Industry Voices—Obstacle or opportunity? How CMS mandates can drive quality care and improved patient experiences

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New Centers for Medicare & Medicaid Services rules give health plans the chance to do more than just meet the “letter of the law.” Plans can and should go beyond the minimums in the mandates to create experiences that are positive, not burdensome, for their members. (Getty/marchmeena29)

Although open enrollment for 2021 is now complete, important changes for healthcare consumers are just beginning.

This year, health plans are preparing to implement two mandates from the Centers for Medicare & Medicaid Services (CMS)—interoperability and price transparency—that will have dramatic and positive impacts on the healthcare system. These new rules also offer plans a unique opportunity to ensure high-value care that includes a focus on quality and cost for improved member experiences.

The interoperability mandate will give people greater access to their health records by removing barriers that have prevented easy data sharing between providers. This will ease a heavy and even painful burden that people and their caregivers have, until now, had to shoulder—in carrying along stacks of records to each new provider, in recounting health histories anew each time and in witnessing the difficulties ailing loved ones have during these encounters. Technology can relieve those burdens; the mandate will make certain it does.

The price transparency mandate will help people and their families with financial planning around healthcare. Recent surveys have shown up to one-third of insured people do not get the healthcare they need, either because they didn’t know what it would cost or the cost was too high.

The new rule ensures people can get an answer to, “How much will I pay?” before getting care. This change recognizes that the financial health of a plan member is just as important as their medical health.

However, the new rules give health plans the chance to do more than just meet the “letter of the law.” Plans can and should go beyond the minimums in the mandates to create experiences that are positive, not burdensome, for their members.

Plans are uniquely positioned to do this because they know their members’ health histories, claims histories and benefits, and members are increasingly looking to their plans for guidance on care. As they implement the new rules, plans could also utilize this wealth of data to help members find high-value care. But who decides what constitutes “high value” in healthcare?

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Defining high-value care

For the healthcare industry, value is a combination of price data and quality data.

Defining price at any one moment is a major challenge, because different stakeholders shoulder different costs. Plan members are sheltered from the ultimate cost; providers are often agnostic about it. But cost matters greatly to health plans: Two drugs might cost a member the same price, but there could be a threefold difference in their costs to the plan. The industry has to solve this complexity before we can give consumers a price.

However, healthcare consumers don’t base their decisions solely on cost: the quality of the care, service or procedure is also a deciding factor. A patient will not want the lowest-cost hip replacement from a hospital or orthopedic surgeon that has a failing grade on quality. This means people are looking for overall value.

In addition to outcomes, quality must also account for the people’s individual wants, needs and expectations. They need measures and metrics of quality that speak to their personal preferences and concerns. To deliver those measures, plans need to understand what people expect from their healthcare experiences and what factors influence their choices.

For example, providers can be scored on quality using standard clinical metrics for managing specific health issues: blood pressure, women’s health and so on. But other measures of quality involve standard consumer metrics such as: when the patient can get an appointment, how long in-office wait times are, what languages the provider and staff speak and so on. Measures of quality can be highly subjective, because what matters to one person may be less important to another.

Ultimately, quality measures should help a person understand, “What will I get from this care center that I won’t get elsewhere?”

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Making value meaningful

There is one more vitally important step for health plans to help members find high-value care: Plans must distill their insights on value, derived from the intersection of price and quality, into easily understood, meaningful information.

There are many groups that offer these kinds of data to professionals and their facilities, especially on the Medicare side. But these insights are not as widely available or accessible for consumers.

In particular, current descriptions of quality right now fall into two broad categories. On the one hand, they are highly complex and seem like a foreign language to the consumer—for example, the Healthcare Effectiveness Data and Information Set. On the other hand, they are over-simplified, such as ranking systems on the web or in magazines. In many cases, the average person will rely on reviews and ratings, but this isn’t a reliable way to assess healthcare quality and cost.

Interoperability will be an important component to delivering quality care. Healthcare data now reside in multiple siloes, rendering the information hard to access or extract meaningful insights. Yet, without a person’s complete health and claims record, care recommendations may fall far short of the high-quality mark—or, worse, have disastrous results. Plans need partners that can help them integrate information from multiple siloes into clean, usable data sets that give the “whole picture” needed to guide members to quality care in an online transparency experience. When this happens, plans can also provide more personalized services.

Clean data sets also enable plans to distill information on quality from all sources and price in context to the member’s health situation to offer guidance that is both easy for consumers to understand and useful for their decision-making.

Such guidance can steer not only plan members but also all stakeholders, such as a plan’s care teams and customer service representatives, toward the best value in care and the best possible care experiences.

Plans already have a lot of work to do to meet the mandates; that much is unavoidable. But if they focus solely on meeting the mandates, they will miss a huge opportunity. With a little more work, plans can turn their data into meaningful insights that, in cooperation with interoperability and price transparency, can guide member’s decisions, deliver them the best care and support and increase satisfaction in the experience.

We acknowledge that it’s a huge step, but we think it is a step that plans should take toward truly empowering members with the right information—and at the right level—to find high-value care. Taking that step means recognizing the best choice for the consumer is not just a matter of price; it’s also about the sometimes subjective matter of quality. It means recognizing that, ultimately, value is in the eye of the beholder—the informed healthcare consumer.

Mark Menton is general manager of HealthSparq Inc., and Minal Patel is the CEO and founder of Abacus Insights Inc.