How a Payer-Provider Partnership Impacts Care

According to recent research, a payer-provider collaboration allowed providers access to timely, actionable patient data related to Healthcare Effectiveness Data and Information Set (HEDIS) quality gaps.

Historically, when health plans attempt to improve HEDIS quality scores, particularly measures that require provider intervention such as medication management and adherence, health plans face numerous barriers. However, according to researchers, “creating performance-based incentive programs that that engage ambulatory care clinical pharmacists (ACCP) within the primary care office is one way that health plans can impact these medication-associated quality measures.”

In order to create a pharmacy-based program that provides timely identification of patients with HEDIS gaps for select medication associated quality measures, as well as include a performance-based incentive to encourage improvement in quality scores, researchers developed practice specific, actionable reports. The reports identified members who were noncompliant with select quality measures, and the reports were shared with the ACCP at a collaborating primary care practice (CPCP) on a quarterly basis. Additionally, the ACCP was responsible for engaging patients and providers based on the data provided by the health plan.

The reports identified members that had a quality gap during the 2017 measurement year in at least one of the following HEDIS measurements:

• Statin Therapy for Patients with Diabetes (SPD);
• Statin Therapy for Patients with Cardiovascular Disease (SPC); and,
• Medication Management for People with Asthma (MMA).

Based on their findings, the research team concluded that the CPCP demonstrated improvement in HEDIS quality scores from 2016 to 2017 for 4 of the 5 submeasures included during the 1-year pilot phase of the program. Further, CPCP specific scores for SPD increased from 67.07% to 70.40%, SPC for men aged 21 to 75 years increased from 82.25% to 86.14%, SPC for women aged 40 to 75 years increased from 66.67% to 79.27%, MMA for Medicare members increased from 50% to 55.56%, and MMA for commercial members decreased from 44.44% to 33.33%.

“Utilizing the ambulatory care pharmacist to lead the intervention at the practice site allowed for clinically sound support for both providers and patients,” the researchers explained. “Determining the appropriate performance metrics and financial incentive were crucial to ensuring full provider participation.”

This research was presented during a poster presentation at AMCP Nexus 2018.

—Julie Gould