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CAHPS/HEDIS Special Edition

Letter From the CMO

Letter From the CMO

Preston Renshaw, MDPreston Renshaw, MD, Chief Medical Officer Avera Health Plans and DAKOTACARE

I recently had the unique opportunity to sit with health delivery system and insurance leaders from across the country to discuss the ongoing burden of health disparities, disease burden and affordability concerns across the United States. Needless to say, these issues are very much dependent on the population dynamics and our unique geographies but still, common themes emerged.

Over the last 30 years, America’s Health Rankings® Annual Report has analyzed a comprehensive set of behaviors, public and health policies, community and environmental conditions, and clinical care data to provide a holistic view of the health of the people in the United States. According to the 2018 America's Health Rankings® report, South Dakota ranked number 25 out of 50 states in regards to overall health of state.

Within the report, there are a few notable areas that Avera Health Plans has been focused on to improve the health outcomes for those we serve. Diabetes and obesity continue to plague our population, as well as infant mortality and behavioral health concerns. In order to effectively improve the health of those we serve, the need for connected and collaborative care has pushed us to become an integral partner in connecting our stakeholders in a meaningful fashion.

For example, the personal health services team is focused on connecting the right individuals to our integrated care delivery teams for diabetes and obesity, and our member health advocates are helping members manage various social and economic issues, also known as social determinants of health.

Our population health team and delivery system partners are focused on connecting, collaborating and caring for our members in order to make a positive difference in these health concerns and improve the health of our communities. This connection and collaboration relates as much to the health care delivery systems as it does to our community partners. Without this collaboration, we won’t be able to address with these growing health concerns. It takes all parties to engage in population health.

In this edition, readers will be able to evaluate our performance as we work to improve the lives of those we serve. We strive to provide insight, transparency and collaboration in the lives that we touch each and every day.

Thanks again for all you do to meet the needs of our communities.

NCQA Accreditation for 2020

NCQA Accreditation for 2020

National Committee for Quality Assurance (NCQA) operates as a quality improvement guide for health plans. Health plans accredited through NCQA’s rigorous process demonstrates their commitment to delivering efficient, patient-centered, high quality care to their members. Consumers and employers looking for coverage that focuses on these important attributes often look for NCQA accredited plans to meet their needs.

NCQA releases annual ratings to help consumers decide what plans perform better than others. Ratings are determined based on a total score of 100, with accreditation standards and guidelines accounting for up to 50 of those points. Clinical performance measures – called Healthcare Effectiveness Data and Information Set (HEDIS) – can account for up to 37 points, and patient experience measures – called Consumer Assessment of Healthcare Providers and Systems (CAHPS) – can account for up to 13 points.

Plans are given a status of Excellent, Commendable, Accredited and Provisional based on their total score.

In 2020, NCQA will change the way ratings are reported. To align with Center for Medicare and Medicaid (CMS) ratings, NCQA will begin to release Star Ratings. The Star Ratings will be based on a 5-star scale with the higher performing plans receiving more stars.

The NCQA methodology used to determine these ratings will also change. First, plans must score 80% on all standards and guidelines to be accredited. Then, to show consumers the health plan’s commitment to quality, the star rating will consider the performance of HEDIS and CAHPS.

Health plans performing in the higher percentiles will be rated higher than the lower performing plans. Ratings will be released to the public annually.

2019 HEDIS Results

2019 HEDIS Results

Healthcare Effectiveness Data and Information Set (HEDIS) is a set of performance measures, collected from electronic medical records and claims data, used to assess effectiveness of care, access to care and experience of care, among other measures. While our HEDIS scores were up slightly from 2018, there are areas of opportunities.

⇒ View HEDIS Scores

Common Problems Affecting Scores

  • Lack of documentation in the medical record
  • Lack of referral or recommendation for services
  • Lack of complete and accurate coding
  • Services received outside the recommended time-frames by HEDIS
  • Member/patient non-compliance

What Providers Can Do To Improve Scores

  • Provide complete and accurate coding, using correct ICD-10, HCPCS and procedure codes. Note: correct coding can reduce medical record requests.
  • Submit claims and encounters timely
  • Capture all services due while patients are onsite to keep patients as up-to-date as possible
  • Document all care in the patient’s medical record
Opportunities for Improvement

Adult Body Mass Index
HEDIS measures the percentage of members 18–74 years of age who had an outpatient office visit and had their body mass index documented during the current or previous year. Obesity is the second leading cause of preventable death in the United States. It is a complex, multifaceted, chronic disease that is affected by environment, genetic, physiological, metabolic, behavioral and psychological components. Approximately 127 million American adults are overweight, 60 million are obese and 9 million are severely obese.1

Cancer Screenings
HEDIS assesses the percentage of women 50–74 years of age who had a biennial mammogram to screen for breast cancer. Breast cancer is the second most common type of cancer among American women.2

Cervical cancer is another screening performed in women ages 21–64 years of age to detect cancer in early stages. Due to the success of cervical cancer screening in the U.S., dramatic decreases have been observed in both mortality and incidence of invasive cervical cancer.3

Colorectal cancer is the second leading cause of cancer-related deaths in the U.S. It places significant economic burden on society: treatment costs over $6.5 billion per year.4 HEDIS assesses whether adults 50–75 years of age have had appropriate screening for colorectal cancer.

Comprehensive Diabetes Care
This composite HEDIS measure with five different reportable rates looks at how well our organization cares for the common and serious chronic disease of diabetes. It uses a single sample of diabetic members 18–75 years of age to evaluate organization performance on aspects of diabetes care. The following criteria need to be met:

  • Had a hemoglobin (HbA1c) blood test
  • Have controlled diabetes (HbA1c <8.0%)
  • Had a retinal or dilated eye examination
  • Have been screened or monitored for kidney disease
  • Have blood pressure <140/90 mm Hg Controlling

High Blood Pressure
This intermediate-outcome HEDIS measure assesses members 18–85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mm Hg) during the current year. About one in three U.S. adults, or about 75 million people have high blood pressure also known as hypertension.5 Hypertension increases the risk of heart disease and stroke, two of the leading causes of death in the U.S.6

1. American Obesity Association. March 2005. AOA Fact Sheets: “What is Obesity; Obesity in the U.S.; and Health Effects of Obesity.”
2. Howlader, N., A.M. Noone, M. Krapcho, D. Miller, K. Bishop, S.F. Altekruse, C.L. Kosary, M. Yu, J. Ruhl, Z. Tatalovich, A. Mariotto, D.R. Lewis, H.S. Chen, E.J. Feuer, and K.A. Cronin. 2016. “SEER Cancer Statistics Review, 1975-2013.” National Cancer Institute. (Accessed December 5, 2016)
3. American Cancer Society. 2018b. Key Statistics for Cervical Cancer. Last modified January 4, 2018.
4. USPSTF. 2002. “Screening for colorectal cancer: recommendations and rationale.” Ann Int Med 137(2): 129–31.
5. Merai R, Siegel C, Rakotz M, Basch P, Wright J, Wong B; DHSc., Thorpe P. CDC Grand Rounds: A Public Health Approach to Detect and Control Hypertension. MMWR Morb Mortal Wkly Rep 2016 Nov 18;65(45):1261-1264
6. Yoon, S.S., C.D. Fryar, M.D. Carroll. 2015. Hypertension Prevalence and Control Among Adults: United States, 2011–2014. NCHS data brief, no 220. Hyattsville, MD: National Center for Health Statistics.

Clinical Documentation Improvement

Clinical Documentation Improvement

Medical records are frequently requested from providers for a variety of reasons, including but not limited to: quality of care reviews, risk adjustment and HEDIS measures.

In order to ensure excellent care for the members served by Avera Health Plans, the clinical information in the medical record must be clearly documented in order to be considered complete for the purposes described above. For example, members with diabetes have multiple exams that must also be completed within a specific time period in order to satisfy HEDIS measures, such as diabetic eye exam, foot exam and documented HgA1c values.

As an issuer accredited by National Committee for Quality Assurance (NCQA), Avera Health Plans must support the completion of these exams via two methods: (1) administrative means, such as a claim with an approved CPT code, or (2) medical record review by a clinician within the health plan. If the documentation is not adequate, Avera Health Plans cannot consider that record complete and is not valuable for the purposes of HEDIS. Since Avera Health Plans strives to be the insurance company of choice for employers and individuals within the Avera footprint, continued demonstration of the highest quality of care through accurate and complete documentation is essential.

To learn more about Clinical Documentation Improvement education and activities, please contact Sara Hansen, Manager of Risk Adjustment, at 605-322-2329 or by email at

2019 CAHPS Results

2019 CAHPS Results

Member experience continues to be a focal point of the Avera Insurance Division’s mission and strategic plan. Sitting down to prioritize upcoming objectives, the question becomes obvious – where do we begin?

There are a number of points, or experiences, along the member’s journey that influence one’s overall satisfaction with their insurance provider. From the delivery time of the member’s ID card to ease in reading an explanation of benefits (EOB) to the interaction with an in-network specialist, each informs one’s view of their health coverage and its value.

To measure performance, two member satisfaction surveys are conducted annually: Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Qualified Health Plan (QHP). Using an independent survey vendor, these surveys are sent to a random sampling of members, from those receiving coverage through their employer’s group plan, members who purchase coverage on their own, and those enrolled through the Exchange. The data collected provides information on the experiences of our members, and how well the plan and its participating physicians are meeting their expectations.

2019 results are now available and reflected top measures as:

  • Rating of Personal Doctor
  • Getting Needed Care
  • Care Coordination
  • Plan Administration
  • Customer Service

For reference, here is a sampling of the questions that inform the rating of personal doctor:

  • In the last 12 months, how often did your personal doctor explain things in a way that was easy to understand? (Never, Sometimes, Usually, Always)
  • In the last 12 months, how often did your personal doctor listen carefully to you? (Never, Sometimes, Usually, Always)
  • In the last 12 months, how often did your personal doctor show respect for what you had to say? (Never, Sometimes, Usually, Always)

Areas of opportunity for improvement include:

  • Access to Information
  • Medical Assistance with Smoking and Tobacco Use Cessation
  • Flu Vaccinations
  • Health Promotion and Education

Customer Care and Population Health leaders have reviewed the outcomes and developed an action plan aimed at improving key drivers influencing these measures.

Connecting with Patients for Better Patient Experience

Connecting with Patients for Better Patient Experience

It only takes a moment for patients to get a first impression that can make a permanent impact on how they perceive their experience. Not only does a positive patient experience improve their health and healing, but patient experience scores also impact reimbursement rates.

Avera’s Service Excellence Team offers these easy steps to make a great impression on your patients:

  1. Knock, then wait two seconds prior to entry. It’s a common courtesy and conveys respect.
  2. Smile, shake hands and introduce yourself to the patient and everyone in the room. Friendliness of a physician will improve patient comfort and satisfaction with you.
  3. Sit, face the patient and make eye contact. When a physician sits, it will significantly increase the patient’s perception of time spent with them.
  4. Look as though you enjoy what you do! Patients want to feel like they are not a burden to you; that you enjoy taking care of them and have time for them.
  5. Use consistent open dialogue and open body language that creates comfort and approachability with you. Use humor when you can – laughter makes a notable, positive impact on patients and conveys unhurriedness and approachability.
  6. Tell patients about your training, experience and personal approach to care. Patients must believe they’re beginning a relationship with a provider who is receptive, accessible, listens and acts in a way that makes them confident in your care.