5 Ways Payers Can Improve Quality Measures for Chronic Members

Updated 7/7/2020: This article has been updated to reflect that CitiusTech is solely responsible for the “COVID-19 Impact on Quality Management” survey. A previous version associated America’s Health Plans (AHIP) with the content.

Nearly three-quarters of NCQA HEDIS quality measures will experience a negative impact from the coronavirus pandemic, according to a study by CitiusTech.

“Socio-economic uncertainties, behavioral changes and altered human interactions, operational failures at both payer and provider ends, over-burdened clinical systems, enterprise budget freeze, regulatory relaxation and rise of virtual care; all will have direct and indirect impact on payer quality management & quality improvement for 2020-21 and will extend cascading effect on future years,” the CitiusTech study began.

The CitiusTech study examined all 89 NCQA HEDIS quality measures for 2020 in order to determine how likely they were to suffer due to coronavirus. The researchers also created four categories to determine the severity of the setback that the various quality measures might experience.

Overall, coronavirus will have a negative impact on 74 percent of the NCQA HEDIS quality measures. This is the result of delayed preventive care and ambulatory visits.

Members with chronic conditions could expect worse long-term quality of care as preventive care grinds to a halt. The study specifically mentioned members with diabetes and cardiovascular disease, conditions which are already among the most expensive chronic diseases in the US.

Behavioral healthcare quality measures are expected to see the most severe negative impacts, along with preventive care and access to care.

This could result from a convergence of multiple factors, including lower rates of provider visits, screenings, immunizations, and therapy sessions. However, socioeconomic factors are all at play, including the high unemployment rate.

“The population drift from employer sponsored plans owing to unemployment will also impact the current commercial quality rates for a health plan negatively,” the researchers argued.

Only 15 percent of the quality measures could potentially see an improvement due to the coronavirus pandemic. Areas expected to see improvement include overuse or appropriateness, utilization, and risk-adjusted utilization. These improvements may develop from low readmissions, fewer unnecessary screenings, and lower drug abuse rates due to limitations on drug availability.

Positive impacts could also be influenced by telehealth regulations. NCQA decided to allow telehealth encounters to count for 30 percent of HEDIS quality measures.

“Health insurers and providers need to strengthen this alternative mode of care together in terms of clinical and claims documentation to improve the quality scores effectively,” the CitiusTech report urged.

Payers can focus on five strategies to strengthen their quality of care during the coronavirus pandemic and beyond it.

First, payers can narrow their provider networks.

A recent report by PwC found that employers are interested in creating more narrow networks in order to control healthcare costs. Thirty-five percent of employer-sponsored health plan members said that they were willing to switch to a lower-cost plan with a more narrow network.

“With falling encounters, focused strategy to integrate with narrower provider network for gathering data across all encounters,” the CitiusTech report stated.

Second, payers can improve their quality measures for virtual healthcare. In order to do this, payers will need to partner with policymakers and providers to determine the most effective ways to gather data on telehealth and virtual care visits.

Third, in order to improve their quality measures, payers need to implement better interoperability through FHIR-based, real-time systems. These systems should be equipped to alert providers to potential care gaps and to collect data.

Fourth, payers can exercise data science in order to optimize their outreach capabilities.

“Enable data science driven high value population cohorts, that require minimum cost of intervention, with propensity to yield maximum compliance outcome,” the researchers explained.

Lastly, payers can implement natural language processing for their clinical data systems. This will support team capacity and improve efficiency.

“COVID19 has virtually stalled the quality improvement journey and has tapered the efforts towards a rising curve,” the researchers confirmed. “With the right strategic approach in place, the quality curve may regain momentum and set course towards the planned improvement journey.”