Improving Healthcare Quality: Four Proven Health Plan Strategies That Providers Should Adopt

As payments become more closely aligned with quality metrics in preparation for a value-based healthcare system, quality measurement and reporting will take on greater importance for healthcare organizations. What used to be an annual check-the-box process for health plans has evolved into a year-round strategic initiative. Meanwhile, providers are being asked to master a new skillset: reporting on quality metrics across their patient panels.

The Role of Data

Data, obviously, will play a key role in healthcare organizations’ understanding of quality performance, but the type of data and the processes involved in collecting, aggregating, and analyzing it vary greatly depending on the type of organization (i.e., health plan or provider). Health plans work primarily with claims data, which provide broad insights across the care continuum, with a goal of managing financial and clinical risk. Providers, on the other hand, delve deeply into multifaceted clinical data for each patient, with goals of making the proper clinical diagnosis and achieving the best possible treatment outcome.

Similarly, although health plans and providers both care about quality, their methods for improving it have differed due to their varying perspectives. Health plans have developed a well-tuned, systematic approach that focuses on population- and network-based analysis and outreach. Meanwhile, providers have focused on individual patients.

Over the years, the evolution of quality measures such as the Healthcare Effectiveness Data & Information Set from the National Committee for Quality Assurance and Medicare Star ratings from the Centers for Medicare & Medicaid Services has driven health plans to create a disciplined methodology to drive quality. Health plans have committed significant resources to support their quality initiatives and implemented tools that help them use their many years of claims data to better inform their quality improvement efforts. They also have adopted innovative technologies that allow them to extract clinical data from claims.

The Transition to Value

One of the most important outcomes of the move to value-based payment is that the definition of value is becoming more standardized and less subjective. Increasingly, quality is being evaluated against a generally accepted, industry-validated set of metrics that have largely been generated in health plan environments.

As providers continue to take on risk and report on quality, here are four strategies that providers can borrow from successful health plans.

Look at the big picture. Providers should look at their entire patient panel across the continuum of care as well as their provider networks. High-performing provider networks can share insights and best practices to help move along low-performing networks. By taking a more horizontal view of their world, providers can find opportunities to improve quality.

Partner with health plans. As risk shifts from health plans to providers, the two must work together. Providers will need to embrace claims data in addition to clinical data, as claims provide a 360-degree view of patients and the overall population. Claims also provide critical historical information. By working with health plans, providers can get access to important data and best practices regarding data aggregation, management, and analysis.

Invest in technology and infrastructure. Interoperability is especially challenging for providers, whose data tend to be unstructured and fragmented. Health plans continue to invest in a wide range of technologies—e.g., reporting platforms, natural language processing (NLP), and optical character recognition (OCR)—and third-party resources to support their quality efforts. Providers will need to deploy similar technologies, tools, and tactics to optimize their quality initiatives.

Focus on one target. Successful health plans follow a formula that helps identify how to reach a certain threshold with the least amount of effort. For providers, the trick is to be similarly mindful about where to focus their efforts, which should be at the intersection where health plan goals and patient needs meet. Because most providers do not have the resources to pursue all identified opportunities, they should carefully outline criteria for determining priorities. Providers that can effectively align with health plans can better leverage resources to meet their own goals.

Keeping the Patient in Mind

Health plans achieve five-star ratings because they excel at delivering the experience their members deserve and desire—something that providers know well. As health care continues to evolve, the best quality improvement approaches will be those based on informed collaboration and best practices learned from both sides of the healthcare equation.

Emad Rizk, MD, is president and CEO of Verscend Technologies, Waltham, Mass.