Why Chronic Payer, Provider and Member Disconnects Are Only Cured By Aligning Quality and Care Management

In Affinite Quality, Care Management, Data Science, Healthcare by Matt D'Ambrosia

As we discovered in our first postthe traditional fee-for-service payment models of the past perpetuated siloed business processes among payers and providers. Thus, Healthcare IT solutions followed suit.  But value-based care and member-driven choice plans like Medicare Advantage plans are demanding more collaboration among stakeholders, systemsdata and operations. Yet, legacy IT systems, functional bottlenecks, and payer, provider and member disconnects  – make realizing coordinated outcomes a seemingly insurmountable task, rather than a reality  

Common challenges faced by each member of the healthcare ecosystem include: 

  • Care managers struggling to effectively communicate with providers and motivate them to perform required interventions to meet NCQA HEDIS® ,  URAC, and other plan and state-defined quality measures. They are often forced to reach out to members and their Providers multiple times, causing “provider abrasion.”  
  • Providers are often in the dark, working without access to patients’ full health histories. Plus, with hundreds of patients a day, providers may be too busy to prioritize reaching a particular  target of well child visits or other measures.  
  • Members fall through the cracks; even if they see their Provider, they may not receive the appropriate quality measure interventions.  

Healthcare IT of the past decade promised to cross these chasms, yet, en masse, technology has complicated more than it has helped, that is – until now.   

Consider the quality measure improvements one community-based Medicaid plan realized by giving their contracted Providers the ability to view HEDIS measures for each member-patient.  

  • 9% increase in compliance scores for physicians using this 360° view of patient by patient quality performance for Annual Well Child Visits for adolescents 12-21 years (AWC), compared to non-user providers.  
  • 5% higher compliance for physicians for Annual Well Child Visits for children 3-6 years (W34), compared to non-user providers.  

The plan’s impact study also showed there was a strong, positive correlation between the number of times the physician accessed the dashboard to see their performance for these quality measures, over this timeframe, and the provider’s performance improvement for these HEDIS measures.  

Why Aligning Payers, Providers and Members Is The Answer  

As this study showed, when health plans enable their contracted Providers to view, in real-time, their quality measure score performance throughout the year, both quality and compliance can dramatically improveHowever, most healthcare IT solutions segregate data and allow only Payers to see quality score performance – and even they may not have access to up-to-date analytics.  That said, Providers are at an equal disadvantage – often relying on exported spreadsheets provided by their health insurance plans.  

Now, with “connected” and “smart” healthcare IT solutions aligning the payers’ care coordination and quality teams, with Providers, and Providers with members, costs and care can improve.   

Follow us on LinkedIn and Twitter for upcoming part three of this six-part series investigating how the challenges of healthcare IT can be solved, and its failed promises finally realized.  

Want Learn Explore How Your Health Plan Can Achieve These Results? 

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