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The following article by Verscend President and CEO Dr. Emad Rizk was originally published by the HFM blog, a publication of the Healthcare Financial Management Association.
As payments become more closely aligned with quality metrics in preparation for a value-based healthcare system, quality measurement and reporting will take on greater importance for healthcare organizations. What used to be an annual check-the-box process for health plans has evolved into a year-round strategic initiative. Meanwhile, providers are being asked to master a new skillset: reporting on quality metrics across their patient panels.
CareOregon's approach to quality improvement
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Data, obviously, will play a key role in healthcare organizations’ understanding of quality performance, but the type of data and the processes involved in collecting, aggregating, and analyzing it vary greatly depending on the type of organization (i.e., health plan or provider). Health plans work primarily with claims data, which provide broad insights across the care continuum, with a goal of managing financial and clinical risk. Providers, on the other hand, delve deeply into multifaceted clinical data for each patient, with goals of making the proper clinical diagnosis and achieving the best possible treatment outcome.
Similarly, although health plans and providers both care about quality, their methods for improving it have differed due to their varying perspectives. Health plans have developed a well-tuned, systematic approach that focuses on population- and network-based analysis and outreach. Meanwhile, providers have focused on individual patients.
Over the years, the evolution of quality measures such as the Healthcare Effectiveness Data & Information Set from the National Committee for Quality Assurance and Medicare Star ratings from the Centers for Medicare & Medicaid Services has driven health plans to create a disciplined methodology to drive quality. Health plans have committed significant resources to support their quality initiatives and implemented tools that help them use their many years of claims data to better inform their quality improvement efforts. They also have adopted innovative technologies that allow them to extract clinical data from claims.
Health plans achieve five-star ratings because they excel at delivering the experience their members deserve and desire—something that providers know well. As healthcare continues to evolve, the best quality improvement approaches will be those based on informed collaboration and best practices learned from both sides of the healthcare equation.
Interested in a deep look at how one health plan works with providers to improve quality year-round? Check out our case study on planting the seeds for measurable quality improvement across CareOregon’s population.