How a payer-provider collaboration around quality reporting can reduce costs and improve outcomes

Too often today, relations between provider and payer organizations can become contentious around issues related to payment and quality of care. Yet such conflict does not serve patients well, because it deflects these organizations’ attention from their underlying shared purpose: To work together to deliver well-coordinated, cost-effective healthcare to patients.

With this purpose in mind, LifeBridge Health, a health system with 1,200+ beds and 120 physicians, and CareFirst BlueCross BlueShield (CareFirst), a payer organization with about 3.5 million members, are collaborating on an initiative to innovate the quality-measures reporting process. The two Baltimore, Maryland-based organizations have developed new processes, procedures and workflows to fine-tune information sharing that supports a more automated quality measures reporting process. The arrangement has proved beneficial to both organizations in helping them improve patient outcomes while meeting regulatory requirements. It offers a viable example of how other payer and provider organizations can begin to collaborate meaningfully.

Why collaboration on quality reporting is needed

The rationale for the LifeBridge-CareFirst collaboration was compelling. Provider organizations enter vast amounts of clinical data into their EHRs and other IT systems every day for myriad downstream functions. These systems then continue to house valuable information that providers must access and retrieve for diverse purposes, among them being the task of generating quality reports. Yet the process of quality measures reporting remains fraught with operational costs, manual procedures, and staff time.

Common challenges include a lack of standardization across data elements, varied quality reporting requirements across CMS and payers and weighting measures that are in constant flux. For example, even within a single health system, there may be significant inconsistencies among the EHR’s data elements, in how laboratory results are presented, and in the way discharge summary sections are formatted. With volumes of quality measures on the rise, human intervention is needed for practically every step in the process.

A proposed expansion of the US Core Data for Interoperability (USCDI) announced by the Office of the National Coordinator for Health Information Technology (ONC) in June 2023 seeks to improve the process through harmonized data and greater use of FHIR-based reporting, Nonetheless, quality measures reporting remains costly and time consuming for healthcare provider organizations.

Effect of innovating the quality measures reporting process

In 2023, the KR Collaborative of KLAS Research in Pleasant Grove Utah, recognized the LifeBridge-CareFirst collaboration for its effectiveness in improving payer-provider workflow (see also the sidebar, “KLAS recognizes payer-provide abrasion in healthcare,” below). The collaboration was praised for its ability to:

• Reduce friction and administrative burden between the organizations
• Break down information silos
• Provide clinicians with an expanded view of clinical data

This type of improved collaboration between payers and providers is only possible through better provider-payer clinical data exchange.

The information-sharing initiative achieved the following specific outcomes:

• A 63% improvement in Healthcare Effectiveness Data and Information Set (HEDIS) quality measures through less manual intervention and finding additional data in the EHR
• Superior performance by participating physicians compared with control group physicians in five quality measures
• Mapping of patients’ longitudinal records across settings
• Ensured data integrity in compliance with the National Committee for Quality Assurance (NCQA)
• Implementation of new best practices to achieve more efficient quality measure reporting

5 best practices for improving quality measures reporting

LifeBridge Health and CareFirst learned many valuable lessons throughout the project. They attribute their positive experience with the collaboration to five best practices.

1 Use aggregate data from all providers, across all formats. This data set should include data from outside physician practice electronic health records (EHRs) and analog documents. Non-standardized data reflecting continuity of care should be mapped into one unified record to give both the payer and the provider the ability to track patients across settings and over time.

2 Build deeper EHR connections. The organizations should apply sufficient resources to ensure proper and efficient data transfer from all the various source systems so providers can focus on patient care instead of quality measure reporting. Key concerns in transferring data are to ensure that data can support accurate quality measurement and that the data is sufficiently comprehensive in representing how well care is being provided.

3 Check data accuracy thoroughly. The provider organization should engage data experts and clinicians to check the quality of data received from source systems to ensure data in each system matches the data sent to the payer and used for quality reports.

4 Establish strong data governance. Strong governance starts with clear and thorough communication with all stakeholders involved and a well-conceived strategy for designing and developing the technology required for effective data sharing. Strong governance ensures the project proceeds in the right direction and accounts for new impacts on people and processes as organizations assume more risk-based contracts and expand quality reporting activities.

5 Educate the providers. As value-based care continues to advance, changes to quality reporting are inevitable. It therefore is important to keep physicians and other clinicians apprised of how improvements in data aggregation and quality impact their quality reports and potential payment under value-based contracts.

Key implementation challenges beyond the EHR

Many provider organizations believe that they can accomplish the foregoing five best practices using the EHR alone, without additional human intervention or technology investment. However, this is not the case. Gaps remain. Three challenges were identified.

1 Overcoming EHR limitations. There are specific challenges around collecting and aggregating information that require specialized solutions beyond of the capabilities of EHRs. These challenges include accounting for varying data formats, unique populations and disparate data segments such as PDF or handwritten documents faxed into the health system, OB-GYN information scattered across multiple documents and specific data needed for risk-adjustment reviews. Organizations need to establish a collaborative process for identifying and managing these diverse elements.

2 Dealing with unharmonized data. Another obstacle the organizations identified during the implementation process was the challenge of dealing with the lack of consistency or standardization among data elements for quality measurement and reporting requirements across CMS, payers and health plans. This challenge was exacerbated by the need to address a substantial number of quality measures. To address these issues, the organizations required the expertise of two types of professionals:

• Data aggregation experts to ensure the ongoing consistency of incoming information  
• Knowledgeable quality reporting professionals to ensure the correct reports were sent in the proper format

3 Maintaining effective communication between the collaborating organizations. LifeBridge and CareFirst also quickly recognized the critical importance of joint operating committee meetings for maintaining communications and building trust. Such meetings facilitate the exchange of information needed to build confidence in the collaboration. They also quickly realized that, for any such arrangement, it is important to begin scheduling these regular meetings as early in the relationship as possible to build and sustain a level of payer-provider trust that will ensure the collaboration’s ongoing effectiveness.

Justifying the spend

The value of clinical data exchange manifests in many ways. For example, providers that participate in value-based care programs such as ACOs can be assured of receiving financial incentives based on their quality performance. Providers and payers alike also can benefit from taking action based on insights generated from quality measures. This benefit is especially important for providers in light of increased labor costs, because of their need to allocate limited resources across care delivery and administrative tasks, while upholding high standards of care.

Putting quality measures into perspective

A recent paper by Johns Hopkins Medicine published in JAMA adds perspective to the volume of quality measures throughout healthcare and the resultant administrative costs.^a The paper identifies 162 metrics used by Johns Hopkins Medicine in the inpatient setting alone. The organization set out to measure the annual cost of data collection and reporting for quality measures and found that it exceeded $5 million (2022 USD) in personnel costs while also requiring more than $600,000 in vendor fees. Claims-based and chart-abstracted metrics were the most labor-intensive, while electronic metrics consumed far less cost and staff time.

Certainly not every organization is like Johns Hopkins with 162 quality metrics. But the challenge remains. New technology, processes and procedures for quality measures reporting reduce costs and administrative burdens. And the provider-payer relationship improves when quality measures are electronically tracked and reported, versus using manual interventions.

Also, some health systems and payers are more adept at quality measures reporting than others. The process is a unique journey for every healthcare organization. Yet through better clinical data exchange providers and payers regain staff time, reduce costs and build stronger alliances along the journey to value-based care.

Footnote

a. Saraswathula, A., Merck, S.J., Bai, G, et al., “The volume and cost of quality metric reporting,” JAMA Network, June 6, 2023.

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KLAS recognizes payer-provider abrasion in healthcare

aunched an initiative, called the Payer/Provider Initiative, to reduce friction between providers and payers. Under its new name, the K2 Collaborative, the initiative includes annual “Points of Light” awards that celebrate success stories from payers, providers and IT vendors that have partnered together to reduce costs and inefficiencies and improve the patient experience.

By recognizing successful efforts and partnerships between health plans, providers and vendors, the awards encourage each party to focus intently on reducing administrative waste and process inefficiencies in the U.S. healthcare system, as part of a comprehensive initiative designed to encourage innovation and improvement. In 2023, KLAS conferred Points of Light awards on 25 collaborations and issued case study reports on each collaboration.