In our last webinar, titled: Streamlining Your Quality Processes, our very own Bruce Carver, Associate Vice President of Payer Services, addressed the challenges and strategies needed to ensure health plans were succeeding with quality management. The healthcare landscape, especially for payers, has changed. With the introduction of MACRA and now with nearly 500,000 physicians submitting data towards it, the shift towards value is in full swing. The promotion and adoption of value-based care and the importance of quality outcomes (from NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare’s Star Ratings) has moved quality from a measurement system to an operational workflow. Payers now more than ever need to create a strong quality management program by establishing processes, leveraging data and establishing best practices to properly benchmark and track their progress.
Bruce outlined the common challenges health payers face when achieving a successful, streamlined quality management program. The challenges range from inaccessible, inaccurate data to inefficient processes and workflows. The bulk of these challenges can be alleviated with organizational processes and analytics which create checks and balances to ensure quality management programs are moving in the right direction.
Today, achieving high-quality outcomes requires an all-hands on deck, year-round effort. To work towards these programs, there are a few stepping stones that will enable health plans to implement effective processes of measurement. Here are some of the key components to quality improvement:
- Continuous, objective, and systematic process for monitoring and evaluating key indicators of care and service
- Identification of opportunities for improvement
- Development and implementation of interventions to address the identified opportunities
- Re-measurement to demonstrate effectiveness of program interventions
Beyond processes, health plans need to look to data for guidance as it is a key to success. The rich source of information enables payers to be more proactive as it offers them the ability to assess where the organization stands and areas of opportunity. Analytics plays a major role as it transforms the data into action, including:
- Timely, near real-time assessment of performance on quality measures and programs throughout the year
- Performance monitoring of various shared savings groups and their pay-for-performance program
- The ability to share data with providers to ensure engagement and follow through on quality metrics
Without analytics, you don’t have the big picture needed to understand the quality measurement processes and outcomes.
The last part of the webinar highlighted some of the best practices health plans could utilize once they established the initial stepping stones in their quality management program, including:
- Engaging providers – involve them early to make reporting faster and more efficient
- Monitoring gaps in care – evaluate quality results to establish goals and benchmarks
- Simplifying and streamlining chart chase – track measurements and add supplemental data in a centralized manner
- Increasing staff productivity – reduce the need for a large, skilled staff
As the industry marches, even closer to value, payers are entering a new role as data aggregator in the healthcare system. Although challenging, with the right data and approach, payers can improve quality and efficiency along with reducing costs to their providers. The key to success is to leverage the right resources at the right time and to work together on common goals.
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