How to bring payers and providers together to improve outcomes
Quality collaboratives are comprised of multiple teams working together from different domains within the healthcare industry. Payers and providers have shown success in working together as a collaborative team sharing the same mission, improving healthcare outcomes in patients within the network each team serves. These collaborative efforts bring focus on improving medical services throughout in-network hospitals under contract with payers whose members are receiving care.
Below are five key features that are evident within successful quality collaboratives.
1. Routine Communication
Open dialogue and routine communication between care management and provider relations departments are strong signs of a healthy and active quality collaborative. Establishing routine meetings provides a foundation for clinical quality teams to succeed who are focused on improving care within patient and member populations. Assigning and maintaining a consistent point-person who’s well-versed in medical terminology, healthcare practices and value-based purchasing that helps bridge the clinical quality gap between payers and provider is in the best interest of health insurance companies.
2. A Shared Mission
Improving healthcare outcomes is the ultimate shared mission. However, there are many possible paths and end-goals which can lead to improved healthcare outcomes. Establishing a consensus between payers and provider on what paths and end-goals will have the most positive impact are necessary details all quality collaboratives need to establish in order to be successful. A hospital’s known weak points may not align with a payer’s initiatives. A payer’s initiative may be influenced by statewide healthcare exchanges, Centers for Medicare and Medicaid Services’ (CMS) Medicare Stars program, as well as claims data revealing negative impacts on payers populations. A hospital’s weak points may be highlighted by, but not limited to, a recent malpractice lawsuit, a low publicly reported national rating and ranking score or a known, in-house quality measure negatively impacting financial and personnel utilization.
3. Achievable Timelines
Course correcting and continuous improvement within large healthcare facilities requires time and resources. Highly specialized professionals with unique backgrounds in quality, clinical data processing and change management are necessary for collaboratives to be successful. Establishing realistic timelines that take into consideration the details of connecting with champions and putting data transfer and reporting systems into place are important. Taking into consideration how latent the data may be and how extreme the needed quality course correction is will help the two teams gauge and align with achievable timelines.
4. Efficient Data Exchanges
At the 2019 Healthcare Effectiveness Data and Information Set (HEDIS) Quality Forum, in Nashville, Tennessee, speakers Michelle Fischer, Chief Contracting and Payers Relations Officer for University of Washington Health System and Dr. Jatin Dave, Chief Medical Officer for New England Quality Care Alliance and Attending Physician Professor at Tufts University School of Medicine, hosted a “Provider Perspective Panel” where they effectively communicated the need for consistent formatting and user-friendliness within payers-provider data exchange portals. The audience, comprised mostly of health insurance professionals, expressed their frustrations in receiving, if any, incomplete and disorganized data. These poor data exchanges then result in frantic chart-chasing during HEDIS season, sometimes contributing to failed attempts to acquire needed patient records, which can result in rating penalties by the Medicare Stars program for reporting insufficient results. Following the panel discussion, there was a consensus that current data exchange systems between payerss and providers have much to be improved. Putting a Health Insurance Portability and Accountability Act (HIPAA)-compliant system in place with efficient import and export functionalities, which lead to clean and complete data, will greatly contribute to the success of a quality collaborative.
5. Incentivized Outcomes
A bonus, quality reimbursement, carrot, whatever you want to call it, quality collaboratives need to incentivize healthcare outcomes. Putting a dollar amount on successfully improving specific clinical metrics within a health facility will help maintain traction and engagement between the two teams. This approach will influence a results-driven culture and go beyond just reporting measurable outcomes.
In February 2018, Blue Shield of California (BSC) began strategizing how to better influence clinical quality improvement within BSC’s 352 in-network hospitals. A Hospital Quality Lead Team was assembled; and through my guidance as Lead Manager, began putting systems in place to actively engage hospitals on improving specific measures mandated by Covered California. One of the primary challenges involved the acquisition of current, risk-adjusted data to establish goals based on national benchmarks. The team’s ultimate mission was not only to bridge the quality reporting gap between payers and provider, but to also influence timely and measurable change within patient outcomes.
An ideal time to engage and incentivize health facilities in aligning with specific quality initiatives is during contract renewals. Building quality clauses to be inserted within hospital contracts in anticipation of these events will benefit health insurance companies in pursuit of forming quality collaboratives within their network. However, some hospitals are on Indefinite Duration Contracts (or CIDs). In these cases, it is best to consult with legal counsel to determine strategies to overcome potential legislative barriers when approaching these perpetual agreements. Introducing an incentive to break these contracts has shown promise in opening the legal doors to include quality clauses within CIDs.
Quality collaboratives are an opportunity to close gaps in payer-provider quality reporting and improve in-network patient outcomes. Routine communication, a shared mission, achievable timelines, user-friendly data exchange systems and incentivized outcomes are key features that provide strong opportunities for clinical quality teams to succeed. Although payers and providers are on two different sides of the curtain within the healthcare industry, both are stakeholders in their community’s health and, after all, they are on the same team. It is in the best interest of both stakeholders to better the health of their beneficiaries receiving care. Health outcomes are improving, and successful quality collaboratives are leading the way to help make this happen.
Evan Osborne, MPH, BSRT(T), (ARRT), is a Manager with Dacarba LLC, a subsidiary of Opportune LLP, specializing in the field of healthcare quality. Evan has over 10 years of professional and leadership experience in direct patient care, continuous improvement, as well as provider and payers clinical quality. With a deep background in change management, oncology, project management and program development, Evan has successfully built and managed programs addressing health equity and social determinants. Scholastic achievements include Bachelor degrees in Biology at Western Oregon University and in Radiation Therapy at Oregon Health & Science University. He later earned a Master’s degree in Public Health at the University of Massachusetts, Amherst, and is currently completing a Doctor of Business Administration at California Southern University.