Jim Slubowski

As Senior Vice President of Healthcare Solutions, Jim is responsible for business and financial growth, new product/service development, strategic planning, business partnerships, and staff development across our healthcare practices.  Prior to joining HighPoint, Jim spent 14 years as CIO and VP of Enterprise Operations at Priority Health. He has also held senior positions as JS Advisory Services, Ernst & Young, and Henry Ford Health System.

Tuesday, 25 October 2016 04:54

Value is in the Eye of the Beholder

Well, it is that time of year for many of us who are thankfully employed by companies small and large alike – it is open enrollment season! 

Human resources departments around the country will once again vet various health insurance companies, either directly or through agents, then review benefits and premium costs. Those employers will finalize their selections and execute group agreements with their chosen health and dental insurance companies.

Next, those departments will communicate health and dental insurance options to their employees – with methods including but not limited to brochures, benefit plan overviews, enrollment forms, employee contribution statements, comparison charts, provider network overviews, etc. Employees will attend overview sessions seeking answers to their questions and talk to co-workers, family, and friends about their experiences. Finally, selections will be made and enrollment forms turned in (or default options chosen for the employee).

For me, going through this annual process for the 30th time, I am always grateful for the generosity of my past and current employers for providing (and, more importantly, subsidizing) this benefit for me. As we all know and respect, it is truly an invaluable benefit to have insurance that protects both our personal health and our financial health. But with my recent experience writing for VBPmonitor about value, this time I viewed this process through a different set of lenses. I asked myself, “how am I measuring value as I go through this decision process to pick a health insurance option?” The brutal fact is that, in the past, I did not consider value in my decision making – I solely considered my cost share, plus metrics such as payroll deduction, deductibles, and co-insurance percentages. Why do I know that I did not consider value when making my decision? It was easy to determine, because I didn’t ask or investigate any of the following questions:

  • Was the health plan NCQA or URAC accredited?
  • Which benefit plan or insurance company would help ensure my compliance with annual physicals and other preventative activities?
  • Which health plan has the best customer service rating and offers the most self-servicing options such as digital tools?
  • What are the STARS and HEDIS ratings of the provider network, and who has the most in-network doctors and hospitals?
  • If I have a chronic disease, which payor and provider relationship will help me deal with my condition so I can enjoy a normal lifestyle?
  • Which provider has a 24-hour “ask a nurse” program?
  • Which in-network doctors and hospitals most effectively use electronic medical records and health information networks, so my holistic health record is available to them to ensure that the best decisions are made for my care and to avoid unnecessary or repeat tests?
  • How do health plans integrate clinical data from providers to provide more informed care and disease management services?

Why was this the case?  Why did I not act as a true consumer, as if I was shopping for home/car insurance or a new refrigerator? It’s simple. I am still not acting like a consumer, since employer-sponsored health benefits continue to be paternalist. The bottom line was that I truly did not have to “shop.” My employer did everything for me – they picked the health insurance company, the programs (e.g. POS, HDHP with an HSA, etc.), the benefit levels, the payroll deductions for each option, etc. Moreover, a simple chart was provided, highlighting comparisons and financial impacts. It was so easy, and, frankly, there was very little decision-making that I had to do other than having a 15-minute conversation with my spouse.

Think of it in another manner. Let’s say you need groceries. If I told you the specific store to go to, what aisles to enter, provided one to two options for up to a dozen grocery staples, and gave you a dollar limit, you would not do any of the following: look at the Sunday ads for price comparisons, check out hours between stores, clip coupons, compare driving distances from your home or office, consider the helpfulness of the employees, etc. In essence, you would not shop and would not consider value. You would simply buy the items that were available to you with an emphasis on cost.

How do we change this model in healthcare? The best motivation for change is through the pocketbook. This may seem radical to some, but I am convinced that the only way to transform the healthcare purchasing system to become more value-based is to eliminate the employer-sponsored model and replace it with an employer-provided tax-free stipend for employees to purchase health insurance from any company and at any benefit level. 

Now, don’t get me wrong, I recognize the importance of a health insurance benefit to attract and retain great employees, and I am not suggesting that the ability to purchase health insurance be abandoned. I also recognize that before taking this radical step, the individual insurance marketplace needs significant fine-tuning so all insurance companies remain involved and choice and premium rates are better controlled. Regardless, until employees are provided with an employer-sponsored stipend, tax-free, to purchase health insurance ourselves, consumers will never recognize or appreciate value as described in the aforementioned examples regarding service and outcomes. It will simply and solely continue to be a cost decision. 

The Triple Aim measures value as service, outcomes, and cost. Once costs and choice are normalized among options, then consumers will consider overall customer service and the outcome of that service. If your employer didn’t provide annual insurance benefits, how would you determine value to make your health insurance decisions? It was a sobering awakening I went through this year. Look at it through a different set of lenses and evaluate your decision process as you go through open enrollment season this year, and you will realize that value is indeed in the eye of the beholder.

About the Author

As senior vice president of healthcare solutions for HighPoint Solutions, Jim is responsible for business and financial growth, new product/service development, strategic planning, business partnerships, and staff development across our healthcare practices. Prior to joining HighPoint, Jim spent 14 years as CIO and VP of enterprise operations at Priority Health. He has also held senior positions at JS Advisory Services, Ernst & Young, and the Henry Ford Health System.

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Over the last decade, the switch to a value-based payment model has continued to intensify. Healthcare is always searching for opportunities to improve quality and cost while purchasers, especially federal and state governments, are demanding it. No longer tolerated are payments for poor quality, poor service, or waste.

Obviously, the herculean challenge associated with our federal and state regulatory processes is actually formulating plans, achieving consensus, and then enacting the law. To exacerbate this challenge is the vacillation on final decisions in Washington, D.C., which causes confusion and perpetuates doubt because of the associated delays. 

For example, we’ve seen delays with ICD-10, the HITECH (Health Information Technology for Economic and Clinical Health) Act,and now potentially, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. During a U.S. Senate Committee on Finance hearing, Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS), indicated that there could be some revisions to the proposed rule, including a possible delay in the Jan. 1, 2017 proposed start date. It appears that delays with MACRA will be no different than those connected to other key pieces of healthcare financial legislation, which is both disappointing and frustrating.

Regardless of the impending delay, healthcare payors and providers must be ready! To that end, what is MACRA, and what can you do to be ready for yet another regulatory requirement?

First of all, at a very high level, MACRA establishes new ways to pay physicians for care delivered to Medicare patients. Within the Quality Payment Program (QPP), participating providers will be paid based on quality and effectiveness of care with two new incentive structures:

One incentive structure is the Merit-Based Incentive Payment System (MIPS), which is described below.

  • It combines three existing incentive programs and adds a fourth component to promote ongoing improvement and innovation to clinical activities into one new QPP.
    • The Physician Quality Reporting System (PQRS), the Value Modifier (VM), and the Medicare Electronic Health Record (EHR) incentive program.
    • Clinical Practice Improvement Activities (CPIAs)
  • Measures will be based on quality, resource use, clinical practice improvement, and meaningful use of electronic health record (EHR) technology
  • Positive, negative, or neutral adjustments to the base rate of Medicare Part B payment will increase each year starting in 2019
  • Adjustments are required to be budget-neutral, demanding no additional spending, as higher performers are reimbursed from reduced payments of poorer performers
  • Positive and negative adjustments will increase from 4 to 9 percent from 2019 (based on performance in 2017) to 2022 and thereafter

The other incentive structure is the Alternative Payment Models (APMs), which are described below.

  • Provides an alternative payment method to incentivize quality and cost savings for Medicare providers
  • Some providers in APMs are also subject to MIPS, but receive favorable scoring with correspondingly higher reimbursement rates
  • Requires use of certified EHR
  • Payments must be calculated using evidence-based quality measures that are reliable and valid
  • Eligible APMs will only include payment models in which physicians bear “more than nominal” risk for financial losses
  • Examples of APMs include accountable care organizations (ACOs), patient-centered medical homes, and bundled payments
  • Opportunity for incentive payment to providers who qualify for advanced APM

As with all healthcare legislation, both providers and payors must be ready. Ensuring the viability of working clinical information systems, sharing information across the care continuum, optimizing clinical workflows, and engaging patients for education and compliance are paramount for success. The following are some key areas regarding how providers will be impacted and can be prepared.

A few other things to remember:

  • MACRA rules and payments only apply to Medicare Part B payments.
  • Providers will need to know what is happening across the system outside of their offices regarding patient outcomes for a longitudinal view. 
  • Informatics will be key, since the reliance for good and accurate data is critical, and it will involve multiple delivery systems.
  • This may require the need to change or modify technology and data infrastructure in order to ensure that current EHR systems can support data interoperability.
  • MIPS data reporting will need to be aggregated, assessed, and mined quickly, efficiently, and accurately to target opportunities for intervention and action.
  • Data sharing standards will be a key component to enable changes in patient care.
  • Penalties for not reporting or for low quality may impact financials this year.
  • Physicians must choose MIPS or APMs after careful review of financial benefit/impact and potential to influence holistic care delivery and adherence to care plans.
  • Understand payment outcomes to MACRA-established physician fee schedule updates each year. Also, understanding exemptions from MIPS will be critical.
  • If a PQRS tool is currently used, determine if it can be leveraged for MIPS requirements. 
  • Analyze current quality and resource use reports (QRURs) to understand your performance in terms of cost and quality to help prioritize improvements.
  • If your practice doesn’t provide chronic care management (CCM), consider the cost-benefit opportunity for increasing revenue to support performance and quality improvements.

To fully promote the focus on paying for value and better outcomes, there is opportunity for payors can consider the following actions with the launch of MACRA:

  • Renegotiate existing Medicare provider contracts to ensure incentives and penalties are included for quality improvement, customer servicing, and cost reductions.
  • Provide transparency for provider and health plan costs, quality, and service performance.
  • Provide comprehensive chronic care management services for the disease states aligned with HEDIS, PQRS, and MACRA.

Regulatory changes bring challenges, but also opportunity to transform internal processes to improve quality and financial performance. Also, with transparency, the opportunity presents itself to market your performance results nationally to promote your health system as a benchmark-setter for quality improvement, potentially establishing yourself as a center of excellence.

Although there’s uncertainty of when MACRA will be enacted, it is advisable to be ready with your planning process. Enacting the proposed guidelines now will certainly improve your organizational readiness to ensure that your desired results are achieved – and hopefully exceeded.       

About the Author

As senior vice president of healthcare solutions for HighPoint Solutions, Jim is responsible for business and financial growth, new product/service development, strategic planning, business partnerships, and staff development across our healthcare practices. Prior to joining HighPoint, Jim spent 14 years as CIO and VP of enterprise operations at Priority Health. He has also held senior positions at JS Advisory Services, Ernst & Young, and the Henry Ford Health System.

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Monday, 25 April 2016 06:29

Finding the Needle in the Haystack

j slubowskiIn healthcare, we are always searching for opportunities to improve. Whether it be in the area of financial, quality, customer satisfaction, growth, new services, or process waste reduction, we are always striving to be better and ultimately to improve the health of the communities that we serve. 

Over the last few decades, significant steps have been taken toward this end. Healthcare has adopted process improvement methodologies such as Lean and SixSigma to eliminate process waste. Financial models have been created to pay for preventive health activities, quality outcomes, and satisfaction versus paying solely for activity. Lastly, information technology is finally being exploited in healthcare, with electronic medical records providing holistic patient information that can be used across the entire delivery system, both locally and nationally. With the convergence of process improvement, financial incentives, and automation, now is the time to synthesize care management processes and data, specifically for predictive modeling/analytics, to pinpoint those populations with the greatest needs and best opportunity for advancement.

Predictive analytics is the practice of extracting information from existing data sets to help health plans and providers identify patterns and forecast, with an acceptable level of reliability, what might happen in the future. Critical data inputs include:

  • Patient history
  • Medical conditions, complications, and comorbidities
  • Lab values
  • Vital signs
  • Medical and drug claims
  • Health risk assessment  
  • Family history

Care management, or population health management, has been an embedded capability in health plan organizations for decades, and the call to action now is to expand it comprehensively into the healthcare delivery system. The labels have changed over the years from referral/authorization management, utilization management, case management, disease management, and wellness to this now all-encompassing term: care management. The intended goal of this evolution – to control, coordinate, educate, and prevent – is to manage cost and quality despite the often-onerous rules and steps involved in the implementation of programs. Care managers now can leverage predictive analytics to narrow the focus of their programs to:

  • Target identification of early readmission risk
  • Facilitate population health management and value-based accountable care
  • Identify patients at risk for early intervention to promote patient engagement and drive better outcomes
  • Lower patient costs when interventions correct patient health practices before more serious complications develop

Predictive analytics, paired with care management activities, are critical to manage and improve the health of an identified population. The key word to describe the value of predictive analytics is identification. Benefits of predictive modeling/analytics include:

  • Predictive, to identify negative health trends
  • Proactive, by identifying who is at risk
  • Personalized, since it identifies the best combination of services for each individual
  • Preventive, since it identifies actions that can be taken to avoid a negative episode

To be effective, these results must be integrated into the care management and/or clinical workflow processes to generate actionable information. This includes timely dissemination of information, staff education, and potentially, creating the role of a clinical screener to further investigate results from the predictive modeling tool. Creating a solid population health management process is an ongoing task that must leverage a robust data environment and predictive analytics. The continuous cycle of activities within a population health management program are listed below. Please note that the first three bullets rely solidly on predictive analytical capabilities:

  • Defining a population for improvement
  • Determining care gaps
  • Stratifying risk
  • Engaging patients
  • Managing care
  • Measuring results

The vendor marketplace offers many solutions to assist with predictive analytics and care management. There are endless case studies and results of predictive analytics, and the value is indisputable. A few examples are highlighted below:

  • By utilizing an improved predictive analytics tool at a provider practice, 44 patients were identified as high-risk. Of this group, only one of those patients had been previously classified as a high-risk patient. The practice reviewed the other patients one by one and since has been able to engage more than 50 percent of the eligible group in care coordination programs.
  • A nationally recognized healthcare institution that had performed more than 2,500 kidney transplants saw that its potential underperformance in transplant success threatened its participation and reimbursement status in the Centers for Medicare & Medicaid Services network. Analytics were used to predict transplant failure rates so improvements could be enacted.
  • At a health plan, the assignment of a health status and opportunity score to each member directed him or her to the most appropriate care management program, whether that was a wellness reminder or catastrophic case management. The resulting benefits included a decrease in manual intervention to interpret analytic results, conversion of these insights into appropriate actions, increased membership, and reduced administrative costs.

Due to the increased adoption of information systems within healthcare, structured electronic data is at an unprecedented high, providing greater opportunity not previously available for longitudinal insight and analysis. Population health management is finally able to be fully implemented using a plethora of patient self-reported data, payor administrative data, and provider clinical data. The proverbial haystack of data is now available. Are you ready to find your needle?

 

About the Author

As senior vice president of healthcare solutions for HighPoint Solutions, Jim is responsible for business and financial growth, new product/service development, strategic planning, business partnerships, and staff development across our healthcare practices. Prior to joining HighPoint, Jim spent 14 years as CIO and VP of enterprise operations at Priority Health. He has also held senior positions as JS Advisory Services, Ernst & Young, and the Henry Ford Health System.

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Monday, 08 February 2016 03:15

Who’s on First?

With the recent announcement that 477 accountable care organizations (ACOs) have signed up for the Medicare ACO program, with over 8.9 million beneficiaries being serviced, the healthcare industry’s interest in being paid for improving quality and lowering risk is at an all-time high. As stated in past VBPmonitor articles I have authored, any movement toward value-based revenue must rely on a firm foundation of information to monitor, manage, and direct action. This is easier said than done, and it continues to challenge many healthcare companies. A common excuse for non-action is to claim that the data is inaccurate, which often causes misdirection and stagnation. At all costs, you want to prevent organizational chaos and avoid anything resembling that famous Abbott and Costello skit, “Who’s on First,” when referring to your value-based reporting.

As organizations strive to expand their business intelligence capabilities, they must rely on additional sources of member/patient information to best manage quality, cost, and experience. Information, often coming from disparate sources, now must be captured and leveraged to address not only individuals, but entire populations of individuals. Information sources have expanded to include:

  • Electronic medical/health record systems, including both inpatient and ambulatory activity
  • Home healthcare and long-term care systems
  • Practice management systems
  • Health information exchanges
  • Insurance marketplaces
  • Self-report data such as health risk assessments and personal preferences
  • Claims and enrollment systems
  • Care management systems
  • Social media
  • Biometrics and wearables

To ensure that data can be converted into information that can be studied and leveraged to manage outcomes, costs, and experience, it must be fortified. Think of the ramifications if data is incomplete and inaccurate. For example, imagine calling a patient regarding a recent emergency room encounter only to find out that they never went. Or envision panel reporting to a physician, citing patients they have never seen, or trying to instill customer loyalty with a friendly “happy birthday” phone call to discover the birthday was 12 weeks ago.

Poorly managed data can severely damage an organization’s brand and reputation. Data quality is often overlooked and/or compromised when organizations attempt to build or expand their data warehouses. The oft-heard notion that “managing data quality will add too much time and cost to the project” is a foolish and shortsighted stance. However, as healthcare organizations recognize the importance of business intelligence and continue increasing their dependence on it, they are learning to embrace data governance, data quality, and master data management as key elements of a successful and reliable business intelligence foundation.

Governance is the human aspect of managing data. A data governance framework defines the orchestration of people, processes, and technology that ensure the accuracy, timeliness, and effective use of data across the organization. The governance framework involves the following components:

  • Organization structure, roles, and responsibilities
  • Data strategy to increase the value, availability, and reliability of data
  • Communication plan involving all stakeholders to promote data sharing and acceptance
  • Data policies and procedures to measure and monitor data quality, ensure adherence to business rules, compliance with laws and regulations, and the protection of data assets
  • Data standards to promote data consistency across the organization

As part of data governance, data quality tactics must be employed to ensure that data loaded and/or derived is accurate, thus building stakeholder trust. A successful data quality program will entail:

  • Creation of data quality rules, including definitions, constraints, and calculations
  • Creation of a data glossary, including terms, rules, tagging, and ownership
  • Implementation of data quality and monitoring, including deploying rules and automation, data validation, and ensuring business engagement and adoption
  • Expanded auditing and controls, including the ongoing process, metrics, and reporting

 

Finally, with the expansive adoption of information technology by payors, providers, and consumers, data sources are embedded, pervasive, and equally valuable. The need to corral all of these disparate sources of information and ensure unique identification is where master data comes into the picture.  Master data management (MDM) is a comprehensive method of enabling an enterprise to link all of its critical data to one master file that provides a common point of reference. For instance, provider organizations traditionally have relied upon master patient indexes, or MPIs; however, with increased provider partnerships driven by ACO regulation and mergers/acquisitions, master patient indexes are deteriorating, with duplicates and inaccuracies emerging. To ensure unique and reliable identifiers of key data, organizations are rebuilding and expanding their master data tables in the following domains:

  • Patients
  • Members
  • Physicians
  • Faculty
  • Customers or prospects
  • Hospitals
  • Locations
  • Employees
  • Codes (i.e. diagnosis, procedure, etc.)
  • Suppliers

Reliance on accurate, reliable, and actionable data is critical to advancing the healthcare industry’s triple aim to lower costs, improve quality, and improve the customer experience. Data-driven decision-making is paramount to succeed in a value-based payment environment. Data governance, data quality, and master data management are the foundational elements needed to buttress a successful business intelligence ecosystem and ensure success with population health and value-based programs. With these elements in place, your organization can respond effectively with “holistic, accurate, reliable, and actionable information, which allow us to achieve our value-based objectives and goals.” That’s how you can respond when asked, “who’s on first?”

About the Author

As senior vice president of healthcare solutions for HighPoint Solutions, Jim is responsible for business and financial growth, new product/service development, strategic planning, business partnerships, and staff development across our healthcare practices. Prior to joining HighPoint, Jim spent 14 years as CIO and VP of enterprise operations at Priority Health. He has also held senior positions as JS Advisory Services, Ernst & Young, and Henry Ford Health System.

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The transformation to value-based medicine is a herculean effort for the healthcare industry. The fee-for-service mentality remains heavily rooted at the core of the industry, although efforts to change are gaining momentum, both within the industry and government. Efforts to achieve the transformation include:

  • Payment reform methodologies that align appropriate risks and rewards based on indisputable performance metrics
  • Development, acceptance, and adoption of clinical and evidence-based guidelines and measures
  • Solidification of true collegial relationships within the entire healthcare system, including payors, hospitals, physicians, pharmacies, home care, long-term care, and patient advocates
  • Active patient engagement with self-monitoring, medical advice compliance, patient advocacy, and treatment protocol monitoring
  • Lastly, yet equally important, using data and information as the foundation for holistic insight and measurement

Just like the monotonous lyrics of the song, healthcare has become increasingly dependent on information technology, and as a result, it’s “all about that data!” The performance of the healthcare industry is being meticulously measured, rigorously analyzed, and publically reported – and this includes satisfaction, outcomes, cost, readmissions, wait times, access, and quality. To that end, we must continue to capture holistic patient data, improve analysis, and provide actionable information reporting in order to move the cost, quality, and satisfaction needles. Based on a recent Gartner survey of payor CIOs, the top priority for 2016 investments will be in business intelligence and analytics. 

Healthcare business intelligence is at an exciting juncture. Over the last few years, with the infusion of meaningful use funding, great success has been achieved to capture more structured data as the industry has moved from paper to electronic medical records. Patient-reported data has increased through health risk assessments and self-charting. The industry is at the cusp of fully leveraging telemedicine and wearable devices. With all of this structured data, the business intelligence value equation can evolve in the following ways:

  • From descriptive, which includes basic reporting and drill-down procedures…
  • To predictive, which is alerts, simulations, forecasting, and predictive modeling…
  • and to prescriptive, which is optimization and changing behavior

Data management and business intelligence strategies are often costly and time-consuming; thus, projects have a high risk of failure if they are not handled in a stepwise manner. Unwavering leader sponsorship, coupled with milestone visibility and promotion, is vital. In most organizations, the ideal executive to champion the data management and business intelligence initiatives is the chief operating officer, since C-level attention is paramount. A few key points on the roadmap to success include:

  • Ensuring that your data management strategies include the capture and analysis of administrative, clinical, and patient-reported information from payor systems, electronic medical records, and member/patient portals. All of these data elements are critical to ensure comprehensive line-of-sight into monitoring and management of quality, cost, and satisfaction performance.
  • Establishing a data/business intelligence governance structure that is represented by all departments – especially operations, medical, quality, and finance – to ensure organizational focus on the key metrics and corporate priorities.
  • Ensuring that your business intelligence initiatives are iterative to achieve incremental improvements so business customers see success quickly; this way, support for the business intelligence program will become contagious. Informatics is always ongoing, which aligns well to an iterative, agile approach.
  • Providing detailed drill-down information beyond just high-level metrics to ensure that actions can be immediately taken to improve financials, quality, and/or customer satisfaction performance.

The way that healthcare is delivered and financed will continually evolve going forward. Informed and targeted intervention – from wellness to chronic disease management – is vital to move the needle to improve results. The ongoing cycle of activities should include:

  • Defining a population for improvement
  • Determining care gaps
  • Stratifying risk
  • Engaging patients
  • Managing care
  • Measuring results

At one point in time, the stethoscope was the most important diagnostic instrument in medicine. Today, with the capture of more structured and unstructured data from electronic medical records, prescriptions, claims, eligibility, health risk assessments, self-reported activity, and telemedicine, information is now an equally important diagnostic instrument. The next transition for the industry will be to leverage actionable data within the clinical workflow process to improve the American healthcare industry, based on cost and quality, with an eye on going from last place to first in relation to other industrialized nations. Our medical bag of important diagnostic instruments now includes information technology. So, in the end, it is all about that data!

About the Author

As senior vice president of healthcare solutions for HighPoint Solutions, Jim is responsible for business and financial growth, new product/service development, strategic planning, business partnerships, and staff development across our healthcare practices. Prior to joining HighPoint, Jim spent 14 years as CIO and VP of enterprise operations at Priority Health. He has also held senior positions as JS Advisory Services, Ernst & Young, and the Henry Ford Health System.

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Tuesday, 22 September 2015 21:50

The Alphabet Soup of Quality

“You cannot improve what you cannot measure” is a wise adage we have heard many times as the healthcare industry adopts Lean and SixSigma measurement in its drive toward repeatable quality and evidence-based medicine. The National Committee for Quality Assurance and the Institute for Health Improvement coined the “triple aim” to focus on critical elements to transform the delivery of care – quality, cost, and satisfaction. However, there are many measurement systems that have emerged, and they all have certain key similarities and differences. The challenge is how to maximize results throughout the healthcare system, both with delivery and insurance. How do we make sense of the alphabet soup of quality-based incentive programs and reporting systems? 

Quality and satisfaction measurement systems may have different dimensions, but they commonly focus on physician collaboration and member engagement. The expanded adoption of information-based technology investments, such as electronic medical records and member/patient portals, have enabled progress, but more effort on optimization, collaboration, and engagement is needed.

The following summary, which is intended to be illustrative and not exhaustive, highlights just a few of the measurement programs in place today.

  • PQRS is the Physician Quality Reporting System: a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare beneficiaries. PQRS gives participating EPs and group practices the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time.
  • The Healthcare Effectiveness Data and Information Set (HEDIS), which is 25 years old, is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. HEDIS makes it possible to consistently compare the performance of health plans.
  • CAHPS, or the Consumer Assessment of Healthcare Providers and Systems, is a survey for consumers and patients to report on and evaluate their experiences with healthcare delivery related to aspects of quality, such as the communication skills of providers and ease of access to healthcare services.
  • The Five-Star Quality Rating System is what Medicare uses to measure how well Medicare Advantage and prescription drug plans perform. This tool scores how well plans perform in several categories, including quality of care and customer service, with ratings ranging from 1 to 5 stars, for poor to excellent. The overall star score provides a way to compare performance among health plans. Medicare health plans are rated on how well they perform in five different categories, such as staying healthy, managing chronic conditions, plan responsiveness and care, member complaints, and health plan customer service.
  • The Medicare Health Outcome Survey (HOS) is the first patient-reported outcomes measure used in Medicare managed care. The goal is to gather valid, reliable, and clinically meaningful data for targeting quality improvement activities, monitoring health plan performance, helping beneficiaries make informed healthcare choices, and advancing health outcomes measurement.

As our healthcare industry continues to shift from a private-based system to a public-based system with the continued growth of governmental programs, regulatory reporting requirements will increase and become more onerous. Health plans and providers are being challenged to close the gaps in care to improve quality and satisfaction for patients. Actions to consider for achieving this desired outcome include:

  • Identify the programs that you are eligible for and map out the measures that are consistent or unique in each measurement program. For those consistently obvious measures, which will be many, ensure that work plans recognize similarities and variations so education and actions are efficiently maximized in all areas of the health plan and care delivery operations. Keep in mind that all of these efforts should amplify best practices and evidence-based medicine, so even if you are not eligible for the program, working toward the same goals optimizes the performance of the healthcare system.
  • Establish a revenue maximization department that combines efforts within the quality management/assurance and finance departments to ensure that revenue associated with each measure is consistently maximized – this should include Medicare premium revenue, which is tied to star ratings.   
  • Ensure that your data management strategies include the capture and analysis of administrative, clinical, and patient-reported information from payor systems, electronic medical records, and member/patient portals. All of these data elements are critical to ensure comprehensive line-of-sight into monitoring and management of quality, cost, and satisfaction performance.
  • Promote and enable increased collaboration between payors and the entire delivery system (primary, specialty, hospital, etc.) with performance dashboards, collective action plans, care team education, care management coordination, etc.  
  • Provide comprehensive staff education to create a laser-sharp focus on quality, satisfaction, and cost to improve the overall healthcare system. A firm understanding of the key measures and financial rewards based on the improvement in patient outcomes, both clinically and satisfactorily, is critical. Providing time-sensitive and context-relevant measurement data at the point of decision-making can help to improve scores.
  • Lastly, but equally important as the other measures, patient engagement is a key element needed for successful improvement in quality and cost. Incentives such as gift cards often are used to motivate behavior. However, efforts should not stop there. Every touchpoint for a member/patient should be scrutinized, whether by phone, office visit, health plan visit, or portal use. For example, a routine call to verify benefits can be used to remind a patient about missing a preventative visit. Also, information transparency, such as that created by pricing and satisfaction scores, is vital to gaining trust with consumers. Consistently reporting organizational performance, including poor results, offers powerful motivation to maintain and improve.

The triple aim for improving how care is delivered will continue to be driven by regulatory requirements, economic pressures, and changing patient expectations. With the evolving healthcare ecosystem, the expansion of government-based programs such as Medicaid and Medicare, and the emerging individual market, performance transparency is becoming commoditized and turning into an expectation of purchasers, including government entities, employers, and individuals. Optimizing performance within the entire healthcare system is critical to avoid becoming an outlier. 

About the Author

As senior vice president of healthcare solutions for HighPoint Solutions, Jim is responsible for business and financial growth, new product/service development, strategic planning, business partnerships, and staff development across our healthcare practices. Prior to joining HighPoint, Jim spent 14 years as CIO and VP of enterprise operations at Priority Health. He has also held senior positions at JS Advisory Services, Ernst & Young, and Henry Ford Health System.

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