For health plans participating in risk-based agreements, gaps in care have serious implications for the health outcomes of members and their ability to attain higher quality scores necessary to receive financial bonuses and drive member enrollment. To remediate these care gaps, payers must improve their ability to access data by making significant changes to their health IT infrastructure.
To facilitate more efficient gap closure and to promote quality improvement, the Centers for Medicare & Medicaid Services (CMS) has increasingly turned to health IT standards and application programming interfaces (APIs) to streamline the sharing of data necessary to identify members who have missed preventive screenings and other services and take action.
Medicare Advantage is one of the most popular risk-based programs and has increasingly drawn the interest of payers. Billions of dollars are available to health plans that achieve high scores under Medicare Star Ratings, a five-star quality rating system to measure their ability to meet members’ healthcare needs.
Underpinning quality reporting for these ratings is a combination of performance measures. The most important to close care gaps are part of the Healthcare Effectiveness Data and Information Set (HEDIS), which measures how well a plan handles preventive care and chronic care disease management. More than 90 percent of US health plans use HEDIS measures to gauge their performance while serving more than 190 million Americans.
For health plans to demonstrate their support for high-quality preventive care, they must identify individuals who have missed essential screenings and aid providers and members in closing these care gaps that could lead to poor long-term outcomes, increases in higher-cost care and greater utilization of emergency care services.
As a result of the covid-19 pandemic, many individuals and demographic groups with known health risks forewent necessary screenings. According to available CMS data from 20 million patients in 2020, staggering drops in preventive care occurred last year: 114,636 missed colonoscopies, 158,717 missed mammograms and 114,367 missed pap smears. All these missed preventive services mean the onus is on health plans in risk-based agreements to reduce the health risks of their member population and to qualify for financial bonuses by successfully doing so.
The data problem of closing gaps in care
To succeed in a changing regulatory environment increasingly counting on APIs to streamline health data exchange, health plans must understand and implement new technologies. The technical lift required is likely to prove a significant challenge.
Under the Interoperability and Patient Access final rule, qualified health plans — including Medicare Advantage plans as well as many Medicaid and Children’s Health Insurance Program (CHIP) plans — must implement patient access APIs based on HL7’s Fast Healthcare Interoperability Resources (FHIR) so that individuals can “easily access their claims and encounter information, including cost, as well as a defined sub-set of their clinical information through third-party applications of their choice.”
Specifically, the federal agency has recommended using the CARIN Blue Button Implementation Guide (IG) for payers to display components of the Common Payer Consumer Data Set (CPCDS) to consumers via the FHIR API and US Core or Davinci PDex for USCDI.
For health plans working in risk-based agreements to address gaps in care, it’s beneficial to develop a working understanding of the Da Vinci Data Exchange for Quality Measures (DEQM), created by the private sector initiative the Da Vinci Project to support the needs of value-based care using the HL7 FHIR platform that contains a focus on gaps in care. Currently, implementation is not required, but it likely to be required or recommended by CMS in the future.
While critical to advancing the healthcare industry’s ability to exchange health data efficiently and securely, these standards represent a considerable challenge for payers. First, they must focus on having the technical knowledge and skills necessary to implement these standards. Second, they must enable themselves to gather data and map appropriate elements to the correct quality measure. Third, they must create a means for identifying and addressing gaps in care.
Payers will need to be able to build out those APIs to retrieve clinical data, often having to go outside their organizations to acquire the patient data to compute these measures. Either through themselves or an intermediary, payers must have the ability calculate these measures and build the logic under the hood to determine actually who has an open care gap
Creating a gap in care report
Closing gaps in care via interoperability mirrors the risk adjustment process currently challenging health plans engaged in population health programs. Both begin with understanding the health risks of individuals and cohorts of members. Data access is vital.
The healthcare industry’s efforts to implement the patient access API offers an avenue to accessing critical clinical data on patients, namely the lack of information indicating that patients of a certain age (e.g., breast cancer screenings for women 50–74 years) or disease state (e.g., eye exams for adults 18–75 years of age with type 1 or type 2 diabetes). By leveraging patient access APIs, health plans can access the data necessary to create gaps in care reports.
Payers are looking to create gaps in care reports for cohorts or groups of patients, such as individuals with diabetes. Then, they share that data with a provider to necessitate outreach and generate diagnostic orders for those patients that have open care gaps. When those care gaps are closed, the data is then returned to the health plans which update their systems and calculate their quality measure scores.
On the surface, it appears to be a relatively simple process. However, putting all the mechanisms — that is, APIs — in place will prove a challenge to payers, straining resources and likely exposing knowledge and skills gaps.
But payers in risk-based agreements cannot afford to ignore the urgency of the present moment. Gaps in care have exploded due to the pandemic and federal regulation spurring advances in interoperability is here to stay. By working with a trusted technology partner, health plans can ensure they have access to the data and resources necessary to close gaps in care and demonstrate the high value of their offerings in a highly competitive market.
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