CASE STUDY

Health Information Exchange solution provides ROI beyond expectation

The Situation

The National Committee of Quality Assurance (NCQA), leverages the Healthcare Effectiveness Data and Information Set (HEDIS) as a performance improvement measurement tool for Healthcare Payers and Providers. Controlling High Blood Pressure (CBP) is one of the most important HEDIS measurements since high blood pressure is directly correlated with heart disease and stroke. CBP assesses adults with a high blood pressure diagnoses that have their blood pressure under control.

According to NCQA, the CBP HEDIS rate had decreased significantly in 2020. The non-profit healthcare organization cites the dramatic effects of the pandemic and COVID-19 as the main reason for the decline in percentage. Due to these unpredictable events, the organization has decided against releasing 2020 HEDIS results. This is significant news for the CBP measure in particular because the effects of high blood pressure continue to be the leading cause of death in the United States.

In fact, CBP is such a heavily weighed HEDIS measure that NCQA assigned it a value of 3 which is their maximum value. For further context of CBPs medical importance consider that the Breast Cancer Screenings (BCS) HEDIS measure only carries a value of 1.

Interesting enough our Healthcare Payer client’s CBP rating had increased during this same time period. In fact, it increased by 2%. Which begs the question, why did our client’s CBP rate increase when nationally its percentage had decreased?

The Solution

From a data perspective, it was attributed to the Health Information Exchange (HIE) solutions we designed and implemented for the organization. After thoughtful collaboration with the client’s IT & business leaders our team was able to align organizational goals with the HIE data model. This cleared a path for standardization of the various data types being pulled from the multiple data sources. Thus, allowing for the successful consolidation of the client’s administrative and clinical data.

So, what does this all mean? Well, by merging paid claims with other vital data such as state registries and provider management platforms, the organization was now working with a single source of truth which provided a more holistic view of their member’s services and conditions. This allowed analysist to expand their CBP data and discover unseen services. Now, they have the ability to perform a more accurate calculation. The Health Information Exchange solution quickly became the organization’s go-to HEDIS reporting tool.

The Result

The result of having quality business intelligence to perform an accurate calculation is what led to the 2% increase in their CBP rating for 2020. The successful results from CBP lead the team to expanding their usage of the HIE with the intent of increasing additional HEDIS measures and further boosting state and federal reimbursement during the next submission cycle. These reimbursements could take the form of 10s of millions of dollars in associate revenue.

Not only does this Payer now have the capabilities of fully integrated Health Information Exchange solution as well as a reusable framework to garner more accurate calculations, but they also have the peace of mind that their data services investment produced a ROI that exceeded expectations.

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