Keep your At-Risk Members Healthy while improving your HEDIS and STAR Ratings

Diabetes is a chronic disease that can create downstream health issues if not carefully watched and addressed. In fact, according to the CDC, over 29 million, or 9.3% of the US population suffer from type 2 diabetes. [1] Diabetic patients need to be aware of their elevated risk of contracting Diabetic Retinopathy. Diabetic Retinopathy is an eye disease in which chronic high blood sugar damages the blood vessels in the retina, eventually leading to complete blindness. Initial symptoms are typically not noticeable until vision is affected and the blood vessels rupture. At first, the symptoms are floating spots that can sometimes correct themselves, but if not addressed early, can lead to irreversible blindness.

The best way for a diabetic patient to avoid or quickly detect Diabetic Retinopathy is to visit an optometrist or ophthalmologist who will give them a dilated eye exam at least once a year. This annual checkup will help diabetic patients reduce or avoid the long-term symptoms of diabetic retinopathy and could ultimately save their vision. It will also save a lot of money for both the patient and the health payer in the long-run.

In the continued effort to move payers to value based care, member outreach and early detection will help payers improve their HEDIS and STAR ratings. Members that are provided with a positive experience, will ultimately help payers customer satisfaction ratings, as well as, improve overall patient health through better outcomes. Payers are now incentivized to improve their members’ health outcomes through preventative procedures and early stage detection; not only because it saves money through reduced major utilization, but also through bonuses paid through Federal Star Rating and MACRA / APM reimbursements that are beginning to take precedent. The outcome doesn’t just benefit the health plan, it will greatly improve the patients’ overall health and help them avoid blindness and other vision symptoms.

Where payers can truly save is through ensuring that diabetic patients are flagged in their risk adjustment reporting to ensure their risk score is accurate. Risk Adjustment for individual and small group business requires payers to pool a fund and the plans that have the higher risk patients get additional funding from the pool. Medicare Risk Adjustment is fully funded by the government but still plays a significant role in a payers’ actuarial estimations and strategy. Diabetic patients are typically very risky and expensive to insure so it is important for payers to make sure that all their diabetic members are diagnosed and included in their risk adjustment reporting to CMS.

As healthcare continues to evolve, there are more solutions that are focused on specific high cost, heavy utilization diseases and how they can reduce costs and mitigate risks for their clients. Payers should look to close these gaps in care. The value that comes with closing these gaps affects the entire organization. Payers’ bottom lines increase due to higher Risk Adjustment and government incentive payments and the quality of care is increased, enhancing Value Based, and HEDIS/STAR reporting.

Check out the Graphic below for a look at how addressing Diabetic Retinopathy can positively impact your Risk Adjustment reporting.


Jimmy is a Strategic Adviser with Leverage Health and can be reached at .

Michael is a Director of Business Development at Leverage Health and can be reached at