Maximizing the Value of Employee Benefits with Quality Measurement & Reporting

This article is an abbreviated version of an in-depth, as yet unpublished report entitled Improving Health Quality in the Employer Sponsored Insurance Market. It would not have been possible without the author's participation in the Better Healthcare Policy Group (BHCPG.org).

Investing in healthcare quality initiatives is a cost-effective strategy for employers. This approach aims to maximize the value of their expenditures on employee health benefits.

The Quality Gap

Despite significant healthcare spending, the United States lags behind other developed nations in healthcare quality. The U.S. has lower life expectancy, higher infant mortality rates, and struggles with managing chronic diseases effectively. Within the U.S., studies have revealed substantial variations in mortality rates among hospitals (up to 3 to 1) and health plans (4 to 1). These variations argue for greater evidence-based provider selection and quality transparency than is currently available to most consumers. Addressing these issues requires:

• Systemic Improvements: Diagnostic accuracy, continuous quality improvement (CQI) practices, better quality measurement tools, and widespread use of electronic health records (EHRs).
• Active Engagement: Employers, consumers, and providers must actively engage in quality initiatives.

The Economic Rationale for Quality Improvement

Employers fund a significant portion of health insurance premiums, contributing about $580 billion in 2022 alone. Beyond direct costs, poor health outcomes can lead to lost productivity, absenteeism, and higher turnover rates. A report from the?Integrated Benefits Institute? found that “Illness-related lost productivity costs [employers] $530 billion per year, … or “60 cents for every dollar employers spend on health care benefits.”?Focusing on quality improvements can mitigate these costs and enhance organizational performance through:

• Reduced Healthcare Costs: Enhanced preventive care and chronic disease management can reduce the need for expensive emergency care and hospitalizations. Effective health management, distinct from aggressive utilization and claims denial, lowers healthcare utilization and overall costs.
• Employee Productivity and Retention: Access to high-quality healthcare services leads to fewer sick days, higher productivity, and improved health outcomes. Offering high-quality healthcare benefits can attract top talent, increase employee satisfaction, and reduce turnover rates.
• Lower Disability and Workers' Compensation Claims: Wellness programs and early intervention reduce the incidence and severity of workplace injuries and illnesses. This leads to fewer disability claims and faster return-to-work rates for injured employees.
• Improved Corporate Image and Reputation: Companies known for their commitment to employee health and well-being enjoy a better corporate image. This commitment aligns with corporate social responsibility goals and enhances the company’s reputation.

The Three-Body Problem: Differing Perspectives

Employers, providers, and employees often have conflicting needs and priorities. Borrowing a phrase from astrophysics (and popular culture) we call this the three-body problem:

• Employers: Focus on cost-effectiveness and the impact of health benefits on productivity and employee retention. Most employers respond to rising healthcare costs by shifting more cost-sharing to employees, sometimes in the form of high deductible plans combined with savings accounts. They often implement wellness programs, offer high-quality health plans, and utilize data analytics to make informed decisions. Large employers tend to be self-insured, thereby assuming all risk and minimizing the role of health insurers in choosing better quality providers.
• Healthcare Providers: Prioritize delivering high-quality care, patient safety, and achieving positive health outcomes. However, they also need to generate sufficient income to survive in a competitive market. Regulatory burdens, complex and proliferating reporting requirements, resource constraints, and possible malpractice liability discourage providers from outcomes transparency. Balancing these demands with patient-centered care and financial viability is crucial for providers.
• Employees: Seek affordable, accessible, and reliable healthcare. They face challenges such as high out-of-pocket costs, limited plan options, and navigating complex insurance benefits. Despite the cost-effectiveness and quality of care offered by HMOs, especially group and staff models, HMOs now serve just 13 percent of the ESI market. Consumers need better tools to choose providers wisely based on measurable quality.

Employers wishing to maximize the value of their dollars spent on health benefits and related HR costs will need to employ innovative benefit design, provide improved consumer access to evidence-based quality measurement and transparency, and pursue closer employer-provider cooperation. This role is embraced by some employer health coalitions, such as the Purchaser Business Group on Health (PBGH) and the Health Transformation Alliance (HTA), and large employers like JP Morgan Chase through its subsidiary Morgan Health.

Four Types of Quality Measurement & Reporting

To effectively address the quality gap and the three-body problem, we recommend considering four types of quality measurement:

1. Adverse Events/Patient Safety: Detect, analyze, and recommend corrective actions for patient safety issues using EHR databases. An EHR database such as Cosmos paired with AI can identify and analyze adverse events, determine their causes, and recommend corrective actions.
2. Total Clinical Outcomes: Measure and report all clinical outcomes using EHR data, providing a balanced picture of quality performance. Applications include provider feedback to promote continuous improvement and publicly reported outcomes (PRHOs) to enhance provider selection.
3. Patient-Reported Outcomes (PROs): Capture patients' perspectives on their health conditions, treatment outcomes, and quality of life. PRO measures, endorsed by the National Quality Forum, are essential for clinical practice and research. However, standardizing and routinely collecting PROs across diverse healthcare settings remains a challenge.
4. Primary Care Process Measures: Assess adherence to clinical guidelines and timely administration of medications and preventive services. Organizations like MHQP and MNCM use process measures to compare primary care and group practices. These measures can apply to any diagnostic and care process that does not yield immediate measurable outcomes.

These four initiatives can synergistically address treatment and diagnostic errors, facilitate consumer Patient-reported outcomes have traditionally been hard to obtain. However, growing reliance on the internet, smart handheld devices, and AI recordings of patient sessions can all contribute to more accurate responses from a larger percentage of patients.

Adding PROMs and primary care process data to an EHR database would further enhance our ability to evaluate diagnostic accuracy and treatment protocols.? What is holding us back, as of now, is (a) lack of provider consent to be identified and (b) lack of consolidation of EHR data from all vendors either nationwide or statewide.?

Critical Need: An EHR Database

All of the above quality measurement initiatives will require a database in order to aggregate outcomes by provider, provider organization, health plan or geographic area.? Databases derived from electronic health records (EHRs) ?Key steps include:

• Achieving interoperability among EHR systems by adhering to federally mandated standards like CMS's Universal Foundation and eCQM initiatives.
• Engaging top-performing health provider organizations (HPOs), other employers, payers, and patient advocacy groups to participate and support the initiative.
• Creating advisory boards and steering committees comprising clinicians, data scientists, and consumer representatives to guide the development and implementation process.
• Establishing a coalition of private and public sector entities to provide funding, technical expertise, and governance to build and administer the database.

While the long-term objective is to build a nationwide EHR database, initial efforts at the state or metropolitan area level could become operational sooner. Existing statewide databases, such as SHIN-NY, CRISP, IHIE, CORHIO, and Cal INDEX, may help inform national system design. Epic’s Cosmos database, covering 262 million patients, represents an excellent start on a national database.

Interoperability within Reach: The Trusted Exchange Framework and Common Agreement (TEFCA), is a framework established by U.S. Department of Health and Human Services (HHS) to create a standardized and secure way for health information networks (HINs) to exchange electronic health information (EHI) nationwide.? Epic, the largest EHR vendor in the US, has “committed to have its customers live on a government-backed medical records exchange network called TEFCA by 2025.”[i]? And Carequality has also committed to “align with TEFCA.”? With those two organizations committed to TEFCA, the promise of interoperability, and therefore an all-provider EHR database, is within reach in the foreseeable future.

A Consumer-Oriented Design for Employees & Dependents

To effectively make quality measurement information available to employees, we recommend a multifaceted approach that ensures accessibility, usability, and education:

1.???? Develop a User-Friendly Platform: Create an intuitive online platform or mobile app that centralizes all the quality measurement data, including patient safety, outcome, primary care, and patient experience measures. The platform should feature easy-to-navigate interfaces, clear visuals, and simple language to make the information comprehensible to all users.? Examples include Consumer’s Checkbook, Amazon, BestBuy and various other sites that enable the “customer” to narrow down their choices based on a variety of “filters” such as proximity, specialty and quality.? The site needs to be well known, easily accessible and the quality data needs to be easy to understand and compare multiple (more than 3) providers.

• Incentivize Use: Offer incentives such as discounts on premiums, wellness rewards, or access to premium services to motivate users to explore and utilize quality information.
• Targeted Messaging: Provide targeted messaging and education to explain the benefits of choosing higher-quality networks over broader, lower-quality networks.
• Integrate with Existing Tools: Embed the platform into existing healthcare management tools and EHR systems to ensure users encounter the quality data during their regular interactions with healthcare services.
• Educational Campaigns: Launch campaigns to raise awareness about the platform and the importance of using quality data to make healthcare decisions.
• Regular Updates and Feedback: Ensure the platform is regularly updated and includes a feedback mechanism for users to ask questions, provide suggestions, and report issues.

Implementing these strategies will make quality measurement information easily accessible and actionable for consumers, helping them make informed healthcare choices and shifting the focus from network breadth to care quality.

An Employer Action Plan

Employers can maximize the value of employee benefits through quality measurement & reporting with the following action plan:

1. Invest in Primary Care: Partner with advanced primary care providers to ensure timely screenings, accurate diagnostics, and adherence to clinical guidelines. Implement wellness programs focusing on preventive care and chronic disease management.
2. Evidence-Based Provider Selection: Use outcome measures to select and negotiate with healthcare providers and networks, focusing on those with the best performance records. Incorporate quality metrics into contract negotiations with health plans and providers.
3. Enhance Access to High-Quality Care: Facilitate access to high-performing providers and centers of excellence for employees and their dependents. Consider narrow networks that emphasize quality over breadth.
4. Promote Employee Education and Engagement: Educate employees on the importance of quality metrics in choosing healthcare providers. Provide tools and resources, such as workshops and online tutorials, to help employees understand and utilize quality measurement data.
5. Collaboration with Healthcare Providers: Encourage providers to discuss quality measures with their patients. Providers can play a crucial role in educating patients about the importance of quality data in making informed healthcare decisions.
6. Leverage Data Analytics: Utilize data analytics to identify trends and areas for improvement in employee health outcomes. Continuously monitor and assess the performance of healthcare providers and networks based on quality data.
7. Implement Value-Based Care Models: Transition from fee-for-service to value-based care models that reward providers for high-quality outcomes rather than the volume of services. Collaborate with health plans to develop and implement value-based care agreements.
8. Join Employer Coalitions: Become an active member of employer coalitions like the Purchaser Business Group on Health (PBGH) or the Health Transformation Alliance (HTA). Collaborate with other employers to advocate for transparency in provider quality and cost-effectiveness.
9. Advocate for Policy Changes: Work with coalitions and policymakers to advocate for regulations that promote transparency and quality improvement in healthcare. Support legislation that mandates public reporting of health outcomes and provider performance.

By taking these proactive steps, employers can maximize the value of their health benefit expenditures, improve employee health outcomes, reduce costs, and enhance overall productivity and satisfaction.