How to take your HEDIS strategy from reactive to proactive


HEDIS (Healthcare Effectiveness Data and Information Set) measures are designed to track health plan performance and improvement across several key domains. This includes preventive care, chronic condition management (for physical and mental health), access and availability of care, patient experience, healthcare utilization, and more.  

Reporting on HEDIS measures requires health plans to analyze clinical and member engagement data—encouraging them to enhance their offerings to meet performance goals. Health plans may face a number of challenges in meeting HEDIS measures, such as: 

  • Reaching members to ensure they get necessary (and preventive) care. It can be challenging to encourage members to get needed services through traditional channels. About 43% of health plan members said they don’t understand their insurance benefits—which means they are less likely to use them. Meet members where they are with accessible resources to improve access to key services and help members understand the value they provide. 
  • Lagging claims data. To evaluate member populations and analyze outcomes, health plans typically rely on claims data. If your health plan primarily relies on medical claims to evaluate performance, you could be left with an incomplete picture of members’ needs outside the walls of care delivery. Having access to members and their information in near-real time can enable your health plan to see your impact and adjust your strategy sooner. 
  • Siloed delivery efforts. Coordination across departments can be difficult for many health plans, as it requires time and resources across care management, quality, customer service, and other areas to close gaps in care. Integrated digital solutions can help unify your clinical and administrative teams’ approach to member support by breaking down internal silos and facilitating communication internally and with members. 

Forward-looking health plans can break this cycle of reactive change. By tapping into the digital solutions your plan has access to, you can succeed with ever-evolving HEDIS measures and position your quality initiatives as a competitive differentiator.  

How health plans can shift their HEDIS strategy from reactive to proactive 

Focus on long-term engagement to avoid the chart chase 

To prevent care gaps and support your quality performance, your members need ongoing personalized guidance and education between healthcare encounters. Providing this level of support with intermittent outreach is difficult. So how can your health plan deliver holistic support to members, that’s relevant based on factors like age, gender, and condition? 

Consider offering your members a convenient digital channel that offers preventative education, such as articles, videos, and daily reminders. Wellframe’s digital care management surfaces a daily checklist that encourages members to take their medications, track biometrics like blood sugar, and read articles with information on managing their condition.  

Take the HEDIS Breast Cancer Screening measure, for example. Care teams can deliver mobile articles on the importance of this screening and why it’s needed. Plus, the care team can leverage 1:1 HIPAA-compliant messaging to reach out to members and hold them accountable. This also allows members to reply on their own time without waiting on the phone.  

By offering proactive support in the context of a trusted clinical relationship, members will build a better understanding of why certain appointments, vaccines, medications, or screenings are needed—and your organization won’t have to scramble to ensure members get needed care. 

Uncover barriers and close gaps in care

Digital health management solutions can provide channels for more frequent member engagement. They offer members a convenient way to reach out to their care teams and benefits managers, while helping uncover care gaps through digital surveys and assessments. 

For example, a member with access to Wellframe may read a health education article on the same platform where they answer surveys from and exchange messages with their care teams. Having care navigation resources in the same place empowers members to share more about their needs that extend beyond medical health—including social determinants of health (SDOH) information, like transportation, employment status, and food access.  

Care teams can also uncover SDOH information through digital surveys and assessments. Members are more likely to answer a mobile survey than fill out and return a survey by mail. Some members may also be more willing to disclose information through a digital survey than through a telephonic or in-person survey. Plus, members can complete a digital survey at their own pace, without feeling rushed. 

Digital care management programs can also include regular assessments to help members and care managers to track their progress and uncover care gaps over time. A digitally enabled platform can help alleviate the typical barriers that limit the exchange of key information.  

Unify engagement to improve experience and get a full picture of members’ needs 

Identifying and targeting gaps in care often requires collaboration across health plan teams to deliver the unified experience members expect. The right technology should position staff to view vital information like member interactions, health history, and conversations, as well as work cross-functionally to address member needs.  

To inform member outreach, digital platforms must quickly and efficiently surface known care gaps to teams as well as track progress, identify next steps, and encourage members to address these health needs. It’s also critical to ensure staff efficiency with time-saving capabilities. For instance, personalized group messaging can help staff reach more members in less time than mail campaigns or telephonic outreach alone. 

From the member’s perspective, this strategy reorganizes support around their health goals, providing them with a single resource to address their diverse needs. Whether that means finding a specialist, getting transportation to appointments, or simply finding answers to their benefits questions, members will feel better supported and more likely to respond positively to the overall rating of their health plan.  

One member’s journey: Proactive quality improvement

Key takeaways 

The right digital health management strategy can help health plans think beyond box-checking on quality measures. By reimagining the types of relationships organizations can build with their members, they will not only drive their quality performance, but can position their proactive capabilities as a strategic advantage to customers. 

Is your health plan focused on improving quality performance?

HEDIS is just one aspect of quality improvement. If your organization is looking to raise your Star ratings, check out our eBook, “Star Ratings guide: Three steps to improved scores.”