In this episode of the Move to Value Podcast we have a conversation about quality and its importance as a driver of success in value-based care with Derrick Stiller, Senior Director of Value Based Contract Operations at CHESS Health Solutions, where he leads the Contract Operations and Clinical Documentation Integrity departments as well as Quality Services.

Today we want to talk about quality and its importance as a driver of success in value-based care. Can you share with us what goes into Quality performance monitoring, data collection, and reporting?

Definitely. Quality is very important in value-based health care. It’s how you get started in the game. Organization can’t move to more advanced contracts without performing well in quality. And then you also won’t have dollars to reinvest in the infrastructure it takes to move on to the more advanced contracts that include more nurse positions that cost more, advanced data that’s required to bend the cost curve. So, it’s very important. You need the quality dollars. You need to perform well. And then of course quality is designed to have better care for the patient. So that’s ultimately what we’re in for. It’s also great because for the most part it is very easy to measure and track over time. Very objective. There are patients who qualify for a measure, that’s your denominator. Patients that are compliant for the measure, that’s your numerator. I went to public school but even I can figure out numerator divided by denominator equals performance. So that’s a very objective measure that people can kind of really grasp. You can see what levers make changes.

Payors are good about sending quality summaries that show current performance compared to target and patient level detail. This is important because you want to identify the non-compliant members. Then you need to come up with a strategy. One thing we’ve helped, found helpful, is adding gaps to target. Some payors provide that, some don’t. But it’s great and you can do a simple, VLOOKUP formula, or some formulas to provide information to figure out what that gaps to target is. And then, that allows you to really focus and find the patients that are going to move the needle for you. Traditional Medicare ACOs are a little different though. It’s definitely a different animal. You have to have the infrastructure to be able to produce these reports yourself. So, most of the time, when I’m talking today, a lot of, it’s going to rely on contracts that are in the MA space versus traditional Medicare ACOs. But of course, we do have traditional Medicare ACOs at CHESS, and we do produce quality data. But it is a little harder than just relying on the payors.

So then, you know, the question becomes what do we do with this information once we have it. So, you need to develop a process that will ensure non-compliant patients become compliant. This starts way upstream. You want to audit templates, such as the annual wellness visit template, that is used for patients. You want to standardize it across the board. You don’t want 30 providers having 10 different templates that they use. You want to make sure quality measures are presented to the provider at the point of care. You want to make sure that data is captured in discrete data fields. What is that, right? That’s some jargon. But that’s just the, think, yes no; integer 1 to 10. Not free text. So, it’s not a, when you’re filling out a form online, there’s text, there’s fields that you can just type in. They’re pretty rare these days because you want, the data folks want to be able to pull the information and compare it and not have, they don’t want to have to have a computer and AI to analyze what’s typed in the field. So discrete data is very important. So, this ensures great performance, and allows you to really take advantage of automated processes that are offered to reduce the manual work.

Then you have to design processes to capture proof that members are compliant where payors say they’re not. So, a lot of times, you’ll have a payor tell you that someone is missing a colonoscopy, and the patient tells you that they’ve had one of those five years ago. Well, it turns out they had it at a different health system, and they had it when they were on Humana and now they’re on Blue Cross. And Blue Cross is the one telling you that they don’t, that they don’t have evidence of the colonoscopy. So, there’s something that has to be trigger for you to know that information and then you also need to know how to go gather that information. And that’s not an automated process, that’s more of a manual process. So, we want to cut down that as much as possible. There are also automated process that are best practice but there’s always records that are going to fall in the manual category. Unfortunately, large health systems struggle with manual processes because it takes so much due to how many patients they have attributed to them. But, we feel like there’s always a place for that.

What is the importance of having a robust quality team in value-based care?

Yeah, this really speaks to my last point about manual efforts. You need folks to perform manual chart retrieval. You need folks to perform telephonic outreach to get ahold of patients to make sure they get in. You need EMR subject matter expert to develop automated processes. From a clinical perspective, you need quality measures subject matter experts who design processes and suggest things like standing orders to automate a process. So, if a patient hasn’t had a colonoscopy in 10 years, there’s a standing order there for the provider when the patient does come in. A quality department can help greatly with that. Of course, as you can imagine, there’s resistance to checking boxes. You’ve got to connect the fact that it’s good patient care is why there’s a box there to begin with. And if you can achieve that, check the box or make the patient compliant, many times that’s going to lead for great outcomes for the patient and better quality of life.

You need someone that can communicate performance. Right? So, you need somebody that can sit in the boardroom and tell executives, and CMOs, nurse leaders, how they’re doing and have a discussion on how to get better at what they do. Maybe talk about processes that are in place and why a health system does something that you don’t understand. Just, kind of, as I’ve talked, and I’m sure I’ve missed things, I’m sure you can see that it takes a lot of expertise, and it is a lot of work. So, a robust team is very important. And there is the fact that increased quality performance is going to help you pay for those positions. So, it’s not just the cost of doing business necessarily. You should be able to connect performance and ROI on those positions.

Tell me about the consequence of data in Quality. What types of data are important and how is it most effectively captured? Can you provide examples of good data and bad or missing data? What is the impact of bad or missing data?

Great question. Many times, when you get your first reports for quality performance, it’s a little bit of a shock factor because you know you’re doing better than these reports say. You know that 75% of your diabetics are not out of control and do not have A1Cs greater than 9. So, kind of back to our point about a robust quality team, you need to find out where the breakdown occurs. And so, what we call them are gaps in data versus gaps in care. Okay. The hard work’s already done. We want to capture that and make sure you get credit for it. Okay. So, it’s very important that that happens. We want to make sure that information is in the right place in the EMR. It’s a real shame when excellent quality patient care is provided, but the health system is not rewarded for their work. You want to set up templates that capture information and fields that can easily be reported. Back to my discrete data comment. Patient matching is a big problem. In my opinion, if we could make strides here, I think, patient care and patient identifying opportunities, it’s kind of out of the quality arena, but utilization and rising risk folks, there’s a lot of time a disconnect between what the payors are telling you versus what’s in your EMR. And one, the fundamental issue there is that the payor is operating off of a member ID that they provide. It’s unique to them. An EMR is working on an MRN, medical record number, that is unique to the EMR. And they don’t share. So of course, you could ingest patient member IDs from payors, but those change and folks come in and check in is entering a number. And it’s just a very cumbersome process if you will. That I think some type of creation of a unique ID for all of us. So obviously you aren’t going to put social security number on there, right. Now, it’s interesting, I’ve read a lot of folks are finding success using email addresses because the nature of an email address is unique. But anyways, I’m kind of digressing a little bit. But I think that’s a big problem.

So, what happens is with quality, in the quality space, missing data is very often caused by the matching problem. The consequences are frustration by patients and providers. They know the work’s been done but you keep bugging them about it, right. So, there’s patient abrasion, there’s provider abrasion, there’s also unnecessary spend due to duplication of services. Right. So, you’ve got to get a colonoscopy, you’ve just had one four years ago, but somehow you talk them into getting one because you can’t find evidence of it. Well now you’re spending more than you should. No cost to the patient, but it’s cost to the health system. So, there are unnecessary spend due to that. And then poor contract performance, you know. I can send in 10,000 lines of quality data to close quality measures back to the payor, but if they don’t know who that belongs to, you’re capped at who they find matches for. So big big problem. Sounds like of fundamental and easy, but it’s hard to change. It really is. It’s something that I’ve been kind of passionate in my six years with CHESS about and have not made the strides I’d like, but it’s an interesting space there.

What advice do you have for our listeners who have been struggling with their quality performance?

Yeah. It’s interesting. I think there’s quite a few things that can be done and they’re not super complex. So, I think it speaks to the folks out there who may find themselves in some early contracts that are quality only. But it’s also, can really help in the very advanced contracts. You know, CHESS has contracts all along that continuum. And so, we find a lot of these items that I’m going to admit, that come to mind, work across all of those contracts.

So, an AWV outreach strategy is crucial. We want to make sure that all patients get in to see the doctor in the calendar year. And the earlier, the better. So, some payors allow you to do it on a calendar year basis. Traditional Medicare is a little harder. They want it, you know, eleven months plus a day from the last one. And, you know, it’s not good practice to have an annual wellness visit in February if you just had one in November. You know, that’s not getting a true picture of an annual visit, right. But I think it’s very important to have the infrastructure set up where you can outreach every patient that’s on your attribution filing. And that can be done different ways. You know, CHESS hubs that. Right, so we have Patient Care Advocates who make those phone calls and do that outreach. But you could also push those lists to the patient, to the provider offices, right. So, you can work closely with them and send them only their patients and ask them to do the outreach. Even better, you can have the patient schedule the following year’s annual wellness visit when they’re in their doing theirs for this year. That’s really best practice. And we’ve seen offices that use that are by far the best performers.

So, make sure all data is captured in discrete data fields. Told you about that earlier. Want to make sure the templates are set up for that. That’s going to allow for you to have the automated processes and cut down on a lot of the manual work. Work on your patient matching, I’d say, is probably another one. You want to develop clinical extracts that, so that’s directly related to the patient matching because the payor needs to know who you’re sending data for and they need to be able to connect that and again kind of the fuzzy matching of name, date of birth, just doesn’t cut it. It takes some pretty sophisticated algorithms to figure that out. So, unique IDs are very important.

So, the clinical extracts will lighten the load for manual labor. See there’s a theme here, right? It’s setting yourself up for success to cut down on manual labor. And then train employees performing outreach on motivational interviewing, I think. That’s probably a must. Get folks to do the behavior that you want them and change their behaviors for the good. And then finally I’d say as the year winds down and your automated processes have taken place and you still find yourself with a area for improvement and you’ve done the things I’ve talked about, what you want to do is go in and say okay for breast cancer screening I need to close 10 gaps to get to a 4-star rating if that’s my goal, or if a five-star rating is my goal. And be able to identify the 18 people that you can get your 10 from and go after those folks. Make sure that you’ve called them, asked them have they done it elsewhere, where at. Google the phone number, call, ask if the facility will send you a copy of the screening. Get that put into the EMR in the right place so next year the automated process catches it.

So, there’s a lot of things that can be done there. But we’ve really found that this manual outreach at the end, this focused outreach, will get you over the hump. It really, it’ll take a 3.75 performance to a 4 or a 4.25. And many many times, there are patients out there that you can close. And a lot of times, like I said earlier, the work’s already been done. So, I think that’s where I’d end it. I think there are, those are some very practical steps that you can take, and you can take them in a small rural health system, or a single provider clinic, or everything to an academic medical center.

There’s a bit of an oversimplification when you talk about one portion of value-based care. Right, so we’re talking quality. A lot of times, some quality measures will add in utilization measures like an inpatient admission per thousand measure or plan all-cause readmission. So, I don’t want, everyone to think that I’m oversimplifying, but I think if we’re going to talk quality, that’s where we land. This is what we talked about today. There are many other parts and pieces. Maybe we can have a conversation at another time about another topic, but I would say that. I don’t want folks to think that it’s easier than, I’m making it sound easier than it is. It’s hard work. It really is. And you have to have buy in all over the place, from the top down, to get folks to do that. The stars align, you can have great performance, do amazing work for your patients, and also for your organization.