What It Takes for Quality Improvement Directors to Succeed in Value-Based Care

Carrie Spunar, Director, Marketing Health Plan Solutions

quality improvement directors

The world of health care is constantly changing. No one understands this better than health plan quality improvement (QI) leaders.

If you think back twenty years ago, the quality improvement department at a health plan was generally considered an administrative cost center. It was challenging to make the case for additional resources, as most c-suite leaders were primarily focused on increasing revenue by growing membership and decreasing medical costs through strict prior authorization rules and medical management policies.

At that time, HEDIS and accreditation were relatively new concepts. QI directors worked closely with IT staff to build the HEDIS database, document processes to pass HEDIS audits, and ensure there was sufficient data to avoid getting a “not reportable” score on a measure. There were very few, if any, financial incentives tied to HEDIS back then. And, there was limited or no public reporting of health plan results. Quality improvement data was primarily used within the health plan to measure performance, or by organizations such as NCQA to demonstrate improvement at an aggregate level.

Over time, the landscape started to shift towards a pay-for-performance model. It began with select employer groups and government payers requiring accreditation for health plans and asking to see the health plan’s HEDIS results. Soon after, there were contract performance bonus dollars at stake – although the dollars were not significant compared to today’s value-based contracts. In Medicaid, some states began to implement auto-assignment algorithms that assigned members to the higher-quality health plans. The quality improvement department started to get more attention, as c-suite executives began to make the connection between quality and increased revenue.

Today, we live in a world of value-based health care. The quality improvement department has become a revenue center instead of a cost center, with millions of dollars in performance incentives at stake every year.

Health plans grow their membership by demonstrating quality on Medicare STAR ratings, state Medicaid report cards, and NCQA health plan ratings. And, contracts can be cancelled if performance drops below an acceptable level. In the c-suite, all eyes are on HEDIS reporting, with technology and systems in place to collect and report HEDIS measures on a monthly, weekly, and sometimes daily basis, depending on the health plan.

It is easy to forget how far we’ve come in a relatively short amount of time. QI directors have been able to successfully lead their organizations through monumental changes. This has required knowledge of quality improvement processes, accreditation requirements, clinical best practices, health information technology, change management, organizational development and many other topics. And there is still more change on the horizon, with new standards and performance goals coming from customers every year.

One of the most challenging aspects of the QI director’s role is that it is mostly a role of intermediary. Health plans do not provide the care that is needed to meet HEDIS and other performance standards. Health plans do not determine the correct diagnosis or procedure codes, nor do they submit the claims that are ultimately used in HEDIS reporting. Health plans do not capture details such as blood pressure or body mass index in the medical record. And yet, their success is intimately tied to all these activities.

Most of the activities necessary for health plans to succeed in value-based care take place in the physician’s office. QI directors must find a way to coordinate, collaborate, educate, incentivize, assist and empower physician practices as a key part of their efforts to improve performance under value-based care arrangements. To succeed in this role, QI directors need to demonstrate empathy. While it is not commonly listed on a resume or job description, empathy is one of the most valuable skills a QI director can possess.

Empathy is the ability to understand and share in the feelings of another person. Quite simply, it is the ability to place yourself in another person’s shoes. When working with physicians, empathy is important because it opens the door for meaningful communication and partnership. Just like QI directors, physicians have also experienced an overwhelming amount of change over the past 20 years. Instead of focusing exclusively on patient care, they are now expected to focus on revenue management, HEDIS performance goals, coding and billing requirements, technology and system implementations, and a variety of other tasks.

Physician practices work with multiple payers, each with slightly different incentives and requirements. It is easy to become overwhelmed by the various provider bulletins, newsletters, emails and other forms of communication. It is easy to lose track of the different passwords and data entry requirements for the various health plan provider portals. It is easy to become frustrated with all the demands being placed on the practice and the constant need to figure out a way to do more with less.

Instead of being one more voice that is contributing to the stress on physician practices, by showing empathy, a health plan QI director can become a supportive and encouraging voice – one that helps drive change and improve quality. Here are a few ways you can provide support for physician practices:

  • Offer hands-on assistance. This is the number one way you can engage physician practices. Most practices do not have sufficient resources to conduct quality improvement activities. By embedding an experienced quality improvement resource within the practice, you can ensure your mutual success.
  • Simplify tools and technology. Instead of making the physicians work with your technology infrastructure, seek out ways to interface with their existing technology. Find out which medical records systems are in use by most of your physicians and offer to fund all or part of the costs of creating an interface on their behalf, instead of making them pay all the costs.
  • Streamline reporting requirements. Stay up-to-date with what Medicare, Medicaid and other payers are requiring in terms of value-based contracts. While there is a competitive aspect to these contracts, there is also the potential for payers to come together and streamline some of the reporting requirements to make it easier for physicians.
  • Ask practices what they need. This seems simple but can sometimes be overlooked. Every practice is unique and they all have different challenges. Often, health plans take a “one size fits all” approach to communication and resources for practices. By engaging in conversations at the practice level, QI directors will be armed with specific information that will help inform their approaches going forward.

Physician practices are the key to meeting your HEDIS targets and earning the bonuses and incentives that your c-suite leaders are expecting each year. Instead of wondering why the physician practices are not “getting it” or why change isn’t happening fast enough, consider starting the conversation from a place of empathy, reach out and engage face-to-face. You might be pleasantly surprised by the results.