Healthcare is transforming itself again, as the industry continues to make improvements in the transition from a fee-for-service model to one based on value. Correspondingly, the demand for measures of healthcare quality has grown. Innovative technologies that facilitate digital measurements of quality already exist, and now organizations such as the National Committee for Quality Assurance (NCQA) recognize that digital quality metrics are foundational to value-based care and true population health. How these practices set the stage for healthcare’s brighter future is the subject of this blog.
A recent article by Health Management Associations asserts: “In the wake of the COVID-19 pandemic, the need for greater health information technology, interoperability, ‘digital’ measures of healthcare quality and performance, and advanced value-based care systems has grown.”[1]
At Leverage Health, we’re completely on board with this take on the future of healthcare.
What is the Digital Quality
As value-based healthcare slowly but surely evolves, it demands that the healthcare system focus on the following:
- Interoperability: The ability for the disparate parts of our healthcare system to aggregate both structured and unstructured data.
- Whole Population Information: Health plans that shift from a fragmented view of populations to an aggregated view of a whole population’s healthcare.
- Revised Guidelines: Regulatory bodies, NCQA, Centers for Medicare & Medicaid Service (CMS), and Health and Human Services (HHS) will lead the change to value-based care using guidelines based on both claims and clinical measurements.
The endgame for value-based care is better healthcare for whole populations, and one of the key elements to achieving this is digital information about quality collected and shared by providers and health plans. In the coming decade, the industry won’t rely on uncoordinated methods that use fragmented data—often derived solely from claims—to establish value and reward physicians, but on cutting-edge technologies and unified collection practices.
A Paradigm Shift
To transition to true value-based care, the entire industry will need to collect, understand, and use data in ways different from anything it has done before.
A provider practicing in the old fee-for-service environment asks: How can I get reimbursed for my services? The answer is to use all available options without necessarily paying attention to the outcome. Not surprisingly, the result of this fee-for-service model is low-quality care.
A provider who adheres to digital quality measurement asks: What treatments for other patients with this condition lead to the best outcomes? As the market continues to evolve, providers will follow treatment plans backed by clinical measurements of quality. The best course of action will be clear to everyone—the practitioner, the health plan, and the patient/member.
A Two-Way Street
In a value-based healthcare environment, information flows to and from providers and health plans: Providers with access to [de-personalized or hashed] anonymous digital records and current clinical data will be motivated to share information with healthcare partners who in turn will reward them for providing patients with the best care possible. This exchange will lead to more contracts based on digital measures of performance, and simultaneously to greater clinical insight. Health plans and regulatory institutions will share real-time data that help other providers, healthcare plans, and members of health plans.
A Cooperative Approach
The paradigm shifts toward a model of risk and reward that drives better outcomes and lower costs results in better healthcare. When providers are rewarded only for better performance, they don’t go around in circles about which actions to take. This saves money. Doctors don’t order from a treatment menu based solely on successful claims. Patients receive clinically backed care that helps them feel better, so they have more confidence in their providers. They see more value in their healthcare plan because quality healthcare is more affordable healthcare. Providers, in turn, experience more fulfilling relationships with their patients, and healthcare plans gain prestige.
Proactive versus Reactive Roles
Armed with digital quality measurements, providers and health plans have more control, and so tend to be proactive rather than reactive. If a provider knows they’ll be rewarded for following procedures that align with a patient’s condition, they’re bound to follow that clinically driven protocol. Value-based medicine backed by digital measurements of quality reduce the friction between health plans and providers because providers aren’t flying blind—they know they’ll be rewarded for taking actions that produce good results.
Improved Network Performance
To improve their health plans’ performance industry executives are developing new care strategies based on digital reporting. For instance, they might group individuals according to such factors as age and/or health condition. Such an approach has proven more effective than global approaches and brings about better outcomes, not only for providers and patients but for the networks themselves.
Emerging Technologies
Nascent technologies such as artificial intelligence, natural language programing (NLP), and machine learning (in which NLP is fine-tuned to a particular environment) directly support the move to digital quality measurement.
Technology companies will continue to innovate for the industry. Astrata, for instance, is focusing on several integrative technologies: NLP, Clinical Quality Language (CQL), and Fast Healthcare Interoperability Resources (FHIR), such as Quality Improvement Core (QI-Core) applications.
Revised Standards
Currently, CMS and the Affordable Care Act (ACA) are starting to move from a reactive, claims- and process-based system to a proactive, clinically sound, evidence-based system built on whole populations.
Advantages
Digital quality measurement offers advantages for providers, individual patients/members, healthcare plans, and the populations they serve. Incentivized collaboration between healthcare plans and providers is the hallmark of value-based care. Digital quality measurement will make clear the interventions that improve the patient experience. Health plans that are early adopters will reap operational benefits, gain prestige, and grow their markets.
- High-Value Care: Physicians will deliver clinically driven quality care. Insurers, whether Medicare or an insurer for people under 65, will no longer reward physicians based on claims or the number of procedures they perform, but instead on positive outcomes. This is healthcare based on the quality of care.
- Better Outcomes: With providers incentivized to deliver better care, patients’ health improves. Good outcomes equal financial rewards for providers, better patient-physician relationships, professional satisfaction, and lower risk for health plans.
- Reduced Costs: Clinically based care improves individual and population health. This lowers the cost of care for healthcare plans, employers, and patients/members.
- Sound Care at Scale: Whole-population healthcare delivers clinically sound care not merely to a segment or a sampling of a population, but to an entire population.
- Payment Equity: All providers and networks will be judged on the quality of the care they provide. They will be acting in the right capacity: as clinicians improving quality from a clinical perspective. Providers no longer need to guess about how to get the best outcomes.
- Transparency: We’ll see transparency in how practitioners are rewarded across networks and health plans.
- Network Efficiency: Emerging technologies give health plans opportunities to upgrade their operations and bring efficiency to their network at scale.
- Customizable Programs: In the future, new technologies will enable health plans to offer customized quality-measurement applications to their provider network.
- Prestige: Like the providers in their networks, health plans will be judged by the quality of the healthcare their members receive, and a high rating will gain them prestige. As an early adapter of digital measurement technologies, Kaiser Permanente continues to enhance its reputation.
Leverage Health fully supports the industry-wide adoption of digital quality measurement practices. With innovative companies developing and gradually improving on supporting technologies, we see digital quality measurement as the clearest path to nationwide value-based healthcare.
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