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Measurable improvements in clinical quality through payer-provider collaboration


For a traditional primary care practice, incentives can range from $3,000 to as much as $25,000 annually if key quality metrics are attained

Over the past several years, healthcare payer’s transition of incorporating traditional fee-for-service care with value-based initiatives has resulted in the introduction of an array of quality data metrics and financial incentive programs.

These quality programs now made widely available by major payrs such as the Centers for Medicare & Medicaid Services (CMS) and numerous commercial insurers; aim to increase the quality of care whilst reducing waste and cost. Apart from a handful of comparable chronic disease metrics, some payers have opted to design unique quality measures, based on the greatest opportunities for their specific patient populations. However, the majority of payer programs have thus far have adopted a similar grouping of key metrics pulling from several of the 90-plus Healthcare Effectiveness Data and Information Set, or HEDIS indicators.

Developed by the National Committee for Quality Assurance (NCQA), HEDIS metrics measure the quality performance of payer plans. This information is designed to compare payer plans to one another and in the more recent years, has been used as a tool by providers to track performance improvement from year to year. With the guidance of the NCQA, many major payers utilize these HEDIS measurement standards to determine thresholds for potential monetary incentives. Its use continues to be more multifunctional throughout as the programs have progressed.

For a traditional primary care medical practice, incentives can range from $3,000 to as much as $25,000 annually if key quality metrics are attained. It is prudent to note that not all payers participate in quality programs, however, for those that do their incentive structure is not risk, but rather reward-based. Ergo, it is prudent to note that national dialogue suggests a future trend where payer reimbursements may be reduced, and therefore punitive for not achieving quality targets. This, at its very core, represents the crux of the payer pay-for-performance movement.

The emergence of payer quality incentive programs creates a multitude of opportunities for independent and integrated medical practices. These opportunities are diverse and include leveraging the original promise of EHR functionality, to promoting a greater focus on patient adherence, and finally the possibility of modest financial incentives. We believe it also provides a sort of foreshadowing of a payer system that continues to press forward with performance associated care metrics, rather than conventional fee-for-service reimbursements.

If a provider or practice can satisfy these requirements, they may be eligible for these modest periodic quarterly or annual incentive payments. In our experience, we have found that one of the keys to improving care quality performance is frequent and consistent interactions with individual payer representatives. We have found great value in establishing focused bi-weekly or monthly meetings with payer program representatives, who can help narrow specific opportunities for a specific practice. We have been able to use these meetings effectively to review short-term goals and address various issues that a specific practice may be facing. This has given us an opportunity to regularly review individual patient opportunity reports and ensure that our patient panel lists remain accurate. Furthermore, through these meetings, we have been able to mutually agree on specific opportunities and areas of focus.Through this partnership, we continue to strategize as to how we can prioritize the various quality measures.

Congruently, we have discovered several payers that are beginning to provide a form of “seal of approval” or “certification of quality” recognition for those practices that successfully adhere to the established performance metrics. One may argue that these certifications will become more commonplace as a form of marketing differentiation for specific providers and practices in competitive markets. Specific examples of this include The Blue Cross Blue Shield - Blue Physician Recognition, The Cigna-Care Recognition, and Humana Star Recognition Program. Recognition offered by the NCQA is commonly referred to as “the Gold standard,” as rigorous metrics must be met by providers to be certified. This program claims to be the only one that is based on clinical performance and consumer experience which has pushed for providers to be more proactive in their care and less reactive.

While there are a multitude of data points and quality measures, we have seen that our payer collaborations have focused on a select group of data points around preventive and chronic condition management. These goals include things such as balancing chronic disease and prevention and included data points such as Breast Cancer Screenings, Colorectal Cancer Screenings, Spirometry testing for Chronic Obstructive Pulmonary Disease Patients, Medication Adherence for Patients with Hypertension, and various measures for Diabetic care. With these focuses, providers are able to catch harmful and often fatal illnesses early on. For example, a quality measure such as Breast Cancer screenings aims to catch potential Breast Cancer signs early on so that we may intervene and work towards preventing the development of advanced cancer.

Selected clinical quality measures are data points that are aimed at quantitatively measuring the efficacy of care, and patient adherence to care. While HEDIS measurements are often the foundation for what health plans use to measure quality, it is not uncommon for health plans to develop additional measures.

During our partnerships, we focused heavily on quality metrics such as A1C monitoring. Here we were reporting out A1C scores for diabetic patients to ensure that it was controlled and under 8.0. If not under 8.0, we would determine the next steps that would be most beneficial to getting that patient back on track. We also ensured that patients were coming in for regular A1C screenings, and if they were not we would contact them to schedule a visit. Colorectal Screenings was one of the measures that had the biggest opportunity for us, as we had over 1500 patients that needed to be screened. In order to address this, we compiled a list of all the non-compliant patients and contacted them to schedule screenings.

For our prescription adherence metrics, by tracking the number of times that a patient claimed their insurance for medication, payors are able to run reports and infer a patient’s level of prescription adherence. We discovered the same recurring challenges with raising our score in this particular area. By having one-on-one conversations with our patients who had low prescription adherence, we discovered a common issue - cost. With this knowledge, we were able to work with our payors to find ways to resolve this issue. For us, two solutions we found were utilizing mail-in prescription programs that were offered at a lower cost by the insurance company or having the physician refer a generic form of the same medication if possible. While this did not solve all of our patient adherence issues, it did help us increase our score.

As we worked towards increasing our quality scores, we saw that social determinants played a huge role in why so many of our patients were pulling up as non-compliant. From the National Association of Community Health Centers, PRAPARE, or the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences, is a data collection tool that helps providers better understand their patients social determinants of health. This tool poses great potential in helping us understand what our patients are facing and how we can take action to improve the health of the community that is facing similar struggles.

Another facet of the quality movement is a peripheral aim at making an impact on waste reduction. A recent study published by the Journal of the American Medical Association (JAMA) found that waste in the U.S. Healthcare system is an astounding 25% of our total health care expenditures. This amounts to approximately 760 billion to 935 billion dollars that is lost due to the failure of care delivery, failure of care coordination, over-treatment, pricing failure, fraud and abuse, and administrative issues. One of the biggest arguments for value-based care versus the traditional fee-for-service is that it may play a role in the reduction of unnecessary expense, whilst improving quality. Specifically, aiming to ensure the right tests, the right preventive measures, and best practices are more consistently adhered to.

Over-treatment according to the JAMA study contributed about 75 billion to 101 billion dollars of U.S. healthcare waste. Under traditional fee-for-service models, at times, incentives lie with utilization, and may inevitably lead to over-utilization, without comparative quality measurement or patient outcomes. Quality and value-based programs attempt to establish a foundation for efficient and objective care to be delivered.

In order to maximize the potential for success in the participation of these quality programs; healthcare providers must have access to and utilize a robust Electronic Health Record (EHR) platform. A robust EHR allows for custom patient queries that make it easier for providers. It is not uncommon for providers to be asked to search for various patient documents and submit them to the insurances. Being unable to perform necessary queries makes this process extremely long or impossible and if you can’t find the documents you need the measures will not be met. Some organizations have opted to hire an employee and dedicate them to the data gathering and metric capture. However, the paradox in this case lies in the fact that the cost to hire the employee may exceed the potential quality financial incentives. Only through having a dedicated employee across multiple practice settings can such a structure be viable.

While features of EHR’s vary from system to system, many have the ability to create custom alerts or “flags” in individual patient records. In our clinics, we have been successful in using the features provided by eClinicalWorks. Our dashboards allow for easy analysis and communication with providers in the event that we need to, for example, remind the provider to be sure to check a patient's A1C before they leave the clinic.

By using this simple feature, we were able to communicate with our providers if certain patients needed to be checked for these various measures. As such, we have enjoyed modest improvements in some of our quarterly scores.

While these external incentive programs from major payors appear to be more common, it is worth noting the potential of implementing internal quality incentive programs. A well-documented example is the Massachusetts General Physicians Organization, which developed a robust quality incentive program that provides monetary rewards directly to physicians who reached quality goals. Though this program was found to be successful, the payer quality programs that we are discussing are generally practice, not provider-specific.

In all, apart from the altruistic desire to provide quality health services; we believe that quality associated reimbursement models will only continue to expand. Only time will tell how these programs will continue to develop. It is possible that depending on a providers ability to meet certain quality measures, programs may opt to reduce reimbursements on the horizon. However, with a high-functioning EHR system and through collaboration with major payors, clinic leadership, and physicians, these incentive programs have promise to be fruitful.

Lilian Le, MHA, is a project specialist with Houston Methodist Physicians Organization and Leslie Jebson, MHA, FACHE, FACMPE, is executive director for Texas A&M Health


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Potential for Savings. JAMA. 2019;322(15):1501–1509. doi:10.1001/jama.2019.13978

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