Tuesday, 21 July 2015 05:13

Aligning Metrics you Already Have with the Interests of Employers

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We always seem to forget one key decision-maker when we talk about health insurance: the employer. Forty-three percent of America’s insured individuals remain covered through employer-sponsored plans despite the Patient Protection and Affordable Care Act reforms of health insurance benefit structures. I’ve even heard employers tell me that since they pay the Federal Insurance Contributions Act (FICA) tax, Medicare itself is an employer-sponsored plan. Employers think differently about healthcare and they are curious about alternative payment models involving quality providers to bring down costs.

I recently sat down with a specialty client to begin identifying meaningful quality metrics that would interest large employers in their service area. We started by looking at the information required by attesting physicians for meeting and exceeding the Medicare meaningful use requirements and then turned to the Medicare Physician Quality Reporting System measures.

Honestly, we found very little data that the employer would not already know. Employers should have access to information on whether their employees smoke (self-attested) and are filling their prescriptions. Employers have access through their partner health plans to more information than providers have. For example, did the patient fill the prescription (and refill), and was it for a generic unless the clinician indicated to dispense as prescribed? That’s something that’s not always clear to all parties. The rest of the data collected by the majority of specialists may not even be helpful. Primary care providers have more options, which are discussed in more depth below.

Data Areas to Focus on and Advocate for

Since so little of the data collection mandated through the Medicare program is useful to employers, what works? Currently, there are three major areas of focus to being able to streamline care to increase coordination and decrease overall costs. While health plans may be interested in decreasing costs for a one-year period, employers are more likely to look at cost savings over a longer period – the average tenure of an employee, for example. Areas to look for mutual interest are chronic disease control, point-in-time cost control, and cost aversion.

Thus far, the evaluation process has pointed to a number of areas without industry measures or peer-reviewed study. Over time, this process may result in proposals for new measures and published results of these activities. And since so few of these data points are recognized in the industry, only a few are captured in association registries and other data-collecting bodies.

Our process began by finding a concept, identifying the appropriate workflow to gather data, and then evaluating the data over a short-term period to see if it is meaningful and yielding a reasonable expectation of better outcomes and decreased cost. If the concept doesn’t glean the anticipated information, or if the workflow is too difficult and time-consuming, the next concept is evaluated. One of the biggest challenges has been capturing data that requires clinical involvement – physicians and other clinical staff are tired of clicking yet another button in their electronic medical records.

Chronic Disease Control

As noted above, Medicare does have key areas of focus for employers regarding adult chronic disease management. For pediatrics, there are some decent measures in the meaningful use data set. However, the main critique of all of these measures is that they are process-oriented and not outcome-focused. That means that these measures are the starting point and require additional data to be collected and evaluated to identify quality outcomes and cost savings. In the end, for the measures to become meaningful, they must be part of a measure set and all data points must be captured, in addition to the outcomes and cost information gathered by the entity.

Measure # Description Age demographic
NQF 0001 Asthma: Assessment of Asthma Control 5-64
NQF 0059 Diabetes: Hemoglobin A1c Poor Control 18-75
PQRS 301 Hypertension: Low Density Lipoprotein (LDL-C) Control 18-90

Additional data points that are required are numerous. Below are a few to consider:

Description Age demographic
Days post-visit (or intervention) to return to work/school 5 and older
Quality of ability to complete work with ailment; post-intervention 18 and older
Volume of previous 12-month visit(s) to an emergency department All
Volume of previous 12-month admission to the hospital for any reason All
Other clinicians seen for all medical, emotional and exercise support 5 and older

Note that the concepts above do not center on quality of life or activity. Those are metrics that interest academics and Medicare. This is strictly focused on working-age productivity.

Also, consider that some of this information may not be reliable if it is patient-reported. So, alternative sources must be considered, including partnering with area hospitals and connecting with health information exchanges. Most data may be captured via patient self-reported data through intake questionnaires for new patients and follow-up visits. Concerns are patient fatigue and answering the same questions over and over again – questions that are repeated at all medical offices – and the level of health literacy of the patient population. Any changes to patient questionnaires should be evaluated and piloted to ensure accuracy of the data collected and patient understanding of the need for correct information.

Point-in-time Cost Control

This has been a key area for public and private health plans, with some active participation by employers. Alternative payment models fit into this area for bundled payments, reference pricing, capitation, and other structures where reimbursement is predictable and some financial risk can be shifted to the provider. Therefore, it is an area of great experimentation, and new concepts are being met with excitement.Areas to evaluate are:

  • Predictable care episodes: Are there treatment regimens that are episodic and standardized in your patient population? Could you establish a universal budget for each patient that has little risk adjustment? Areas with some success in this realm are knee and total hip replacements and colonoscopies.

  • Prescriptions: Are you prescribing generic drugs when possible? Are you managing patients with multiple prescriptions to reduce the overall quantity and costs while producing the same outcomes? This may be a controversial topic for many clinicians that don’t see their role as involving the management of polypharmacy. As biologics expand and new genetic therapies emerge, however, this area will become a point of emphasis. Groups that move past cultural barriers and take on this role can and should use this area for shared savings discussions with both health plans and employers.

  • Productive workforce: Employers invest in healthcare coverage so they can have a productive workforce to accomplish their business objectives. But for the last several decades, employers have been stuck with a lackluster investment that leaves their workforce less than optimized due to health issues and missed days in the office. Data shows that interventions and therapies with superior return-to-work time periods and heightened activity (more time able to stand, walk, carry items, etc.) are exactly what employers are looking for, and most will be very willing to partner with groups able to deliver results.

Cost Aversion

The most longstanding measure that falls into this category is the aversion of readmission to a hospital during a specified global period. It’s a big-ticket item and a hard nut to crack across all diagnoses. Other areas that ambulatory facilities can evaluate include:

  • Alternative treatment settings: Several pilot programs have evaluated readmission and emergency department visits following initial patient encounters in an alternative treatment setting such as an urgent care center or chronic care education clinic (an asthma center, for example) or post-care visits in the home. Here the cost aversion is somewhat speculative, but it’s a significant win if a hospitalization is avoided. However, ambulatory care runs into an inherent problem that the inpatient and outpatient sides of the Medicare dollar do not flow back and forth. Instead, these are programs to evaluate for the working aged until the Part A and Part B buckets are aligned in forthcoming reforms.

  • Protocol adherence: Offices with standardize protocols for diagnosis and treatment regimens are at an advantage. For example, offices that don’t require a CT or MRI for a pneumonia diagnosis, and instead encourage the order of a flat X-ray, will be a step ahead in the game of cost aversion. Where clinicians can agree on protocols, workflows can be modified as required by medical necessity – but consider the overall cost of modification, should it be pursued and adopted. These protocols help demonstrate clinical integration for care coordination models, group practices, and other health provider models scrutinized for abuse of market power. And these protocols can be used to reduce overall treatment costs.

  • Prevention: This is an exercise of population health data analysis. For example, primary care offices that give flu immunizations can evaluate the incidence of complication and hospitalization in their populations and extrapolate using relevant data. This can be applied to numerous other existing measures for preventive services such as breast examinations, screening colonoscopies, etc.

As this new era of reform in the healthcare industry takes hold, data holds a key to success. It also provides an opportunity to meet bedfellows that were not as transparently at the table before. Direct engagement with employers must be a part of the medical provider’s strategy for success; otherwise, important initiatives and mutual areas of benefit will be lost.

About the Author

Jennifer is the founder and CEO of SCG Health. Previously Jennifer was the vice president of external provider relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare, and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payor operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare. Prior to this, Jennifer served as the external relations liaison for the Washington, D.C.-based Government Affairs Department of the Medical Group Management Association (MGMA). As the external relations liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the government affairs representative for the Eastern and Southern sections. She began her work with MGMA in August of 2001. She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics in Context.

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Last modified on Tuesday, 21 July 2015 05:23

Jennifer is the Founder and CEO of SCG Health. Previously Jennifer was the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payer operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare. Prior to this, Jennifer served as the External Relations Liaison for the Washington, DC-based Government Affairs Department of the Medical Group Management Association (MGMA). As the External Relations Liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the Government Affairs Representative for the Eastern & Southern Sections. She began her work with MGMA in August of 2001. She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics In Context.