Can We Get to the Next Level When It Comes to Quality Measures for the Care of Patients with Complex Needs? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Can We Get to the Next Level When It Comes to Quality Measures for the Care of Patients with Complex Needs?

June 27, 2018
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A blog on the Health Affairs website makes extremely important points about the landscape around care delivery and care management for patients with complex needs

A blog posted online on Tuesday on the Health Affairs website makes extremely important points about the landscape around care delivery and care management for patients with complex needs.  Even its title says a lot: “Measuring What Matters Most to People with Complex Needs,” authored by Julie P.W. Bynum, M.D., M.P.H., an adjunct professor at The Dartmouth Geisel School of Medicine in Hanover, New Hampshire.

Dr. Bynum begins by noting that “Recent efforts to increase accountability for health outcomes and costs has put a spotlight on the immense challenge of providing high-quality and efficient care to people with complex needs, many of whom require inputs from both the medical and social care systems to remain at their highest functional capacity. People with complex needs often have functional limitations, such as the inability to effectively communicate, move about, or take care of themselves without additional help, and they may have behavioral health needs that typically incur high health care costs. Traditionally, these individuals have been a source of revenue for health systems due to the sheer number of covered services they receive. Yet, under new payment and delivery models, such as accountable care organizations and bundled payments, these people could be viewed as a serious financial risk because of their outlier expenditures and potential for poor health outcomes. Herein lies an opportunity to improve the management of care for this population.”

As Bynum continues, “The National Academy of Medicine’s (NAM’s) special publication, ‘Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health,’ serves as a primer for how health care stakeholders can use evidence-based approaches to effectively manage care for this population. How to measure quality and outcomes as models of care and policies are implemented, while also managing costs of care, should be further discussed. Accountability measures for this population are necessary to assess the effectiveness of health financing reform efforts.”

Bynum points out something that those caring for patients with complex needs already know: “People with high needs often have multiple chronic conditions and seek care in many different settings for which quality measures already exist. Yet, simply applying the myriad condition- and setting-specific measures separately to this population will not sufficiently inform whether care was high quality. That approach ignores the complex interplay of factors, such as degree of care coordination, quality of life, independence, and overall mental and physical status that drive outcomes and care experience for this population.”

Further, Bynum notes, “A conceptual framework of performance measurement for people with high needs must take the whole person into account. Referring to the high-need population as “patients” reflects our tendency to overlook needs that extend beyond the walls of the disease-based medical care system. If the social care needs of a person—such as food and housing insecurity, transportation needs, supports for daily activities such as mobility and personal care in the home environment or addressing behavioral issues—are not adequately met, they may in fact end up as “patients” in hospitals or clinics that are ill-suited to address the root causes of their decline. Without accountability metrics that incorporate gaps between medical and social care domains, it will be challenging to assess whether health financing reforms are effective or if they result in adverse consequences, such as delays and denials in care, for high-need individuals. Measures of unmet need for social care or caregiver burden are examples that capture core elements of any effective management team and may provide balancing measures for potential cost shifting from medical to social care providers.”

Dr. Bynum captures some of the core issues here with great insight and articulation. What’s more, we’re talking about quite a large number of people here. “As of 2014,” a 2017 RAND Corporation report authored by Christine Buttroff, Teague Ruder, and Melissa Bauman, notes, “60 percent of American adults had at least one chronic condition, and 42 percent had more than one chronic condition. NOTE: Percentages may not total 100 because of rounding. The prevalence of multiple chronic conditions is higher among older adults.” Those researchers note that “[C]hronic disease is a burden not only for these patients but also for the health care system overall. Those with multiple chronic conditions have poorer health, use more health services, and spend more on health care—trends that have been stable since 2008.”

So, given that 42 percent of American adults are living with two or more chronic conditions, the lack of meaningful systems to accurately measure the quality of their care and care management can only be seen as alarming. What’s more, we are heading into a phase in the overall evolution of the U.S. healthcare system in which it will become more vital than ever for policymakers, purchasers, payers, consumers, and providers themselves to obtain more accurate insights into the quality of care and care management that patients with multiple chronic illnesses are receiving. And yes, one could draw an analogy to the idea of refueling planes while in flight, as we need to reimagine quality measures at the same time that more and more providers enter into accountable care organization (ACO), population health, bundled-payment, and other value-based contracts with the purchasers and payers of healthcare.

And it goes without saying that healthcare IT leaders will necessarily play a very important, even crucial, role in all of this. Senior healthcare IT executives, both clinical and non-clinical will inevitably be a part of the broad (and specific) discussions that will be evolving forward in this arena. I’m especially thinking, of course, of CMIOs, CNIOs, and other senior clinical informaticists in patient care organizations. Without them, any measurement regimens that are developed will only be seen as externally imposed—and therefore unwelcome to the practicing physicians, nurses, and other clinicians on the front lines of care and care management.

So these are challenges that were inevitably going to wash up against our healthcare delivery system, and, in fact, are already doing so. But there are opportunities inevitably embedded in these challenges, too; and the biggest is the opportunity for CMIOs, CNIOs, and other clinical informaticists to take part in the grand enterprise of developing meaningful measures that will accurately measure the levels of quality of care delivery and care management taking place right now in the healthcare system, and will encourage improvement in all areas.

As Dr. Bynum notes, “The biggest challenge for measuring quality of care for high-need people may be a technical one—identifying the population to be measured. The starter taxonomy is a tool to help health systems and payers segment individuals based on the care they need and how often they might need it, and is set out in the NAM report. It is informed by research that uses costs from administrative data to define who should be considered high need. These data do not include use of social care services, the unifying factor linking the disparate groups comprising the high-need population, which precludes identification of people with high needs before their medical costs skyrocket. We lack tools in electronic medical records (EMR) that capture social care received through community organizations, long-term care providers, or informal caregivers. Inclusion of these tools in EMRs would allow identification of people who require community-based supports earlier and will ultimately augment our ability to improve their experience and possibly affect downstream costs of use.” What better opportunity for clinical informaticists to help lead the industry forward?

And Dr. Bynum concludes her blog on an optimistic note. “It’s a promising time for people with high needs, whose struggle with complex care is increasingly being addressed using evidence-based models that have incentives in place for their wide-scale dissemination,” she writes. “Strategies for assessing quality that incorporate social care services and providers, attend to goal-aligned care plans, and consider innovative approaches to measure coordination, or the lack thereof, will be important for marking the path toward better care.” I sincerely hope that the intelligent, thoughtful leaders in our industry take up this challenge with the same vigor and dedication with which they’ve taken up every challenge so far, because this is a very important—and consequential one indeed.



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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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