Guest Column | October 11, 2019

3 Steps For Improved HEDIS Scores

By Jessica Schiller, RN, BSN, Wellframe

Rising Hospital Safety Scores In Health IT

According to the Kaiser Family Foundation, 72 percent of Medicare Advantage members enrolled in plans with 4 or more stars in 2019. Plans that fell below 4 stars took a financial hit from decreased enrollment, reduced ACA rebates, and lost ACA bonus payments.

To capture valuable enrollment revenue and additional bonus payments, organizations should consider a new health management approach that will help them score high marks on this year’s measures. The following steps position health plans for Medicare Star Ratings success:

  • Step 1: Deliver omni-channel support to help health plan members stay healthy
  • Step 2: Support the whole person to help health plan members manage chronic conditions
  • Step 3: Make the system easier to navigate to improve the health plan member experience

Step 1: Deliver Omnichannel Support To Help Members Stay Healthy

This falls into the Star Ratings category: Staying healthy: screening tests and vaccines.

In the smartphone era, health plan members want options for convenient, omni-channel support when it comes to managing their health and care. They have voiced a preference for mobile messaging, so they can respond on their own time. This also provides the opportunity for more frequent support and guidance, rather than intermittent calls.

This shift to omni-channel health management rewards care managers as well, giving them the effective tools they need to develop long-term, trust-based relationships with their members, which can help organizations more effectively earn higher Star Ratings.

By meeting health plan members on their terms and providing value up-front, care managers can hold members accountable for reaching their health goals, scheduling follow-up appointments, and taking actions that help improve Star Ratings for screenings, vaccines, and other check-ups.

Step 2: Support The Whole Person To Help Members Manage Chronic Conditions

This falls into the Star Ratings category: Managing chronic (long-term) conditions.

In order to successfully address this heavily weighted category, plans must think beyond today’s episode-driven approach to chronic disease management. Instead, plans should focus on encouraging members to adopt a new perspective on the factors that contribute to their overall health. By delivering personalized, long-term health management support that addresses both social and clinical determinant needs, as well as comorbidity, organizations are in a better position to succeed with these critical measures.

Meet Both Clinical And Social Healthcare Needs

To improve Star Ratings, plans must support the whole person, not just the chronic condition—that means addressing lifestyle and socioeconomic factors that are critical to improving health. Plans should utilize interactive surveys to screen for social determinants such as transportation, financial concerns, social support, and safety that may act as barriers to medication adherence and better health management. Healthcare organizations should then deliver personalized health education tailored to those social needs, within the context of their clinical needs, so the health plan member can visualize how therapeutic lifestyle changes can have a positive, direct impact on health.

Address Comorbidity With Comprehensive Clinical Programs

One in four Americans have multiple chronic conditions* so plans must avoid treating diseases independently of one another and instead deliver support that addresses overlapping symptoms simultaneously. Consider offering a broad range of clinical programs in a single solution to support multiple chronic conditions like diabetes, COPD, asthma, and more, as well as transitional care and behavioral health.

When health plans deliver holistic, comprehensive support that is personalized to members’ needs, members will feel more engaged in their clinical program, and have a better understanding of why tests and treatments are needed—making the plan better positioned to improve Star Ratings for chronic disease management.

STEP 3: Make The System Easier To Navigate To Improve The Member Experience

This falls into the Star Ratings category: Member experience with the health plan.

Members’ experience with a health plan is another critical component of an overall Star Rating. But when it comes to getting health plan member questions answered and needs addressed, many members often encounter a confusing, overwhelming experience with the plan.

To ensure organizations can improve ratings on Medicare’s member experience survey, consider implementing a coordinated, unified concierge service to reduce frustration and better meet the member’s needs.

The Concierge Approach

Appointment booking, finding the right provider, and verifying coverage for medication or appointments are often major obstacles to getting needed care or maintaining healthy behavior. As a result, members may postpone care or make choices that are not cost or quality effective.

The integrated concierge reorganizes and unifies engagement around the goals of the member, providing them with a single resource to address diverse needs. Always accessible by mobile app, the concierge develops a long-term, trusting relationship to help match members to healthcare resources, such as finding a specialist, getting transportation to appointments, and more.

By giving the member a clear point of contact for the plan and addressing and prioritizing their needs, health plan members will feel better supported, and more likely to respond positively on the overall rating of their health plan.

About The Author

Jessica Schiller, RN, BSN, MAS serves as the Director of Clinical Programs at Wellframe (, overseeing the creation of their evidence-based portfolio of clinical programs. She focuses on improving care coordination and quality through innovative interventions and care models. Her nursing expertise spans blood cancers, bone marrow transplant care, palliative care, chronic healthcare management, health across the lifespan, and socioeconomic and racial disparities in care.

Reference: *County Health Rankings