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Recommendations for Medicare’s Future Quality Improvement Initiatives

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In my last post, I put forward some core “change principles” to guide our communities in working to transform the U.S. health care system. In this installment, I’ll try to apply those principles in recommending ways to enhance the value of the quality improvement work that HealthInsight and similar organizations perform for the Medicare program.

As the nation’s largest single purchaser of health care, the Centers for Medicare & Medicaid Services (CMS) has long been a pacesetter and incubator for change. The Quality Improvement Organization (QIO) program represents the largest sustained investment in large-scale quality improvement in history. HealthInsight has served as a contractor for this program since 1984, and our mission has evolved throughout the decades, at the leading edge of change in this national effort, to address changing goals, changing theories about what drives improvement, and changing models of care and care delivery support.

CMS is now designing its quality improvement initiatives for the Quality Innovation Network-QIOs (QIN-QIOs), spanning the 2019‒2024 contract period. These new initiatives give CMS a crucial opportunity to propel the health care system toward meaningful transformation.

At HealthInsight, we believe that sustainable quality gains and cost reductions will not occur without active participation from every segment of the health care system. Multiple stakeholders need to work together and employ diverse, but aligned, strategies and approaches to drive transformation.

The Regional Health Improvement Collaborative (RHIC) model offers a useful example of what we believe is required. In this model, developed by the Network for Regional Health Improvement (NRHI), community-focused organizations create a space where stakeholders come together to tackle complex and shared challenges that stand in the way of transformation. Three current QIN-QIO prime contractors are NRHI members and two other QIN-QIOs are actively pursuing membership. Additional QIN-QIO prime contractors and subcontractors have active partnerships with a local RHIC. We believe that other QIN-QIOs could house, help create, or help sustain such critical workspaces in their respective communities as well.

Against that background, we offer these recommendations for substantive change.

  1. Align payment reform at the community level. Shift efforts from engaging national plans, providers and employers toward working through the QIN-QIO field force in local communities where care delivery is organized and where most other care is purchased and managed. QIN-QIOs can organize and align multiple payers in local payment reform efforts and can help advance and assess progress in the adoption of alternative payment models. In addition, QIN-QIOs need to continue to help their communities implement the Medicare Quality Payment Program, hospital value-based purchasing and similar CMS efforts―especially in settings with limited resources, such as rural and critical access hospitals, inpatient psychiatric facilities and ambulatory surgery centers.
  2. Promote data transparency. Take full advantage of QIN-QIO program capabilities to house, organize and disseminate critically needed CMS data to local communities in support of transparency, care management and care design. Once again, the models for dissemination, engagement with the data and action planning need to reach local communities where they are needed.
  3. Focus resources on cross-setting and cross-system coordination. CMS has increasingly splintered its overall improvement investment by setting of care, provider affiliation, clinical focus area, programmatic theme or other lines of delineation. Multiple contracts and contractor models tend to limit coordination across care settings and systems. This structure also contributes to the proliferation of performance measures and to increased burden for providers and for support contractors, which in turn results in fewer support resources reaching the front lines of health care delivery.
  4. Sharpen performance measurement. Align higher-level common measures of quality, utilization, and cost across communities and nationally to ensure that performance measurement advances long-term transformation aims. The National Quality Forum-endorsed total cost of care measure offers an example of a useful high-level metric to gauge interim progress. Metrics and analytics are always more valuable and effective when captured across multiple payers and aggregated at levels that help other stakeholders evaluate the learnings and outcomes. However, gathering and reporting such information often requires the convening of competitors around a common table, careful planning, and negotiation, continuous improvement of processes, combining and analyzing multiple data sets and redesign of workflows. Effective QIN-QIOs have all of these skill sets and could partner with existing RHICs and health information exchanges to gain additional expertise over time.

In summary, we encourage CMS to view success for the QIN-QIO program, going forward, through the lens of broad-based principles of transformation, to invest in and commit to supporting community collaboration, and to resist the pressure to multiply extensive and expensive interim data-counting activities and measurement of processes.

QIN-QIOs, if appropriately tasked and evaluated, and with the continued development of effective partnering skills, can bring local stakeholders together to work through these significant challenges at the community level—where real change happens.

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