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Dr Stephen Ondra: Consistency Is Driving Payment Reform Momentum

Public and private payers all heading in the same direction in regards to payment reform is sending a consistent message to providers and creating alignment in healthcare, said Stephen Ondra, MD, senior vice president and enterprise chief medical officer at Health Care Service Corporation.
AJMC: CMS and AHIP recently led an effort to define core sets of quality measures. What is the importance of that effort?
SO: That’s really important for a whole number of reasons. The first thing is as we’ve moved to alternative payment models based on value instead of fee-for-service volume, you have to ask yourself: what do you mean by value? So that’s a classic equation of quality over cost. And we can measure that denominator pretty well, you can understand what an episode of cost is. That numerator is a little more difficult to measure and when everyone measures it differently, it’s impossible to make sense of it.
So by getting public and private payers working with providers and consumers and purchasers to say, “we’re going to agree on this one subset of 7 categories of measures and agree that we’re all going to use those,” that creates an opportunity, a starting point, to build consistency of quality measures. So you’re all using the same yardstick. Somebody is not on metric, somebody’s on the English system, somebody is on something else, and what does it all mean?
It’s a start for that consistency that we need to be able to measure that numerator, because if we don’t measure quality in a way that is really relevant clinically what you’re going to do is simply have the move for fee-for-value be a race to the bottom on cost. That’s not something anyone wants. So it’s really important that we define that numerator in ways that are consistent. So we say we want to reduce the variability, we want to refine the ease of collection, we want it to be relevant clinically—everybody has different versions how to say that, but those are the 3 things we all want.
When you have a health problem and want to see someone, it would be nice if you had some way as a consumer to understand what is the quality of the outcome of the experience you are expecting. And then how do I relate that to cost, so I can make an informed decision? Right now as a consumer even if you want to make and informed decision on value, it’s really difficult because you don’t have the information you need. Cost is an important piece, but quality is an equally, arguably more, important piece.
AJMC: Talking about the consumers: giving them the information around quality is one thing, but how much do they understand about what that information is saying?
SO: You’ve probably gathered that consumers are a heterogeneous group of people and so you have people with different backgrounds, different levels of engagement. And it’s incumbent on payers and providers to help consumers understand what this all means.
By shifting from an alternative payment model, it’s actually in our business interest. So number 1, it’s the right thing to do: we have a moral and ethical reason to want to help consumers understand. But that only gets you so far in terms of investment. If you can line up that right thing to do with your business model, you’ll actually get the business investment to do that.
When you start doing population health and shared risk, now helping a consumer understand what is value, what is quality, and how do you make good choice and sort out the different options, when it’s in your business interest to do that, you’re going to make the investments to help the consumer. So that’s a big piece of that: how do we provide the consumer with the information so it’s understandable, educational, how to use it? Things that are actionable. So you’re seeing a lot of investment on both the payer and provider side for consumer engagement, whether it’s mobile apps or things that HSCS has, a benefit value advisor to help people understand their out-of-pocket cost. We have tools that we reach out to help consumers make good decisions for them and it actually, in the end, lines up with everyone’s interests.

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