Collection and reporting of key metrics are required by many emerging initiatives.

New care and reimbursement models are forcing healthcare organizations — physicians, hospitals and health plans — to step up their game when it comes to performance data. Collection and reporting of key metrics are required by many emerging initiatives, while several long-established programs are now embracing strong quality-enhancement strategies. Many are going so far as to link reimbursements and financial or other incentives to quality scores.

For example, the Department of Health and Human Services (HHS) in January 2012 issued a set of 26 core quality measures to be used for adults enrolled in Medicaid. Though initial reporting will be voluntary, it nonetheless sends a strong signal to states that have been lax in addressing low Medicaid program results that the federal government intends to continue sharpening its focus on quality reform.

Similar quality-based approaches are being taken by the Centers for Medicare and Medicaid Services (CMS) with Medicare Advantage plans, accountable care organization (ACO) pilots, Medicare physician and hospital quality programs and the Comprehensive Primary Care (CPC) initiative. For example:

  • Providers that wish to establish an ACO must report on 33 quality and performance measures, many of which are more holistic health plan measures and therefore relatively new concepts for hospitals and physician groups. CPC initiative pilot entities will also need to report on quality over time.
  • As of 2015, Medicare Advantage plans with lower than four stars will not receive quality bonuses to help them remain competitive from a benefits standpoint. Further, high-performing plans will be allowed to enroll year-round, giving them a leg up in a very competitive enrollment environment that is usually limited to a few weeks per year.

To aid organizations with compliance, integrated care management, quality and compliance platforms deployed via the cloud have emerged as a secure and cost-effective way to consolidate, analyze and exchange actionable and meaningful data with all participants in a patient’s care. Doing so facilitates the efficient and accurate monitoring of key data in real time so that steps can be taken when necessary to increase (and protect) quality and risk scores and deliver higher-quality care at lower costs.

Data takes center stage
The metrics required or proposed under today’s care and reimbursement models are not new. They draw from those of a myriad of other programs, such as National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures, Star/Quality Assurance Reporting Requirements (QARR) ratings, electronic medical record (EMR)/electronic health record (EHR) incentive programs and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

What is new is the need to integrate clinical and administrative data from multiple disparate sources to enable real-time exchange and continuous monitoring to remediate care gaps and influence performance outcomes and quality scores. Also required is the ability to undertake more accurate predictive modeling and risk profiling to better manage care and utilization and lower costs without impacting quality.

To accomplish this, provider and payer organizations must be able to share comprehensive clinical histories for each patient. For example, because they are essentially plan-like entities operating in the fee-for-service (FFS) system, provider-centric organizations, such as ACOs, must have the technical capability to receive enrollment, eligibility, demographic and claims data on assigned beneficiaries from multiple sources. To maintain Star ratings, Medicare Advantage plans need real-time access to HEDIS, pay-for-performance (P4P) and proprietary quality and performance measures, as well as data for patient, provider and population profiling.

However, access to data is not enough. Success hinges on the ability to utilize that data in a way that allows initiatives to influence outcomes and quality scores, such as through the proactive patient assessments to determine and properly address chronic care and preventive health needs. This includes identifying high-risk individuals through risk stratification and provider intervention through case, care and disease management. It also requires comprehensive medication reconciliation and drug monitoring capabilities for improved patient safety and utilization management.

Enter the cloud
Taking a traditional approach to building a technical infrastructure capable of addressing the complex data requirements of today’s care and reimbursement models is not for the fainthearted. Cost barriers are prohibitively high for many healthcare organizations whose resources are already stretched thin to comply with multiple emerging mandates, such as ICD-10 and meaningful use. Other challenges also come into play, including interoperability with existing legacy systems and data ownership and other governance issues.

The aggressive timeframes to meet initial reporting deadlines are also problematic. Finally, establishing the connections with CMS, commercial health plans and pharmacy benefits managers to gain access to claims data poses multiple challenges for physician groups, hospitals and other provider organizations that are typically unfamiliar with the processes and procedures for doing so.

This is where an integrated care-management, quality and compliance software platform holds the most promise. It can facilitate the connections necessary to securely link physicians, case managers, home health providers and others involved in patient care to meaningful, actionable data while enabling integration of workflow processes and improving interoperability by utilizing open standards.

Because they are on the cloud, these integrated platforms provide a high level of flexibility, so initiatives can custom-configure everything, from user access to business intelligence tools, to meet unique organizational and patient population needs. For example, they enable an ACO or Medicare Advantage plan to deploy tools that target those metrics that have the greatest impact on quality scores based on populations served. These tools should include:

  • Predictive modeling and stratification tools to identify high-risk or multiple comorbid cases in need of intervention;
  • Tools to identify HEDIS, Star and other care gaps and trigger appropriate care/case, disease and quality interventions;
  • Comprehensive case and disease-management modules, where assessments can be conducted, care plans created and tasks and clinical/social interventions fulfilled and monitored;
  • Tools to generate profiles based on clinical, quality and financial data for member, provider and local populations; and
  • Risk-score calculators to more-accurately predict future care costs and pharmaceutical utilization.

Integrated care-management, quality and compliance platforms that leverage the cloud lower the barriers to innovation and modernization of health IT systems by minimizing costs, increasing scalability and improving accessibility and security. They eliminate interoperability issues by facilitating real-time information sharing without requiring organizations to replace existing legacy systems. This keeps initial capital requirements and total cost of ownership low, resulting in a rapid return on investment.

Importantly, this flexibility also allows for rapid deployment – weeks versus the months or sometimes years required for site-based implementations – and quick response to regulatory and market changes.

Metrics in the cloud
Performance monitoring is a major component of successful participation in today’s care and reimbursement models. Without the ability to quickly, easily and cost-effectively share complex information within the organization and across the patient’s care continuum, it will be impossible to track quality measures and influence clinical outcomes – both of which are critical to achieving benchmarks.

An integrated care-management, quality and compliance platform provides a solid foundation to accomplish these objectives. It ensures physicians, hospitals and other providers have access to the information they need to better manage patient populations and enables the entity to demonstrate the quality and outcomes that dictate shared savings.

About the author

Anil Kottoor is the CEO and president of MedHOK. For more on MedHOK, click here.

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