Three strategies for health plans to take control of quality performance | Geneia

Three strategies for health plans to take control of quality performance

September 18, 2019
Shelley Riser, Vice President, Consulting Services and Clinical Innovations


Make strategic improvements in rules management, consumer engagement an clinical integration to take control of quality performance.

The success of value-based care hinges upon measuring and reporting on the value of care delivered. Unfortunately, and despite efforts to reduce the burden, measuring and reporting quality metrics has become a barrier to delivering the very care it is attempting to measure. 

In fact, 86-percent of physicians cite the “heightened demand for data reporting to support quality measures” as a top driver of physician burnout, and view multiple and duplicative quality measures as one of the main barriers to accepting downside risk and moving into value-based care arrangements.

Quality performance management has become unmanageable. 

And yet, organizations have little choice as value-based reimbursement structures steadily usurp traditional fee-for-service models. By the end of 2020, 59 percent of all healthcare payments are expected to be value-based, up from 34 percent in 2017.

Gaining control depends upon assessing quality management maturity across the organization and implementing purposeful strategies to move methodically toward the ideal state. Ask yourself:

  • Are you, like many, scrambling to keep pace and tracking quality measures on spreadsheets?
  • Do you leverage analytics to manage some aspects of quality management, but are still largely working with isolated solutions?
  • Have you integrated analytics with enrollment and outreach activities to boost member engagement and deliver impactful population health-based initiatives?
  • Can your clinical teams and provider partners easily understand and act on open care gaps?  
  • Is it easy for them to return care gap closure information to you? 
  • Do you rely solely on claims data or have you integrated clinical data to close care gaps faster and provide more meaningful and actionable insights? 

Once your baseline is understood, we recommend health plans take control of quality performance through strategic improvements across three foundational domains – rules management, consumer engagement and clinical integration. 

Robust Rules Management

To manage and improve the overwhelming quantity, variation and application of quality measures and reports, we recommend health plans establish a single home for rules management, powered by a robust rules engine. This rules management center then becomes the hub for quality, contractual and organizational rules management to drive the harmonization and distribution of rules across the payer organization and throughout value-based provider networks. 

Optimize Member Engagement 

Every member interaction is an opportunity to improve the member-plan relationship, gather key information, close gaps in care, educate, enroll in programming and connect members with providers.

To drive quality improvement year after year, today’s consumer-centric insurer must include a strategic approach for member engagement that combines predictive analytics with education, screening and enrollment activities. These activities must be supported by clear, integrated and customizable workflows along with compelling call scripts. This enables engagement specialists to be successful, whether they come from a provider or payer perspective and whether or not they are clinicians. 

Clinical Integration

Clinical teams remain the front-line and linchpin of all quality improvement initiatives. It is imperative that reducing reporting burden be part of every long-term quality improvement program. 

Thoughtful clinical integration is a big part of the solution on both fronts, but, before we can talk about clinical integration, we must have a shared understanding of what clinical integration is. There are two types of clinical integration driving the highest value for improving quality performance – data integration and systems integration. Long-term success in quality improvement requires increasing degrees of integration between clinical and claims data sources, workflows and systems.

When health plans, physicians and clinical teams can easily share information, view each other’s notes, documentation, activities and care plans, it drives better quality performance while improving physician, care team and member experience.

To learn more, I invite you to download our latest white paper, Take Control of Quality Performance: Three Proven Strategies for Health Plans.

Download the white paper


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