Quality Metrics

In the first few years after officially adopting the Affordable Care Act in 2010, the government focused on broadening the definition of Medicare and Medicaid to improve quality and efficiency for those eligible populations. Now five years since the signing of the ACA, the focus is shifting more heavily towards quality of care for all patients.

Payers (be they private insurers or the Centers for Medicare and Medicaid Services) determine how providers are reimbursed: whether fee-for-service or capitated. Some insurance companies, such as Blue Cross Blue Shield, developed an Alternative Quality Contract (AQC) for patients enrolled in an HMO-insurance plan to hold providers accountable for providing quality care to their patients. The AQC has actually demonstrated its ability to improve the quality of patient care and lowered costs.

This initiative is the next step in healthcare but many practices are finding it difficult to meet and document the specific quality metrics determined by the payers. These metrics pertain both to management of chronic conditions (e.g., diabetes, cardiovascular disease, and hypertension) as well as to preventative measures (e.g., cancer screenings and adolescent well care).

The responsibility of meeting these quality metrics lies on both the provider and the patient to comply with these standards. Despite having these responsibilities, in reality, providers may not remind patients to complete certain tests due to lack of time, lack of awareness, or simple disregard for the metrics. Even if the provider reminds the patient, the patient can still forget or ignore the clinician’s suggestions. Ultimately, the burden then falls on the provider and the result is that the healthcare organization loses payer reimbursement for that patient if the metric is not met.

Electronic Medical Records (EMRs) typically highlight items the provider needs to address during the patient’s visit, but this is still not enough to ensure that appropriate metrics are captured.  Patient portals may have the capability to remind patients of overdue items, but engagement in portals has so far been low due poor user interfaces.

These gaps in communication are creating a new opportunity for innovation in healthcare technology. What is truly needed are systems that populate a patient’s care plan with the required quality and clinical tasks, while providing an easy, collaborative interface through which both providers and patients can view progress against those tasks. By providing good tools designed to support quality improvement, healthcare organizations can help clinicians and their patients to be more accountable for adhering to care plans and the relevant quality measures.