In 2019, Medecision and SPH Analytics launched a strategic partnership aimed at helping health plans improve quality performance. As the pandemic progresses, how will quality measures reporting change? Kevin Weinstein shares his thoughts.
By Kevin Weinstein, President, Population Health, SPH Analytics
In February 2019, Medecision and SPH Analytics announced a strategic partnership to help health plans improve the quality of care their members receive and reduce related costs. Of course, back then, no one could have predicted that a pandemic would turn the global healthcare industry on its head just a year later. But as the coronavirus has spread rapidly through the nation, the healthcare industry has been forced to shift gears and change processes—and one of those processes has been quality reporting.
In March, the Centers for Medicare and Medicaid Services (CMS) announced that it was granting exemptions from reporting requirements and offering extensions for clinicians and providers participating in Medicare quality reporting programs. On April 6, CMS announced a change to the Star Ratings system, eliminating Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) score reporting by Medicare Advantage plans during the global health emergency. And then, on April 18, CMS suspended all activities related to the collection and reporting of data for the Quality Rating System, Qualified Health Plan Enrollee Survey and Quality Improvement Strategy for Medicare Advantage plans.
How Will Quality Measurement Change Moving Forward?
Right now, it’s hard to know how the quality measures reporting situation will unfold over the next 12–18 months. There’s the obvious uncertainty about how the pandemic will affect 2021 and 2022 Star Ratings and reporting, but there is also the possibility that COVID-19 could be an opportunity for the federal government to decide whether quality measures programs should be significantly redesigned. And perhaps most exciting, this general pause in the market, creates a very real opportunity for payers and providers to similarly take stock and consider changes that they otherwise wouldn’t have the time to evaluate or implement.
For example, with fewer outside pressures during quarantine, many people took the time literally getting their houses in order and cleaning out their closets or garage. As the world slowed down, at my house, we took the time to make changes and do the work we previously couldn’t find the time to pursue. The same is true for many payers and providers as they think about ways to better utilize quality measurement to impact care outcomes. In a normal year, there is a “treadmill effect” for many participants in healthcare quality. Whether it’s CMS driven, state mandates, or the pressures of annual contracts, there is often so much “reporting” there isn’t much time left over to truly consider possible innovations. With this extra time, we’ve started to see both payers and providers ask questions like:
- How do I move from periodic measurement to constant surveillance?
- How do I make information actionable in a smooth, non-disruptive way for patients and providers?
- What other information, beyond what I report on today, is required to truly form a picture of quality of care, and positively impact outcomes?
- How do I partner more smoothly with my provider/payer counterparts to truly measure what matters in an easy to administer way?
The contemplation of these questions is accelerating innovation, from all participants. From real-time HEDIS measurement embedded in care management software, to redesigned value-based contracts, to the inclusion of social determinants of health, changes are happening at the tactical level as COVID-19 has given folks the ability to think a bit differently.
Also, and perhaps this is stating the obvious, I certainly think we’re going to see measures that support the current public health emergency. With the expectation that we need to be better prepared for something in the future, I expect that you’ll see changes in how new measures are rolled out in cases of emergency. We simply can’t take 6–12 months to develop new quality measures, and another 12–18 months to roll them out. We need a faster path to impact in the future, and I expect we’ll see technological and regulatory changes to allow that to happen.
On another note, I really think we will see more innovation to help ease the reporting burden for all participants. For the past few years, physician groups have expressed a need for more simplified measures to streamline reporting and reduce the burden on providers.
For example, Jerry Penso, MD, MBA, President and Chief Executive Officer of the American Medical Group Association said in a 2018 report, “Used correctly, quality measures provide an opportunity to evaluate care and drive improvements. But providers are saddled with too many measures that are not meaningful to how they deliver care.”
To help ease this burden, I think you’ll see innovation in a few areas:
- More standardized outcomes measures based on clinical information. So many quality measures today are really process measures. I think this will change to include measures that are much more reliant on clinical outcomes. This, of course, requires more use of EHR-based information than just claims data.
- Increased alignment around what measures actually create impact. As payers and providers collaborate more openly, I believe that there will be more consensus around the most impactful measures, reducing some of the measure variation we see today.
- Regulatory changes encouraging interoperability will make data more accessible. The impact of interoperability is hard to gauge in the short term as it ramps up, but it is inversely hard to overstate its impact in the long run as data becomes much more readily available. More accessible information means lower costs to acquire data, and the ability to automate the entire measurement process which today is stymied by proprietary data formats. Everything gets easier, faster, and cheaper with true interoperability.
Need convincing of the power of interoperability? Just think back to the early days of ATMs. In the beginning, you had to go to your own bank to use an ATM. Then, things improved, and you could go to a bank on your network—or risk paying exorbitant fees. Today, you can go to just about any ATM and pay a nominal fee and transact the same as at any other ATM.
Interoperability in healthcare will be no different once it truly arrives, and things are now moving more rapidly. In early March, the Centers for Medicare and Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) finalized and distributed rules that fulfill the interoperability requirements of the 21st Century Cures Act. Of course, COVID-19 has delayed the enforcement of those rules. But I think, as the dial gets turned up, we’re going to see pressure for interoperability from all players in the industry—whether that’s consumers, purchasers, employers or payers. Interoperability will allow for much easier consumption of both clinical and claims-based data.
And last, but certainly not least, as we’ve learned over the past several months—and we’ll continue to recognize over the next 18 months—that patient cohorts are not as monolithic as we’ve treated them historically. We often think of population health as cohorts—such as “This group of people are our pre-diabetics” or “This group of people over here are my diabetic patients whose A1C isn’t well managed.” And then we design programs to treat all the folks that share that characteristic in the same way. But as the above changes take place, I think we’re going to move beyond a cohort mentality into a population health model with a much higher level of specificity. Look at Amazon, for example. Amazon has many people who all buy the same product or watch the same movie. But the profile that drives that purchase behavior is customized, down to the individual level. It won’t happen overnight—and it certainly won’t be here for the 2021 reporting period—but the machine to provide for similar “mass customization” in healthcare is now in motion.
The Fragility of the Fee-for-Service Model
If nothing else, the past several months have exposed the fragility of a fee-for-service reimbursement model. When you have providers who don’t have some form of a pay performance or value-based contracting in place, you have to ask yourself, “Should we really go back to that model?”
From a provider perspective, I would expect that more people are going to have more of an appetite or willingness to experiment with what I refer to the “deep end” of the value-based pool. For example, how many people said, “Oh, we would love to let our employees work from home, but we couldn’t possibly do that”? Well, COVID-19 forced them to, and now employers are unlikely to revert back now that they’ve made that monumental change. I think we’re going to see organizations take advantage of this time and put things in place to accelerate the shift to value-based care, as opposed to just going back to the way things were before.
