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Questions to Ask When Developing an Effective Clinical Quality Reporting Improvement Strategy


Questions to Ask When Developing an Effective Clinical Quality Reporting Improvement Strategy

March 22, 2023 | 2-minute read

Clinical Quality Reporting

Having an effective clinical quality reporting suite is essential for all health plans. Timely and accurate quality reporting is crucial for health plans who develop and manage value-based provider reimbursement contracts. The need for effective quality reporting is also true for Medicare Advantage plans looking to maintain their CMS 5-star rating as well. This also applies to those plans who want to realize the enrollment and revenue benefits of improving their current Medicare star rating.

Approximately 51% of Medicare Advantage plans with prescription drug coverage collectively earned 2023 ratings of 4 stars (above average) or 5 stars (excellent). While most MA members are enrolled in above average plans, there is still an opportunity for low-rated plans to improve their star ratings if they consider these IT analytics questions during their quality improvement planning cycle.

  • Does our decision support system enable us to easily access and evaluate existing CAHPS data? For some plans, data is siloed and difficult to access. There is no real benefit in waiting for the latest release of the annual Consumer Assessment of Healthcare Providers & Systems survey results if your informatics team isn’t making good use of existing data. A best practice used by one of our highly CMS Star-rated clients is to enhance internal business user access to clinical quality data lakes by using advanced, real-time clinical data exchange tools.

  • Are we using quality reporting dashboards effectively? Insights resulting from analysis of critical quality measures can have a big impact on quality. Some leading health plans are providing earlier visibility to key provider and hospital quality metrics and trends by publishing easily deployable FHIR data-driven dashboards and analytics, enabling real-time intervention to proactively target quality metrics with their provider networks.

  • Do we have the right resources in-house? In almost every situation, health plans come to a “make vs. buy” crossroads point when evaluating the staffing resources required to implement a quality-focused clinical data integration strategy. According to Gartner®, Inc., “payer IT, analytics and informatics organizations typically do not have the combination of science skills and clinical knowledge needed to normalize and derive meaning for blended clinical data sources. Solution partners offer this capability ”unicorn” as a service.”

As a best practice, many health plans endeavor to implement a year-round CAHPS and Star Rating quality reporting improvement plan. As a first step, plans should ensure that these three questions are considered during their next planning cycle opportunity.

Gartner®, Clinical Data Integration: IT Readiness Assessment and RFP Questions for U.S. Healthcare Payer CIOs, September 2022

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