How Care Navigators can help payers close care gaps and improve HEDIS scores

The Healthcare Effectiveness Data and Information Set (HEDIS) is used by more than 90% of healthcare payers as a means to assess their performance. HEDIS is important to payers because it impacts their reimbursements rates from the Center of Medicare and Medicaid (CMS), which accounts for one third of all healthcare spending in the US. Simply put, better HEDIS scores mean more money for the payers – and better patient outcomes.

There are 90 HEDIS measures ranging from prenatal care screenings rates to mental health utilization rates to lead screenings rates. One of the biggest areas of focus for payers to improve their HEDIS scores is to close care gaps by increasing preventative screenings rates, e.g. colonoscopies, mammograms, diabetic retinopathy, annual wellness visits, etc. Let’s look at colonoscopies as an example.

Colorectal cancer (CRC) is the second leading cause of cancer deaths in both men and women in the United States, with one in 20 Americans developing colon cancer in their lives. Yet, if caught early, the survival rate of CRC is 90%. To detect and prevent CRC, it is recommended that patients have a colonoscopy at least once every ten years, starting at age 50. It has been found that a single colonoscopy can reduce the rate of CRC by over 50% in a single induvial. This is an easily preventable form of cancer, but the national screening rate is only 63%. However, for low income, un-insured, under-insured, and immigrant patient populations, the screening rate is much lower, only 30%.

Depending on the size of the plan, payers could be spending anywhere from hundreds of thousands to millions of dollars trying to improve their preventive screening rates. Typical strategies include phone and mail campaigns to convince members of the importance of preventative screening visits. As evidenced by the anemic colonoscopy rates, these campaigns fall short because they only take the first step of awareness, but don’t take the second step of action. Research shows that by making a patient appointment on behalf of the patient, the likelihood that the patient goes to that appointment increases by more than 60%.

One of the most effective ways to improve preventative screening rates is to employ care navigators to reach out to patients on behalf of the plan. After a care navigator, either employed by the plan or a third party, convinces the member that they should seek a preventative care appointment, the care navigator needs a tool to help them find and schedule the best in-network specialist for the member. The care navigator needs to find a specialist that takes the member’s specific insurance, is in a convenient location for the member, and has convenient availability. This requires partnering with a company who works with specialists in local markets to get them to upload schedule availability for the plan’s members.

After the care navigator schedules the member’s appointment, there are a number of strategies that can be employed to help increase the likelihood that the member will show up to the appointment. For example, the scheduling (referral) system can send the patient text and email confirmations at the point of booking, the day before, and the day of the appointment (adding a same day appointment reminder has been shown to increase show rate by an additional 25%). The care navigator can send a physical confirmation and educational materials. Plus, the care navigator can call the member a few days before the appointment to talk directly with the member to help eliminate any potential barriers to care. Employing these strategies has been shown to more than double the show rate for preventative care outreach programs.

The care navigator outreach is central to the success of any care gap closure program, but there are three other important things to consider to ensure success of the program. First, it is important that the appointment is made on behalf of the PCP so the specialist knows who to return the consult notes to, which will improve care coordination and long-term care outcomes. Ideally, this can be done electronically through the same scheduling (referral) system, regardless of EMR. Second, the company that networks with the specialists needs to work with them to ensure the loop is being closed promptly with the members’ PCP. Third, all of the data needs to be aggregated and shared with the plan so they can track, measure, and report on their care gap improvements.

In a case study conducted by ReferWell to improve CRC screening rates, ReferWell care navigators were able to positively impact 82% of patients reached, scheduling them for a CRC screening or sending information about a previous CRC screening to the plan and the member’s PCP, and scheduling 56% of eligible patients “right then and there” while on the call. The patient show rate was double the rate of similar programs without the point of care scheduling; once completed, the specialists closed the loop 85% of the time -- 2.5 times the national average for closing the loop – thereby improving care coordination and patient outcomes.