Category Archives: Electronic Health Records

What should qualified health plans understand about the CMS Quality Rating System?

The Centers for Medicare and Medicaid Services (CMS) issued a Quality Rating Information Bulletin in August 2019, announcing that public display of 2019 quality rating information by all exchanges will begin during the individual market open enrollment period for the 2020 plan year. The initial guidance regarding this program was released in October 2018, and there have been several deadlines for health plans to meet throughout 2019. However, there may be some uncertainty for both plans and consumers regarding what the quality scores represent, how they are developed, and/or how they may be used now or in the future.

This paper by Milliman’s Dustin Grzeskowiak, Darin Muse, and Daniel Perlman provides some clarity on these topics, general background on the program, and a summary of the 2019 quality information published by CMS in the public use file.

Considerations for implementing population health management programmes

Population health management (PHM) is a hot topic in the healthcare industry, but it means many different things to different people in different contexts. Deciding where to focus effort when developing PHM strategies and programmes is difficult without a clear policy framework and approach. Milliman consultants have written a guide to help managers think through the practical components of a PHM programme, from overall objectives and definitions through to the people. The guide also explores processes and technology enablers that are critical for success. Real-world case studies are referenced to demonstrate how the concepts discussed in the guide can be applied.

Best practice considerations for third-party provider risk-sharing contract audits

Shared-risk contracts between health plans and healthcare providers are becoming increasingly common and sophisticated. As these arrangements become more prevalent, there is an increasing amount of money at stake between health plans and providers. Transparency and verification are best practices in any relationship between parties that involves money, and this includes provider risk-sharing agreements. A settlement audit prepared by an independent third party is a recommended best practice for any organization considering entering into or already participating in one of these arrangements.

The underlying principle in these agreements is straightforward: healthcare providers are in the best position to identify and reduce unnecessary, duplicative, or inefficient care, and shared-risk arrangements provide a financial incentive for providers to do just that. While shared-risk contracts may be conceptually simple, the actual real-world financial adjudication of them is usually complex.

This paper by Milliman consultants Colleen Norris and Tom Snook explores some proposed best practices for an independent audit of provider risk-sharing settlements, and discusses the value of this review for all parties involved.

Small healthcare providers: The challenge of quality measure reporting

How is your hospital, healthcare system, or clinic measuring up to national standards? Are your patients receiving proper and timely care? For many small and rural systems, these are difficult questions to answer without proper (and often third-party) support.

In late 2017, the Centers for Medicare and Medicaid Services (CMS) introduced the Meaningful Measures initiative, with a goal to improve the delivery of care while also reducing costs for both patients and providers through the culling and prioritizing of existing quality measures. Part of this initiative aimed to reduce the burden of reporting for providers. For large hospitals in urban settings, it is likely there are employees whose roles are dedicated to the encumbrance of quality reporting. When new quality initiatives come down the pike, adjusting priorities may take some time, but these teams are largely equipped to handle it. For smaller clinics, measuring success—let alone demonstrating it—under complex and shifting quality standards is a huge challenge. Small clinics are also less likely to have adequate health information technology, which adds another layer of difficulty. There are several options that should be considered as small providers look to improve their quality performance.

Health information exchanges

As healthcare has moved more toward patient-centered care, health information exchanges (HIEs) have increased in popularity. If a patient had an emergent event at Big Hospital A but a follow-up appointment at Small Clinic B, does Small Clinic B have access to the medical records completed at Big Hospital A? HIEs help to improve the timely sharing of medical information among providers, aiding in record completeness and informing better decision making at the point of care. Many HIEs are free to join and work with a wide variety of electronic health record (EHR) vendors. Additionally, these HIEs will often provide analytics tools designed to help providers keep tabs on their quality metric performance.

Upgraded EHR systems

The American Recovery and Reinvestment Act of 2009 saw the call for nationwide adoption of EHR systems by all eligible providers. With additional funding and incentives made available, a veritable swarm of EHR vendors suddenly appeared, and today we’re left with hundreds of EHR platforms. As time has passed, several large players have emerged, and these vendors, though expensive, can offer up enhanced quality measure reporting at the click of a button. Unfortunately, some of the price tags of the bigger EHR platforms make them unfeasible for practices with small budgets. Still, grants may be available for those who are in desperate need of an upgrade, and benefits beyond quality measures are frequently seen.

EHR vendor support

It could be that a small clinic’s EHR vendor already has quality measure capabilities, but the clinic lacks the staff or knowledge to successfully retrieve and analyze the data. This is where an EHR vendor contact can come in handy. Check your EHR vendor’s website or manual for contact information, and fire away. They should be happy to show you the more advanced features of your EHR, including quality measure reporting. It is also worth reaching out to other clinics and practices that utilize the same EHR. Sharing challenges and accomplishments in using an EHR vendor is a good way to learn.

Third-party contractors and software

Many smaller organizations choose to “outsource” their quality measure tracking to third-party vendors who specialize in such calculations. This is a wise choice for many, given that these third parties can provide the technology and manpower that is lacking within the organization. However, it’s prudent to thoroughly vet these types of vendors, as the options are extensive within the healthcare industry. Some questions to keep in mind include:

  • How will quality measures be reported?
    • On an aggregate level, or on the patient level? Will individual physicians or clinics be able to see their overall performance?
  • How are quality measure reports delivered?
    • Is it a web-based dashboard? Is it interactive? Will we need separate software to view results? Can I easily share the results with others?
  • How often will results be updated?
    • Monthly? Daily?
  • How often is the measure logic updated to conform to specifications?
    • Is there an extra annual fee for these updates?
    • Is the vendor certified by the National Committee for Quality Assurance?
  • What other health plans use this technology?
  • Is the vendor compliant with HIPAA regulations?
    • How will data be transferred to you?
    • How will data be stored?

It’s important to find a vendor that will help your organization reach and exceed its own unique goals. Do your research and you will see benefits.

Start small

Keeping track of the myriad quality measures can be overwhelming. Many small practices have found success in focusing their efforts on a few measures, which can be a great way to build confidence and momentum among staff. For clinical quality measures, diabetes, high blood pressure, and tobacco use are popular for beginners to focus on, as well as high-impact for patients. Using internet searches to find examples of workflows and processes other small clinics have been successful with can help to ease the initial burden.

While small providers and clinics face challenges unseen by larger organizations when it comes to tracking their quality performance, these challenges are not insurmountable. Small providers and clinics will be able to succeed by utilizing the options above and several more support options available to them.

This blog post was first published by Katherine on LinkedIn.

Final rule considerations for association health plans

In October 2017, the Trump administration issued the “Executive Order Promoting Healthcare Choice and Competition Across the United States.” This sought to provide additional health insurance coverage options for small groups and individuals outside of the Patient Protection and Affordable Care Act (ACA) market. One option the executive order addressed directly is the association health plan (AHP) for small groups and certain individuals.

In January 2018, the proposed rules for AHPs were issued, and in June 2018, the final rule was released.

Prior to the release of the final rule, associations did not have a well-defined pathway to being determined bona fide. Instead, each association’s facts and circumstances were evaluated against three broad issues:

• Does the association exist for a purpose other than providing benefits?
• Do employer members of the association have a close enough relationship to be essentially a single common entity?
• Do employer members control the health plan in form and substance?

With the new pathway identified in the June final rule, the second criteria is made much more explicit and can be satisfied by demonstrating that association members share a common industry or geography.

Many, if not most, of the currently existing associations, including local and national chambers of commerce, local or national industry groups, professional groups, and regional interest groups, could fairly easily fulfill all the conditions to become a bona fide association under the latest rules and thereby offer a large-group health plan as an employer. This was not the case prior to the president’s executive order.

In this article, Milliman consultants Fritz Busch and Jason Karcher examine the final rule released in June, evaluate considerations for sponsors of AHPs, and briefly assess the final rule’s impact on the small-group health and individual markets.