Case Study & ROI Analysis

Capital District Physicians’ Health Plan, Inc (CDPHP®) 2024 Case Study: Accelerating Quality Improvement with Astrata’s Digital Quality Solutions

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Impact of using an AI-driven prospective HEDIS solution on clinical quality rates, labor costs, and operations

ABOUT CAPITAL DISTRICT PHYSICIANS’ HEALTH PLAN, INC (CDPHP®)

Founded and led by physicians for 40 years, CDPHP is a locally-based, not-for-profit health plan with main service areas in the Albany and Hudson Valley regions. CDPHP Provides health care coverage to nearly 400,000 members across all lines of business (commercial, self-funded, and government programs) in 36 counties in upstate New York. CDPHP Value-based payments reward providers for quality performance, member experience, and desirable clinical outcomes.

As a high performing health plan (4.5 – 5 Stars for all product lines), CDPHP quality programs are data driven, and guided by the CDPHP Board of Directors and Quality Management Committee. “Drive to 5” is an enterprise-wide theme, encouraging employees to think about HEDIS as an everyday activity. As NCQA measures transitioned to more ECDS measures, CDPHP began using NLP to supplement data as a first step towards a full DQM solution.

CDPHP BUSINESS GOALS

DRIVE TO 5

Increase HEDIS Quality Rates for Key Populations
Reduce Labor Costs to Scale Prospective Review
Decrease Provider Documentation Burden
Avoid Member Abrasion
Accelerate and Simplify Hybrid Season

CDPHP BUSINESS PROBLEM

SCALING PROSPECTIVE REVIEW

CDPHP sought to leverage unstructured clinical data to enhance their quality improvement programs. CDPHP was already performing prospective HEDIS review across a smaller number of measures and members, using internally-developed natural language processing (NLP) software. However, scaling the internal solution to a larger number of members, across different measures and data formats was challenging. CDPHP selected Astrata’s Chart Review solution to take their prospective review program to the next level.

Key Metrics

CDPHP first engaged Astrata in 2023 to help them scale their prospective HEDIS season. Over a period of 2 months in 2023, CDPHP closed over 15,000 gaps.

96.8%

Agreement of CDPHP abstractors with gap identified by Astrata as compliant

94%

Percentage of noncompliant member encounters that did not require manual record review by CDPHP abstractors

11.1%

0.1%-11.1% – Measure Dependent

Unique additional HEDIS compliance from Astrata source obtained in 2023

Per Hour

Median Gaps Closed Per Hour With Chart Review

Per Hour

Gaps closed per hour (Historical, Without Chart Review)

Solution Overview and Summary of Impacts

CDPHP first engaged Astrata in 2023 to help them scale their prospective HEDIS season. Over a period of 2 months in 2023, CDPHP closed over 15,000 gaps.

CHART REVIEW
NLP-powered chart abstraction

Ingests PDF charts, HL7 and other formats to analyze entire medical record
Classifies gaps as Hits, Exclusions, Leads or none of these.
Guides reviewers to gaps and encounters that produce the most value
Provides abstraction interface for reviewers to confirm service details and close gaps
Produces non-standard supplemental file
Works with any HEDIS engine

DATA FLOW

CDPHP implemented the standard Astrata data flow using our cloud-based product. Astrata’s products are designed to fit cleanly into existing data flows, and integrate easily with any HEDIS engine.

MY 2023 Snapshot

Strategic measure and population selection is an important yearly activity for establishing a successful HEDIS prospective season

High Abstractor Agreement

Percentage of gaps where abstractors agreed with the Astrata classification and were able to close the gap.. Percentage agreement directly correlates with the value of the product to a prospective review season.

Gold Standard Accuracy

Assesses False Positives and False Negatives using an annotated “gold standard” on customer data. Provides the most rigorous yearly assessment of NLP accuracy, and is used to monitor and increase accuracy for each customer prior to yearly release.

Reduced Abstractor Workload

Percentage of Members, Gaps and Documents (encounters) that were triaged for review. Quantifies the reduced workload of using the Astrata Platform.

Increased Abstractor Speed

Speed of Gap Closure (gaps closed per hour) By Abstractors using the Chart Review product. Used to compare against baseline speed and model averted costs through marked efficiency gains.

Multiple mechanisms contribute to the increase in HEDIS rates observed when performing prospective review during the measurement year. Impact will be proportional to the fraction of population and data used.

Uniquely Impacts HEDIS Rate

Measures the unique rate impact of the Astrata implementation on a smaller dataset and population in Year 1, and then extrapolates impact across population.

Highest Specificity NSSD Source

Gaps closed by the CDPHP HEDIS engine as a percentage of the total data loaded. quantifies the reduced effort that must be expended on non-standard Supplemental (NSSD) Data source review compared to alternatives.

COL Impact

Colorectal Cancer Screening (COL) is important in preventing the second-leading cause of cancer death, and is a CMS Medicare Advantage Star Rating measure. Once a hybrid measure, Colorectal Cancer Screening (COL) is now “ECDS-only”. This measure is highly susceptible to under-measurement because of the long look-back period and prevalence of this data within free text fields and clinical notes.

A two percent increase in the COL rate represents over 2,200 members with a closed care gap, which supports gap list accuracy and prevents wasteful and unwarranted member outreach and provider attention.

WCC Impact

Weight Assessment and Counseling for Nutrition and Physical Activity of Children/ Adolescents (WCC) is a a key NY state Medicaid measure that addresses the growing epidemic of childhood obesity. As of 2024, WCC remains an NCQA hybrid measure, abstracted yearly. However, improving pediatric health is a year-round effort at CDPHP.

CMS has set 2030 as the date for health insurers to transition to digital quality measurement, closely aligned with the goal for all Medicare and most Medicaid beneficiaries to be in an accountable care relationship by that time.

This timeline also aligns with ONC interoperability requirements. A complete digital quality platform supports faster, less-burdensome and more accurate healthcare quality measurement.