Tuesday, 22 September 2015 21:50

The Alphabet Soup of Quality

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“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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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.