Quality requires assessment tools that operate in an objective manner. That’s where healthcare performance measurement programs come in.

Cate Higgins, Senior Clinical Consultant, Medecision

Beauty is definitely in the eye of the beholder. Quality, however, requires assessment tools that operate in a more objective manner. That’s where healthcare performance measurement programs come in.

“All these programs arose out of a very basic need to be able to normalize how people were measuring quality across multiple organizations. While it’s possible to argue whether specific performance measurement programs offer the best ways to measure quality, it’s clear that these programs do create some standardization,” says Cate Higgins, Senior Clinical Consultant at Medecision. As such, performance measurement programs provide a mechanism for health plans to compare quality both across and within organizations.

The Healthcare Effectiveness Data and Information Set (HEDIS®), for example, provides standardized measures that specify how healthcare organizations collect, audit and report performance information across clinical areas, as well as important dimensions of customer satisfaction and patient experience. Administered by the National Committee for Quality Assurance (NCQA), HEDIS includes more than 90 measures across six domains of care:

  • If Medicare beneficiaries remain healthy while on their plan
  • Effectiveness of care
  • Access/availability of care
  • Experience of care
  • Utilization and risk-adjusted utilization
  • Health plan descriptive information
  • Measures collected using electronic clinical data systems

The Centers for Medicare and Medicaid Services (CMS) uses the CMS Star Ratings to assess the quality of Medicare-sponsored plans. Star Ratings for these plans are established by an analysis of six factors:

  • If Medicare beneficiaries remain healthy while on their plan
  • Management and improvement of beneficiary chronic conditions
  • Member experience with health plans
  • Customer service performance
  • Member complaints with health plans
  • Changes in overall health plan performance

Via participation in these performance measurement programs, health plans can:

Make sure members are receiving top-notch care. Performance measurement programs provide a nice way to ensure that members are getting a higher quality of care. Are they the be-all and end-all? No, they’re not. But by leveraging these programs, a health plan might be more likely to ensure that a member gets their blood pressure checked, gets their annual mammogram, and gets their colonoscopy. And, when members receive these services, outcomes are likely to improve.

Save costs by reducing utilization. As health plans steer members toward receiving quality care, overall utilization could be reduced. If members are in good health or stable condition, then they are staying out of the hospital and that obviously keeps overall costs down.

Nan Sloan, Vice President, Compliance, Medecision

Address quality issues with providers. Performance measurement programs make it possible to participate in an honest, quality discussion with providers. “If everyone acknowledges that the performance standards are used across the industry, then providers will not look at the measures as something that the health plan has made up to trick them out of reimbursement. This way they become a means for taking the natural distrust out of the equation, which is especially important when providers are sharing risk with health plans under value-based programs,” says Nan Sloan, Vice President, Compliance, Medecision.

Keep tabs on performance in a variety of areas. CMS Star Ratings enable health plans to perform some level of a quality assessment on how well they are functioning across multiple areas. The measures don’t just assess quality of care but also other factors such as the level of member satisfaction with the plan’s services.

Provide consumers with a comparative metric. “Consumers are likely to look at the Star Ratings to decide which plan to enroll in. And, if members are in a poorly performing plan, Medicare will send them a letter and the consumers can opt to change plans. If a plan loses a half Star of rating, there will most likely be a significant reduction in enrollment,” observes Connie Webster, Senior Director for Clinical Consulting, Medecision.

Connie Webster, Lead Clinical Consultant, Medecision

Perhaps most important, though, participation in performance measurement programs can help health plans lay the foundation for comprehensive quality improvement initiatives.

“From a strategic level, these measurement initiatives can serve as the building blocks of more comprehensive quality improvement programs,” Higgins adds. Health plans can cull the performance measures down to a cohort that makes sense to them. So if they really care about Hemoglobin A1c, for example, or they care about certain physician practices, they can focus on the relevant outcomes and the care managers can work to close those gaps. Thus not only do plans have access to performance information, they’re going to have a way to make that information actionable.

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