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Healthcare: Ensuring Higher Quality Scores with a Single View of the Member

Achieving high quality scores in today’s shift to value-based payment remains a key goal for payers. But achieving that goal often is hindered by the inability to see where they stand on the specific metrics and to take corrective action throughout the year. Being able to measure and react in a timely manner requires smart planning, lots of collaboration and innovative digital tools optimized to achieve the all-important single view of the member.

They say, “If you can measure it, you can improve it.” And that is the thought behind quality measures as healthcare shifts to value-based payment. But it’s often easier said than done, especially when healthcare organizations lack sufficient visibility into the full spectrum of member interactions before, during and after receiving care.

In this new environment, organizations need tools that provide a single view of the member—a comprehensive understanding of each member, including an understanding of who the member is beyond their clinical profile, as well as visibility into each care interaction. This single, comprehensive view enables health plans to know how to best communicate with members in order to improve satisfaction and outcomes that lead to higher quality scores and improved financial performance.

Of course, there are other tangible and intangible benefits from high scores for healthcare quality beyond payer reimbursements, for both public and private plans. Quality scores typically reflect operational efficiencies of payer-provider collaborative efforts, like accountable care organizations (ACOs) and Patient Centered Medical Homes (PCMHs). Additionally, high scores are powerful marketing tools to drive enrollment and retention.

The realities of today’s regulatory environment, and the transformation to a value-based payment model, mean that the stakes have never been higher for organizations to ensure high quality care. Numerous payers and major ACOs have lost huge sums of Medicare reimbursements due to small lapses in quality scores, and the introduction of millions of high-risk patients into ACOs’ universe has put even more pressure on those organizations to ensure they are well positioned to deliver the best care possible to a wider and more diverse population of patients. A drop of a single star on the Medicare 5-star scale can mean the difference between economic vitality and potential cuts in services and staff for ACOs, at least until the scores are improved.

Healthcare Ensuring Higher Quality Scores with a Single View of the Member