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Quality programs best served with clinical data analytics


Paying for performance will cause many health plans to rethink how they contract with provider networks, and experts say there are tremendous changes ahead.

Paying for performance will cause many health plans to rethink how they contract with provider networks, and experts say there are tremendous changes ahead.

Margaret E. O'Kane, president of the National Committee for Quality Assurance (NCQA), notes that the organization has recognized 14,000 individuals and 3,000 practices as a Patient-Centered Medical Home (PCMH). One of the key abilities demonstrated by a PCMH is electronic support for quality measurement and performance improvement programs. O'Kane says as of yet, there is no national consensus on how to gather data to measure provider performance.

"There are various stages of evolution in different parts of the country. Some of them are focused on the practice, and some of them are building out to a more collaborative community model," says O'Kane.

"We've been talking about this for 20 years," says Andrews. "Clinical data has been hard to get and difficult to work with. It's reminiscent of where biotech and pharma were about 15 years ago, when they started generating a lot of data. Suddenly there is real insight-and everything changes."

The indicators that are in use now have been developed over time largely on the basis of claims data and are still rudimentary.

"We also need to better understand the relationship between quality and cost," he says. "Even if we made people healthier, what was the impact on the economics? Right now it's an assumption that higher quality costs less."

The first order of business is putting the infrastructure in place: extracting the usable data, opening up access to it, and filtering out invalid data. Andrews cautions against taking a narrow view that simply creates an "electronic paper flow."

"There is value to electronic referral, for example, but it's a low-value activity compared with performing population health studies and beginning to understand how we could affect the care of large populations with the chronic conditions that drive much of healthcare cost," Andrews says.

Paul Oates, senior enterprise architect at Cigna, says the industry must be careful in using the existing data. Studies performed in recent years show that improved data and data collection efforts help drive better control of costs-but those results were demonstrated by baselining a historical experience, applying changes to the process of managing care, and then seeing what happens.

"It's a challenge to identify causality in those results-to make sure the results are not due to chance but to something we can all influence, in partnership with physicians, and that we can repeat," says Oates.

He says legacy systems facilitate analysis of claims information, which conveys what occurred for the purposes of payment, but not why. The time lag around claims-based data also can create a lengthy delay between the event and the reporting of it downstream.

His group is restructuring for better analysis of data sources with clinical depth and breadth, such as lab and pharmacy details. Cigna hopes to focus less on data gathering and more on dissemination of actionable information to providers. Within some medical practices, the plan embeds a care coordinator to support members; in others, the practice uses the analytical tools provided by the plan to improve the quality, affordability, and experience of care.

"There's a lot of variability; we need to be able to work with what physician practices are most comfortable with-and not all of them are-using electronic health records. Sending the information back out in a way that physicians can use in their workflow, based on their capabilities, is critical," says Oates.

Plans must determine the metrics they will use to measure quality, particularly if they pay for performance targets. Choices include NCQA, with its Healthcare Effectiveness Data and Information Set (HEDIS) and PCMH; the Joint Commission, which recently designated its first Primary Care Medical Home; meaningful use measures, with plans and providers picking those relevant to them; and National Quality Forum measures, which also deal with gaps in care and evidence-based practices.

"There are probably as many metrics as there are demonstration projects," says O'Kane. "We think it works best when the payers get together and come up with an approach they can all live with, and we are seeing that in many PCMH pilots."

She says she understands why plans have developed their own metrics, particularly in specialty care, where measures are not widely available. But this creates a burden for providers with too many quality metrics to report.

"A lot of parts have to get into place, and everybody has to agree, which is why large payers like CMS often have to move the needle," says Andrews.


Traditional relationships among plans, providers, and the federal government are changing. Plans are purchasing or building technology they think providers will want, which also enables them to obtain provider data. Integrated systems heavily invested in their IT systems during the past 10 years and are now looking at the analytics. Large payers have been buying provider IT platforms to gain access to physicians and their data, and others have directly purchased provider groups and clinics.

The overarching idea, says Andrews, is for plans to make investments that connect with providers.

"The more plans understand, the easier it is to design benefit plans that reduce costs without reducing the quality of care," he says. "The providers are very interested because best practice right now is a tough thing. Does it really affect outcomes, or does it just affect what we think outcomes will be? There will be tremendous change, and the desire for these sophisticated analytics that integrate clinical and cost data will go through the roof."

Although smaller plans may not have the capital to invest in all of the IT that would enable them to connect directly with providers, they can align with projects and communities around health information exchanges. Plans without deep pockets can still engage their physician/hospital networks in collaborative arrangements to try and learn what works in improving care.

"I think it's better to do something and measure the results, and add to the universe of learning that we are all experiencing as an industry, than not to try," says Oates.

Cigna is investing in tools to interact with providers in real time at the point of service. Oates says that will entail additional investments in connectivity and interoperability that will enable the company to gather and send data more efficiently. Physician EHR adoption will help drive that forward. Plans must also invest in clinical data standards.

"Providers have been using clinical data standards for many years," says Oates. "Payers have been focused on claims-based standards, so we are making those investments to understand the clinical side better and in greater depth and to adhere to those standards."

It is critical that the metrics align with evidence-based preventive, chronic, and acute care medicine.

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