HEDIS MY 2023: Prevention, Equity and Engagement
September 6, 2022

NCQA recently released the changes that healthcare plans can expect for 2023, including new measures and stratifications to improve equitable, quality care. Encouraging preventive care, better management of chronic conditions and identifying social needs is crucial in improving the quality of healthcare. 

These changes require a foundation of trust, engagement and monitoring support between beneficiaries and health plans and their provider networks. Health plans must build solid relationships, strategic partnerships and innovative solutions in order to improve quality scores and member outcomes. 

Boosting Prevention Activities

NCQA continues in its commitment to prevention activities. Two additional measures in 2023 include Oral Evaluation Dental Services (OED) for Medicaid members under 21 years of age and Topical Fluoride for Children (TFC). Oral health has been linked to chronic conditions such as diabetes, heart disease and stroke

Gaps in these and other preventive care services can indicate some level of disengagement with the healthcare system. There are many reasons for missed or unscheduled appointments and completed vaccinations; in order to improve these metrics, it’s important for health plans to understand why their members are not completing preventive care services. A new concept that has been emerging in the healthcare space–but well known in other spaces–is behavioral science, or an understanding of human behavior.

The New York Times best seller Atomic Habits explores how long term habits (behavior changes) are made. Health plans and providers can utilize this, and other behavioral science principles, by partnering with companies that focus on prolonged behavior change.

Companies like Wellth encourage not only one-time behaviors (like going to the doctor) but also longer-term health behaviors (like taking medications every day). Practicing daily health behaviors is a daily engagement with one’s health (or with one’s health plan). 

Managing Chronic Conditions

Diabetes and cardiovascular conditions continue to be a top priority for our nation. The Emergency Department Visits for Hypoglycemia in Older Adults with Diabetes (EDH) measure helps plans understand how well older adults are managing their diabetes through diet and exercise (and regularly checking blood sugar).  

Health plans and providers have employed many digital tools to support the management of diabetes. Strategic partnerships improving member engagement, medication adherence tools and reminder apps work well for people who need “a nudge”. For individuals that might require an extra push of motivation, behavioral science can inform the approach as it has for Wellth’s partners.

Wellth’s daily interaction with members is easy, fun and effective in assisting members with diabetes improve their A1c and ultimately lower ED utilization. Programs such as Staten Island PPS yielded results of 92% reduction in avoidable ED Utilization and A1c decrease of an average of 1.29. Wellth has supported health plan partners with programs for members with multiple chronic conditions. Over the years Wellth has averaged a 43% average reduction in high-cost utilization and 90% daily adherence in their members.

Daily engagement with beneficiaries, home monitoring and other technology can improve health outcomes beyond the measure. Deprescribing of Benzodiazepines in Older Adults (DBO) is an issue that deserves attention.

The American Geriatrics Beers Society recommends that benzodiazepines be avoided for adults over 65 because of their ability to impair cognition and mobility while increasing fall risk. This measure is an effort to decrease existing prescriptions, avoiding withdrawal, until the medication can be completely de-prescribed. 

Like many medication measures, the intent of the measure is challenging to “prove”. Knowing if prescriptions are picked up is one issue, while knowing which medications are actually taken is another issue altogether. Adherence based digital health platforms remind people to take their medications, but follow-through is unknown. 

Programs that combine human support with technology can work to improve results and get to know what happens after prescription pick-up. Daily habit building through a platform allows for a scalable solution, while live support encourages accountability and commitment. The use of AI can catch any discrepancies in dosage closer to real time, supported by individualized outreach to address any necessary questions or concerns. Wellth’s understanding of human behavior and motivation supports plan offerings to improve medication adherence across multiple measures. 

Engagement & Trust

Social determinants of health and health equity are more than buzzwords as NCQA introduces new measures and stratifications in 2023. The Social Need Screening and Intervention (SNS-E) measure will help plans assess and impact their members’ access to food, transportation and housing. 

NCQA added race and ethnicity stratification to a handful of measures and plans to expand over the next several years. Understanding measure results by race and ethnicity will help to create personalized, culturally appropriate responses to care. 

As with other screening tools, complete and accurate results require a level of trust and consistent engagement with plan beneficiaries. Engaging members is a challenge due to inaccurate contact information or call screening or due to socio-economic challenges such as membership who is unhoused or lacks minutes on their cell phone plan. Plans work with partners, community organizations and supportive technology can improve engagement and agreement to participate. 

Once members are contacted, they may not trust that the health plan is there to help, or they may not understand why the information is required. Trust is built over time, with compassionate support staff and consistent communication. Meeting members where they are, listening to their concerns and letting them know why you are asking questions about race/ethnicity and social drivers of health is foundational. Further supporting them with new portals, apps or other technology is worth the time and investment. 

NCQA is moving toward gender-affirmation by acknowledging that non-female identifying patients may experience pregnancy and childbirth. This is a solid first step to creating safety and trust within the membership and enhancing the care experience. NCQA contends they will “explore other ways to make measures inclusive and affirming of sexual and gender minority members.” 

Digital health platforms have opened new (digital front) doors for member engagement. Through consistent and personalized outreach, health plans show that they are invested in their members and their outcomes. Innovative partnerships and digital tools can overcome engagement barriers and lay the groundwork for better, trusting relationships. 

Addressing engagement is a big picture issue as it is the smaller behaviors along the way that lead to the habit changes over time in a flywheel effect that ultimately turns out the improved results and participation health plans are looking for.

As measures change in an effort to improve quality of care and health equity, health plans need to focus on forming the most strategic partnerships to carry them into the future. 

In order to keep up and continue to improve their member experience, explore solutions that encourage trust, member engagement, health equity, and provide timely intervention as close to real time as possible. 

Wellth offers many diverse solutions to health plans that are member centric and results driven. To learn more, contact us today.