The current NCQA Health Plan Report Cards are out, and payers are evaluating their performance to understand how to improve quality of care and patient satisfaction.
Scores for Commercial, Medicare and Medicaid plans are based on their combined Healthcare Effectiveness Data and Information Set (HEDIS?) scores, Consumer Assessment of Healthcare Providers and Systems (CAHPS?) scores and NCQA Accreditation status.
HEDIS collects data from claims, surveys, and medical records with a focus on:
- Effectiveness of Care
- Access/Availability of Care
- Experience of Care
- Utilization and Risk Adjusted Utilization
- Health Plan Descriptive Information
- Measures Reported Using Electronic Clinical Data Systems
The CAHPS survey, which measures the perception of patients’ care from a payer, is one of the primary sources for determining NCQA Report Card scores. The survey measures everything from care coordination, to how quickly appointments and care are administered, to overall customer service, to the effectiveness of accessing prescription drugs.
UNPACKING PROVIDER ABRASION
Provider abrasion is the frustration and dissatisfaction that providers experience when they interact with payers. Some common causes of provider abrasion include claim denials, payment delays, cumbersome administrative processes, lack of transparency, and inadequate access to real-time information.
While provider abrasion is not directly measured in NCQA Report Cards, the impact of abrasion can indirectly impact scores in different ways.
- Quality of Care: HEDIS scores heavily rely on clinical quality measures. If physicians are frustrated or burdened with administrative tasks due to provider abrasion, they might not be able to devote adequate time or attention to patient care. This could potentially impact the quality of care and thus affect HEDIS scores.
- Access to Care: HEDIS ratings include measures related to access to care. If providers are dissatisfied with certain payers, they may choose not to participate in their networks or limit taking on new patients, which could affect access to care and, subsequently, the ratings.
- Patient Satisfaction: The CAHPS survey measures patient satisfaction, which can be influenced by provider abrasion. For instance, if administrative burdens lead to long wait times, limited patient interaction, or delayed treatments, patient satisfaction may decrease.
- Medication Adherence: Some HEDIS measures focus on medication adherence for chronic conditions. If prior authorization processes (a very common cause of provider abrasion) are cumbersome, it may result in delays in patients receiving their medications, which could impact adherence.
- Preventive Care and Health Outcomes: Many HEDIS measures focus on preventive care and the management of chronic conditions. If provider abrasion leads to lower engagement with payer programs or frustration around reimbursement, it may indirectly impact the preventive services provided.
THE ROLE OF CONTRACT DISPUTES AND DENIALS IN PROVIDER ABRASION
According to an article in Beckers Healthcare “Contract negotiation disputes between payers and providers that were reported in the media increased 69% between 2022 and 2023, and the number of communities affected across the country grew as well, according to data published by FTI Consulting.”
Contracting has always been a laborious process, but with the rise in inflation the stakes are higher than ever before. For providers, the goal is to have payers absorb some of the cost of the inflation increases. Payers have a different opinion. As noted in May of 2024, a statement by America’s Health Insurance Plans (AHIP) said that “many providers have more leverage to demand above-market reimbursement rates.”
While contract disputes rage on, providers are struggling with the challenges of prior authorizations, which are among the most significant sources of administrative burden and associated costs. In a survey by the American Medical Association (AMA) 94% of respondents reported delays in care and a third reported serious adverse events for patients — even death. These results underscore how the existing prior authorizations process contributes to provider abrasion.
Physicians complete an average of 43 prior authorizations per week, with staff dedicating about 12 hours to this task. In some cases, staff members work exclusively on prior authorizations. Moreover, 73% of physicians reported an increase in denials over the past five years, while only 3% saw a decrease. Despite the rise in denials, less than one in five physicians appeal adverse decisions due to pessimism about success, the urgency of patient care, and insufficient resources.
Contract disputes and prior authorization challenges have downstream ramifications on physician satisfaction, which permeates every interaction throughout the care continuum. This can indirectly influence HEDIS, CAHPS, and NCQA ratings.
PROVIDER ABRASION MITIGATION STRATEGIES
There are things payers can do to effectively decrease provider abrasion. Creating administrative efficiencies, improving collaboration, and implementing technology solutions that make life easier for physicians and their staff can go a long way in easing the burden on providers.
- Improve Communication: Providers often complain about a lack of clear, concise, and timely communication between themselves and payers. Payers should actively work to enhance communication channels, ensuring that providers have quick, easy access to information about policies, payment procedures, and any updates or changes. Providing a dedicated contact for physicians, along with regularly scheduled calls or meetings, can also help create an open dialogue, fostering trust and better understanding on both sides.
- Streamline Administrative Processes: Physicians often express frustration over time-consuming administrative tasks related to billing, claim denials, and authorizations. Payers should seek ways to simplify and streamline these processes. This could involve adopting technology solutions for easier submission of claims, faster processing times, and automatic checks for common errors, thereby reducing the burden on providers.
- Collaborate on Care Coordination: Payers can involve providers in certain care management initiatives and decision-making processes, giving them a voice in how care should be delivered and reimbursed. This includes shared decision-making models, quality improvement initiatives, or care integration programs. Collaboration can foster mutual understanding, align interests, and promote higher quality and more cost-effective care.
- Embrace Transparency: Transparency is critical in reducing misunderstandings and conflicts. Payers should aim to make their policies, including the specifics of coverage, reimbursements, and the process for claim disputes, as clear as possible. Providing user-friendly online resources and educational materials can also help fill any gaps that may arise.
- Implement Value-based Care Models: Traditional fee-for-service models can create tension as they often fail to reward providers for outcomes and quality metrics. Shifting towards value-based care and payment models that reward efficiency and improved patient outcomes can help align incentives between providers and payers. There are several approaches that could be implemented, including shared savings programs, pay for performance, bundled payments, and the use of Patient-Centered Medical Homes or Accountable Care Organizations.
COLLABORATION IS THE KEY
The rising cost of healthcare is driving payers and providers to investigate novel approaches to mitigate the challenges resulting from burdensome administrative processes, inefficient prior authorizations, clouded transparency, and inadequate collaboration. Payers and providers can use the following strategies to coordinate their efforts:
- Use real-time data and analytics to inform care delivery: Data tools can help teams both quantify and manage the cost of care. Advanced analytics can also help payers and providers accurately stratify patient risk, identify care gaps, inform point-of-care interventions, and monitor performance.
- Align financial incentives between payers and providers: With aligned financial incentives, teams work towards unified goals with joint accountability. One way to achieve this is a shared savings program that rewards the cost savings associated with improved patient care.
- Implement efficient collaboration technology: Effective communication powered by near real-time data sharing between payers and providers can reduce care delays and waste associated with manual processes, such as prior authorization. Point-of-care tools and integrated clinical support systems can help providers deliver evidence-based care with improved efficiency.
- Improve authorizations and utilization management with streamlined episodic care: Provider-payer organizations can use EMR-integrated care pathways and preferred regimens to match individual patient needs with the best treatments rather than using service-line level authorizations that may not be appropriate for all patients. This level of personalization also expedites care coordination by the primary care provider and promotes care quality to naturally reduce the leakage of services away from the network.
- Build trust with payer-provider transparency: The proper data tools can improve transparency and assist payers in measuring performance. Visibility into patient outcomes, provider costs, and the impact of quality measures on bonuses is necessary to inform cohesive interventions toward mutual goals.
