Most employers and healthcare consumers have traditionally purchased their coverage plans based on price, and with spiraling costs, who can blame them? In recent years, however, the proposition of value-that is, price in relation to quality-has slowly gained traction as a guiding principle.
At the forefront of the value-awareness wave is the not-for-profit National Committee for Quality Assurance (NCQA), now in its 11th year of producing objective, comparative quality measures for health plan performance and accreditation. NCQA President Margaret E. O'Kane, who has led the organization since its beginning, says the simple measurement of quality alone has brought about improvements in the past decade that never would have happened had healthcare quality never been tracked or publicly reported.
Because the healthcare system is not working as well as it could for patients, health plans have an opportunity right now to recreate their relationship with members and build it in conjunction with the quality agenda. It begins with measurement and reporting then comes together through coordinated efforts to make improvements, she says.
PricewaterhouseCoopers recently presented its research in "The Quality Conundrum: Practical Approaches For Enhancing Patient Care" and found that quality improvement and value-based purchasing is top-of-mind for all stakeholders today, but the obvious challenge comes in coordinating efforts and developing standards across a patchwork of programs.
"Currently, there's too much confusion, resulting in redundancy of effort," says Hindy Shaman, director of PricewaterhouseCoopers' Health Research Institute. "Providers are working at cross purposes, faced with differing reporting requirements from various payers and accrediting organizations. With coordination, we can harness the great energy out there into measurable results."
Health plans are actively engaged in measuring and rewarding quality and are on the same page with CMS regarding the importance of pay-for-reporting, pay-for-performance and value-based purchasing, Shaman says. However, there are still improvements to be made in standardization of metrics and reduction of administrative burdens.
"Everyone recognizes the need to advance quality measures, and quality is no longer just the clinicians' realm-it's advancing through the added efforts of payers and employers," she says. "When it comes to quality measures, payers and providers are often limited by the availability of clinical data-sometimes all they have are claims data, which were not designed for quality reporting and contain limited clinical information. And in many cases, we just have proxy structural or process measures, rather than metrics that truly reflect outcomes."