Engaging Providers in Quality

According to a recent study by researchers from Weill Cornell Medical College, and as recently reported in Health Affairs, medical practices in four common specialties (cardiology, orthopedics, primary care, and multi specialty practices) spend an average of 785 hours per physician and $15.4 billion annually reporting quality measures to Medicare, Medicaid, and private payers.

As the transition to value-based care, alternative payment models, and quality-related financial incentives continues, the number of quality measures and complexity of both measures and payment methodologies will also continue to expand in the coming years. To best preserve and strengthen the provider partnerships we’ve worked hard to create within Medicare Advantage (MA), we must consider the effectiveness of our provider engagement and support strategies in our pursuit of success within quality measurement programs such as Star Ratings within MA and the Quality Ratings System (QRS) within the Health Insurance Marketplace.

Although many providers have established robust quality programs with expert resources to build workflows, streamline care pathways, and coordinate care across their patients’ clinical and social realms, many more are still adapting to this new reality of quality measurement, and some are struggling to develop workflows that meet the wide array of their various payers’ requests. In order to successfully impact the Triple Aim, payers and providers will have to continue actively collaborating and coordinating care across differing specialties, differing clinical settings, and with their patients’ pharmacies and pharmacists. Similar to a Customer Experience strategy, which a health plan may develop to support members’ needs, a health plan should similarly develop a Provider Engagement strategy to support providers’ needs during this evolutionary period. While such strategies are often built around a foundation of quality-related financial incentives, many plans are finding success using other incentives that more closely align with a practice’s needs, such as staff support, member engagement and outreach support, and enhanced care coordination efforts.

Despite growing efforts to align measures and measure criteria across federal programs, measure developers will likely continue adding measurements associated with more complex clinical conditions. For example, the Centers for Medicare & Medicaid Services (CMS) is considering the addition of measurements of Medication Reconciliation Post Discharge and Hospitalizations for Potentially Preventable Conditions to the 2018 Star Ratings program and Statin Therapy (both in Part C and Part D), Asthma medication management (Part C), and Depression (Part C) to the 2019 Star Ratings program. Because more than 25% of the 2018 Star Ratings Healthcare Effectiveness Data and Information Set (HEDIS®) measurement year has now passed, many plans are already opening a new dialog with providers to broaden quality improvement efforts into more intensive, higher return on investment, member-centric engagements that will address these important clinical areas.

As many plans begin delivering their initial 2016 Gaps in Care reports to providers, this may be an ideal time to evaluate your provider engagement strategy. Following are some important elements to be considered in an effective provider engagement strategy:

•  How closely is your provider profiling aligned and prioritized with the full scope of Star Ratings and/or QRS quality measurement needs? Have you evaluated your providers’ historical performance across the entire spectrum of cost, quality, risk, and utilization to help manage current year expectations and risks?
• How effectively are field personnel (Provider Relations, Quality, Contracting, etc.) identifying the “ask” for each provider among all quality measures (including HEDIS®, Consumer Assessment of Healthcare Providers and Systems (CAHPS®), Health Outcomes Survey (HOS), and Prescription Drug Event (PDE) measures) and communicating the right “call to action” to your high-need providers based on your contract’s highest priority measure gaps?
• How effectively are various field teams (including those across product lines, including MA, Medicaid, and commercial plans) collaborating and partnering to deliver seamless, unified service to your providers? How effectively are field personnel identifying each provider’s barriers to success and sharing examples of proven industry best practices that have proven to be successful within similar practices?
• Are your provider compensation programs strategically designed in ways that minimize risk and optimize provider engagement and performance?
• Has your provider engagement strategy been designed to evolve naturally and contextually throughout the year? Do all field personnel understand which clinical areas, quality measures, and resources to focus on each month? How effectively have CAHPS® needs been woven into the strategy?
• Do you know which providers need your support and expertise and are open to your help? Do you know which providers need improvement but are not open to help?
• Are your reports and data comprehensive and actionable for providers? Can providers easily access and use your data-related tools and resources?
• Do your providers understand how to support their patients’ social and lifestyle needs after a clinical visit? Do they have adequate resources to meet such needs in a way that accomplishes your goals?
• How effectively are plan-driven activities, such as case and disease management, health and wellness coaching, etc., coordinated with providers?

We often assume our providers will rapidly move with us to a more proactive, more coordinated model of care. The reality is, many providers are still struggling to adapt their practices to meet day-to-day operational demands while trying their best to meet as many payer needs as possible. Because the quality bonus payments to MA plans for strong Star Ratings performance expedited the pace of learning and adaption within MA plans, MA personnel now have a unique opportunity to participate in the industry evolution by educating and supporting their providers.

The industry’s transition to proactive care coordination is just the beginning. This is an ideal time to truly expand our provider partnerships with high-value, mutually-beneficial resources, support, and tools to help our providers redirect some of their valuable resources from quality measurement reporting to caring for our members.

This blog was originally posted on blog.gormanhealthgroup.com.

John Gorman: Under John’s leadership, Gorman Health Group has become the leading professional services and solutions firm for government-sponsored health care, providing thought leadership and expert strategic, operational, and technology-based solutions. Read more.