Solving for Quality: Using Data to Boost Health Plan Value
As employers work to comply with the new transparency requirements some are stepping up efforts to pair price and quality data to reduce costs, improve quality and enhance the patient experience. By looking at consistent metrics across markets, employers can assess the amount of variation in healthcare cost and quality from one location to the next. With that information in hand, there are various actions employers can take to identify and quantify savings opportunities in shifting care from some providers to others. Here are five examples.
Enhanced decision support. We helped one employer measure their network’s quality of care down to the provider level. The data indicated that about half of the 5,700 PCPs in their largest market were in the sweet spot in terms of providing high quality care at a low cost. While this was an impressive result, it led to the next question: whether the plan members’ utilization of specific providers mirrored the market – and if so, whether it would be possible to encourage greater utilization of the best PCPs. This analysis prompted discussions with the carrier about how they rate primary care providers. As a result, the employer is thinking and evaluating decision support resources differently since there is a lot of opportunity in the market to steer towards great primary care.
High performance network evaluation. An employer that implemented one carrier’s high-performance network asked us to evaluate its effectiveness. The network was supposed to deliver both higher quality and lower unit costs by curating the broader list of providers. Our analysis showed that, in the market in question, the high-performance network produced quality results similar to those of the broader PPO network. This didn’t mean the network wasn’t effective – in fact, it did deliver savings. But in this market, the network value was being driven by the more traditional cost side of the “value balancing act”.
Moving from volume to value. Another project focused on the major care categories for an employer – maternity and orthopedics. We determined where the plan participants were being steered for these services and ranked those systems by the volume of care provided. After looking at the quality and episodic price data for each of these major systems, we told the employer how we would rank the systems based on value instead of volume. This conversation was eye-opening for the employer, and the analysis has allowed them to dig in with their medical carrier on where their members are getting care versus where they should be getting care.
ACO assist. For employers who are already a part of an ACO arrangement with a local health system, or are entertaining entering into such an arrangement, a credible source of third-party quality data can be a big help. After working with one ACO partner for many years, an employer decided it was time to conduct a systematic review of their current partner and other available health systems. We compared key clinical metrics across all the systems, and the employer is using the analysis to renegotiate a contract with their current partner.
Advanced primary care. Quality data can also be used to inform decisions about worksite clinics. An employer was considering implementing a clinic near corporate headquarters. However, we discovered that in this market the average primary care quality score was well above the national benchmark – in other words, employees in this location already had good access to great quality care. As a result, this employer has shifted focus to other markets where our analytics showed the average primary care quality score wasn’t as favorable. Employers with clinics already in place have used the data to identify providers in the market for referrals, to ensure that the care the member receives next is of the highest quality.
In the year since we launched QualPic, our care quality database tool, we’ve been able to have ground-breaking conversations with employers, helping them to innovate around their benefit offerings and push the market towards better value. Together we’ve made a great start -- but we think the best is yet to come.
QualPic is Mercer’s proprietary database tool that functions as a diagnostic to help paint a picture of cost and quality for different categories of care, ranging from primary care to orthopedics and more.