIS engines look like? Check out Astrata’s eMeasure digital HEDIS engine – one of the very first native FHIR and CQL HEDIS engines. And learn how you can use a maturity model to move your organization forward on this journey.