Ladders are only stable when rungs are connecting the sides at regular steps. Building rungs between two independent functions takes work. When risk and quality teams commit to the strategic planning and sweat equity needed, they can unlock one of their toughest combined challenges: provider abrasion and engagement.
Mapping requirements and aligning approaches
The first steps for risk and quality functions to work together is to better understand themselves. This requires a good audit across program and compliance timelines, data and document requirements, vendors used, and typical provider touchpoints.
Next, the functions need to come together and look for areas of alignment, overlap, and consolidation.
Get granular in your planning, particularly around data: When are charts requested? What dates of service are required? What documentation is absolutely necessary? Can you use a CCDA, or do you need the physical chart? Risk and quality also need to align around a plan’s “Most Valuable Patients” so providers can work the member one time.
Value-based care plans looking to integrate risk and quality more tightly could extend this work to integrated provider incentive programs and shared organizational goals. However, a great first step up the ladder is aligning on the data when it’s asked for and how its retrieved.
Data: your ticket to entry with providers
Providers get frustrated by outdated, unhelpful data and the perception that “administrative” burdens take focus away from patient care.
Risk and quality functions can win a lot of hearts of minds just by making sure the information that they share is clear, timely, accurate, and actionable. More innovative plans are even exploring how to bring new clinical insights to providers at the point of care.
In plans where that’s a longer-term goal, simply making takeaways more transparent is a start. If data is good through a particular date, bold it. Reconsider the schedule you deliver data, so it is shared within a week of the time frame listed on the report, making it more relevant. Data shared with providers should be accessible by offering print and online formats, and when asking for data back from providers, be as generous as possible with the formats you accept it.
Finally, consider a single point of contact to interface with providers. This person needs to be aware of the message, conversant in the data, and able to pull in support when necessary.
Tech to manage the new reality
Forward-looking risk and quality teams understand the potential value of presenting new clinical insights at the point of care in time to close gaps and influence outcomes. The question is how to get there.
1. Outside data sources to create fuller picture views
The key to provider engagement is giving new insights about their patients when it’s actionable. By tapping data outside health plan walls, risk and quality organizations can build longitudinal patient compendiums that can tell providers something about their patients they don’t know.
2. AI to sort massive amounts of data
The volume of data generated in health care is overwhelming even before considering how to ingest, collate, and transform outside data. AI is the only way to do this.
3. Centralized member information that feeds risk and quality programs
Next, for risk and quality teams to align, they need the same single source of truth when it comes to member data, which can be complicated when using disparate risk and quality platforms.
4. Integrations to make provider access as easy as possible–preferably in their EHR
Providers will be more engaged the easier it is to review suspected gaps in time to influence the point of care. Interoperability will be key in reducing the workload associated with sending those MVP-patient lists to providers, ideally integrated into their EHRs.
When risk and quality are more aligned, they can take a “year-round-approach” to provider collaboration. The “audit” mentality can start to fade, and more focus goes to member care. Most importantly, with better alignment, value-based care organizations have the opportunity earlier in the year to close your gaps and manage members’ conditions throughout the year.
About the author
Elissa Toder, vice president, quality and improvement strategy and solutions, Reveleer, has worked in managed care for 16 years. She is the former staff vice president of quality improvement strategy at Centene, focusing on all lines of business, HEDIS® improvement, and vendor management. Prior to Centene, she spent 15 years at WellCare Health Plans where she ran quality improvement programs.