Diabetes is a major public health concern, affecting millions of Americans. One of the most serious complications of diabetes is diabetic retinopathy (DR), which can lead to vision loss and blindness if left undetected and untreated. Early detection and timely treatment can prevent or delay vision loss in 95% of cases.
For healthcare organizations, ensuring that diabetic patients receive comprehensive diabetic eye exams is not only crucial for patient care but also impacts important quality measures. The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA) to evaluate the quality of care and service provided by health plans to their members as well as financially incentivize meeting these measures.
How HEDIS scores work
HEDIS is the preeminent performance measurement tool in healthcare, comprising over 90 standardized measures that evaluate care delivery across key areas like chronic condition management, behavioral health, preventive screenings, emergency utilization, and hospital readmissions. HEDIS measures are divided into several domains, including effectiveness of care, access/availability of care, experience of care, utilization, and health plan descriptive information. Each measure has specific criteria that must be met to achieve a high score.
For example, the Comprehensive Diabetes Care (CDC) measure evaluates the percentage of patients with diabetes who received essential services, such as HbA1c testing, eye exams, and attention for nephropathy. A high CDC score indicates that a health plan is effectively managing its diabetic population’s care.
Health plans collect data from various sources, including claims, medical records, and patient surveys, to calculate their HEDIS scores. These scores are then reported to the NCQA and made publicly available, allowing consumers to compare the quality of care provided by different health plans.
How to get more revenue from higher HEDIS scores
Meeting or exceeding HEDIS measure targets can directly translate into significant financial benefits for healthcare providers and organizations through higher reimbursement rates and performance-based bonus payments from health plans and payers. Many payers tie a portion of their reimbursement rates to HEDIS scores to incentivize high-quality, value-based care delivery. Health plans with superior HEDIS performance are often eligible for enhanced reimbursement from programs like Medicare Advantage’s star ratings system. Likewise, provider groups that demonstrate better HEDIS scores may qualify for increased payment rates from these same health plans. Additionally, most health plans now offer pay-for-performance or pay-for-quality bonus programs that provide monetary rewards to providers for achieving certain benchmarks on key HEDIS measures.
Meeting HEDIS performance targets allows healthcare providers and health plans to unlock significant financial incentives from employers and payers. Key ways this occurs:
- Enhanced reimbursement rates – Many payers tie a portion of their reimbursement rates directly to HEDIS scores as a way to incentivize high quality care delivery. Stronger HEDIS performance leads to higher reimbursement.
- Pay-for-performance bonuses – Employers and payers structure contracts with bonus payments to health plans and providers for achieving certain HEDIS measure benchmarks like the 75th percentile nationally. These bonuses can represent 1-2% of premium/revenue value.
- Shared savings/risk arrangements – In value-based contracts, a percentage of plan premiums or provider revenue may be put “at risk” and recouped only if HEDIS targets are met, creating further financial incentive to improve scores.
By requiring HEDIS data transparency, setting aggressive but achievable performance targets aligned with national benchmarks, and putting a meaningful portion of compensation at risk via bonuses or shared savings, NCQA and CMS can create strong financial motivators for plans and providers to prioritize closing gaps in key HEDIS measures. For example, “Contractor agrees to meet or exceed the national 75th percentile quality benchmark or show improvement of 5.00% or better from the previous year in the [insert HEDIS measure], with 2% of annual fees at risk.”
These bonuses can amount to millions of dollars for large medical groups or health systems that prioritize closing gaps in HEDIS measures like comprehensive diabetes care, controlling high blood pressure, or conducting timely prenatal care visits. Beyond direct reimbursement impacts, strong HEDIS performance signals high-quality care delivery, which can attract more members and patients to a health plan or provider organization. This increased market share results in more premium revenue and patient volumes.
How to meet the Comprehensive Diabetes Care HEDIS guidelines for Eye Exams
The Comprehensive Diabetes Care HEDIS measure includes an eye exam component, assessing the percentage of diabetic patients who had a retinal or dilated eye exam by an optometrist or ophthalmologist during the measurement year, or were negative for retinopathy the prior year. Only about half of patients with diabetes get an annual eye exam, making it a focused care gap to close. Achieving high CDC HEDIS scores can be challenging due to barriers such as access to eye care specialists, patient compliance in going to the eye care appointment once referred, and documentation issues in receiving the eye care specialist report and reconciling the associated CPT II code. However, the advent of AI-powered DR screening platforms offers an innovative solution to overcome these hurdles and improve HEDIS performance. Let’s look at the measure in depth.
According to the American Diabetes Association (2022b) guidelines:
- For type 1 diabetes, an initial comprehensive dilated eye exam by an eye care professional should occur within 5 years of diabetes onset.
- For type 2 diabetes, the initial exam should take place at the time of diagnosis.
- If no retinopathy is found for one or more years and blood sugar is well-controlled, screening every 1-2 years may be considered.
- If any diabetic retinopathy is present, annual exams by an ophthalmologist or optometrist are required.
- For worsening or sight-threatening retinopathy, more frequent exams are necessary as warranted by an ophthalmologist or optometrist.
The CDC measure requires documentation of one of the following:
- Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist or artificial intelligence (AI) interpretation documented and reviewed; with evidence of retinopathy
- Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist or artificial intelligence (AI) interpretation documented and reviewed; without evidence of retinopathy
The key points are timely initial screening based on diabetes type, followed by annual or more frequent monitoring based on the presence and severity of retinopathy findings. Also, these screenings can be completed and documented using AI DR screening tools according to the guidelines. By using an AI DR screening solution and including CPT 92229, this meets the intent of the quality action for this measurement.
How to effectively improve Comprehensive Eye Care HEDIS measure
Using AI to screen for DR
Automated screening systems could significantly improve diabetic retinopathy (DR) detection efficiency by initially sorting fundus images with no pathologies from those with referrable DR. This approach could halve the need for human grading, reducing costs and analysis time, as nearly 60% of patients had no DR in a study using the Optomed Aurora and various DR screening platforms. AI systems have demonstrated cost reduction by partially replacing human graders, improving diagnostic accuracy, and increasing patient access to DR screening. These algorithms offer advantages such as consistent performance and rapid results. Our recent study showed the feasibility of the handheld Optomed Aurora fundus camera for AI-based DR screening, achieving 92% sensitivity and 100% specificity with low rate for ungradable images. This aligns with other research suggesting that portable handheld fundus cameras could be cost-effective alternatives for DR screening, particularly in resource-limited healthcare settings.
The Aurora AEYE is the first FDA cleared handheld fundus camera with built-in AI screening for DR. It passed rigorous quality assurance testing and delivers exceptional clinical accuracy. Its portable design allows you to bring the camera to the patient – wherever they may be. It allows anyone in the office to take high quality images and obtain a certified report delivered to the camera display in less than a minute. AI screening platforms like the Aurora AEYE have reimbursable CPT code 92229 associated with their use, with a current Medicare average reimbursement rate of around $40.
Comprehensive eye disease screening at the primary care level, powered by AI-enabled retinal imaging, offers numerous benefits. It allows for early detection and timely intervention of vision-threatening conditions during routine visits. AI-powered risk stratification ensures eye care specialists receive patients truly needing their expertise, optimizing their clinical time and resources. This streamlined approach enhances patient experience, fosters collaboration between primary care and eye care providers, and ultimately improves visual health outcomes for the broader population. By integrating these screenings, primary care providers contribute to more efficient, targeted eye care while ensuring specialists focus on treatment-ready patients.
As a healthcare provider, it’s important to understand the HEDIS measures that are relevant to your practice and patient population. By closing these care gaps and ensuring that you meet the necessary criteria, you can not only improve the quality of care you provide but also increase your chances of receiving higher reimbursement rates and incentives from health plans. Moreover, many patients are now using HEDIS scores as a factor when choosing a healthcare provider or health plan. By maintaining high HEDIS scores, you can differentiate your practice and demonstrate your commitment to delivering high-quality care.
Choose the accurate, efficient, elegant screening solution with Aurora AEYE. Your patients and HEDIS scores will be thankful. Contact Optomed today and get started.
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