How Common Health Plan Policies Can Negatively Impact HEDIS Rates

Linda Mackensen, RN, Director of Healthcare Transformation Health Plan Solutions

Here’s How Common Health Plan Policies Can Negatively Impact HEDIS Rates

Health plans are constantly balancing the needs of members, providers, purchasers, and government regulators while also taking steps to ensure their long-term financial viability. This often places health plan leaders in the delicate position of selecting medical policies that are both cost-effective and provide the highest possible quality of care. At the same time, there is mounting pressure to offer competitive premium rates for both the individual and group markets. Customers want to have maximum coverage for the lowest possible price. It’s no easy feat balancing each of these priorities.

The current value-based care environment demands that health plans perform well on HEDIS and other quality measures in order to retain their accreditation status, achieve top Medicare Star ratings, attract new customers, and retain existing customers. While quality is always top-of-mind for health plan leaders, there may be times when a health plan’s medical policies or benefit structures can have the unintended consequence of limiting the plan’s ability to maximize its performance on HEDIS and Medicare Star ratings.

Medical Advantage Group works with physician practices every day to improve quality and increase operational efficiency. Our practice consultants are talking with providers about the issues that are of most concern to them and gathering valuable insights for health plans each and every day.

Below are some of the systemic issues that impact provider and patient behavior in a way that might prevent health plans from achieving their HEDIS and quality goals:

  1. High-Deductible Plans

It can be extremely frustrating for providers to see patients who have insurance, but still cannot afford to get the care they need. This is true across every state, but especially in rural areas where patients are struggling to make ends meet. Providers understand what patients need to maintain their health and address their chronic conditions, but patients may delay getting the necessary services due to high out-of-pocket costs. It is not uncommon for health plans to have annual deductibles in the range of $7,000 per year for an individual, which must be met before the health plan will pay for any of the patient’s care. These types of policies can limit a patient’s ability to obtain necessary services to close gaps-in-care.

  1. Co-Pays for Essential Services

The same situation applies to co-pays. While many health plans have changed their policies to eliminate co-pays for preventive services, there are still co-pays for office visits, lab tests, prescription drugs, and many other services needed to manage a chronic illness. Health plans have an opportunity to create special programs or offer cost savings for patients to help them manage their chronic conditions and obtain the necessary services to improve their health, while also increasing the health plan’s HEDIS rates.

  1. Prior Authorizations and Referrals

Practices spend an inordinate amount of time on prior authorizations and referrals. Many practices have one FTE that is solely dedicated to these processes. One emerging trend that is especially challenging for providers is the requirement for prior authorization of generic drugs, in addition to brand-name drugs. It is especially time-consuming to obtain these authorizations, given the volume of prescriptions that are flowing through the practice. If health plans simplified the authorization and referral processes, providers would have more resources to dedicate to providing patient care and filling gaps-in-care, people who may be currently tied up in dealing with administrative paperwork.



  1. Formulary Changes

One of the main ways that health plans can manage costs is through their pharmacy benefit. Pharmacy benefit managers are always coming up with new programs to shift patients from one drug to another to take advantage of rebates and other offers from drug companies. While this makes perfect sense at the health plan level, it is confusing and frustrating for patients and providers. Often, the patient’s condition is not managed as well on the lower cost formulary drug, which means the required HEDIS results for lab tests and blood pressure may not be met. Physicians need more leeway and flexibility in the treatment of individual patients.

  1. Conflicts Between Evidence-Based Care and HEDIS Measures

Changes to HEDIS measures happen slowly and may lag behind trends in evidence-based care. Pap smears and blood pressure measures are just a few recent examples of when this has occurred. Physicians tend to treat their entire population the same and follow evidence-based guidelines, regardless of the payer. HEDIS may be viewed as an additional administrative burden imposed by health plans. The more payers can keep track of evidence-based care and offer providers cross-walks and other tools, the more likely they will be to obtain the desired results.

Of course, health plan policies are influenced by a wide variety of factors, other than just HEDIS and quality ratings. No matter which policies you choose, it is important to have clear communication with physician practices and offer assistance to help them implement the necessary operational changes seamlessly. That’s where Medical Advantage Group can help.

With years of experience supporting physician practices as they navigate through the ever-evolving health care environment, Medical Advantage Group has ‘boots on the ground’ in physician offices to help health plans maximize performance and determine the impact of their policies. Learn more about our health plan services and how we can help you achieve your performance goals.