Payers and Providers as Allies Quality and Value-Based Care

Posted July 27, 2017 by Adele Allison and Gala Fary

Health plans have an opportunity to collaborate more fully with providers (physicians, nurse practitioners, physician assistants, pharmacists, and other clinicians) to achieve higher quality results in HEDIS® as well as other quality programs. There is a strong basis for such relationships since performance measurement is not only for health plans. A combination of factors are moving healthcare providers into value-based care and payment arrangements. The US Department of Health and Human Services (HHS) is moving Medicare toward payments tied to quality and value beginning in 2019. Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare providers have strong financial incentives to improve the delivery of healthcare services and consumer health outcomes. Likewise, states are transforming Medicaid by expanding managed care and quality incentive programs. In this transition, physicians are increasingly participating in value-based payment programs that tie compensation to measurable improvement.

The transition from volume to value creates a framework that encourages payers and providers to work ever more closely together. The long-standing payer vs. provider mindset will shift toward a more cooperative partnership as both parties become allies in achieving shared goals. In this move toward value-based payment, two best practices that health plans can adopt to foster valuable working relationships with providers are:

  1. View providers as data partners.
  2. Ease the burden on providers by using core measures in value-based payment arrangements.

#1: View providers as data partners

Constructing new ways to aggregate more comprehensive data is one of the most important steps health plans can take to perform better with HEDIS and evolving new value-based payment arrangements. As NCQA introduces more HEDIS measures that rely on ECDS data, health plans will become increasingly reliant on providers sharing electronic data; as providers take on risk and enter into value-based payment agreements, providers will increasingly recognize the benefits of the health plan sharing data with them. Aligned on mutual objectives, data sharing from your health plan to providers and vice versa will help both partners gain a more complete view of member/patient health. This will give you and providers better insight into where additional resources may be needed to close care gaps. You can then collaborate through member/patient outreach to increase engagement in healthcare, thus achieving better success with quality measures for both your health plan and the providers.

#2: Ease the burden on providers by using core measures in value-based payment arrangements

Defining metrics for value-based care based on core measures will help ease the data reporting burden on providers and can help facilitate successful payer-provider value-based care relationships. While NCQA’s HEDIS is one of the most long-established and well-recognized systems of healthcare assessment, there are a multitude of other quality stewards. Such programs include the Pharmacy Quality Alliance, the CMS Star Ratings, Quality Payment (incorporating the former Physician Quality Reporting System and Meaningful Use), state Medicaid programs, hospital inpatient and outpatient quality reporting (HIPQR and HOPQR), and others. Managing the data necessary to report on the broad and variable range of measures from different organizations such as these is time and resource intensive for providers.

Highlighting this challenge, Health Affairs recently reported the Billings Clinic, for example, must report on 102 different aspects of care to government and commercial payers, each with different requirements and deadlines1. The numerous measurement sets and a lack of industry-wide harmonization produces such a burden to providers like the Billings Clinic that this is recognized as a factor slowing the advancement toward value-based care.

Given the need for a more consistent approach to quality assessment across government and private payers, the Core Quality Measures Collaborative has developed a list of standard measures to be used in value-based payment arrangements. These cover the selected clinical areas the collaborative identified as priority based on measures currently used by CMS and health plans and those endorsed by the National Quality Forum. Core measures are identified in seven sets2:

  • Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMHs), and Primary Care
  • Cardiology
  • Gastroenterology
  • HIV and Hepatitis C
  • Medical Oncology
  • Obstetrics and Gynecology
  • Orthopedics

The NCQA and HEDIS are a vital part of these core measures, with NCQA stewarding approximately 17 of the 22 agreed-upon measures from the ACO and PCMH set and nine measures among the other six specialty sets3. As a health plan, adopting standardized measures such as these into your value-based payment contracts with providers is a strategy that can help ease the data reporting burden on providers and thus help facilitate a smooth and more rapid transition to value-based care and payment.

*HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

Adele Allison headshot
Gala Fary headshot
Adele Allison
Director, Provider Innovation Strategies
Gala Fary
Business Solutions Executive


1 Health Affairs. Obstacles on the Road to Risk. http://healthaffairs.org/blog/2017/02/15/obstacles-on-the-road-to-risk/. Published February 15, 2017. Accessed June 8, 2017.

2 Centers for Medicare & Medicaid Services. Core Measures. https://www.cms.gov/Medicare/Quality-initiatives-patient-assessment-instruments/qualitymeasures/core-measures.html. Accessed June 8, 2017.

3 National Committee for Quality Assurance. Core Measures: We Have Quality Consensus. http://blog.ncqa.org/core-measures-quality/. Published February 16, 2017. Accessed June 8, 2017.




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