As US health care evolves, some payers are moving beyond the stereotype of cost cutters tying the hands of care providers. In fact, the insurers that measure quality, design financial incentive programs, and restructure payment models can play a pivotal role in helping care providers; they can help enhance the patient experience, improve population health, and reduce per capita costs.
In other words, health insurers can help health care achieve the Triple Aim.
At their best, payers can provide quality improvement support to providers as they change care delivery to meet the goals of value-based contracts.
Payer-Supported QI
Health plans and insurers support providers in building improvement capability in many ways. For example, IHI researchers spoke with one large insurer that assigns improvement coaches to primary care practices. To facilitate transitions to patient-centered medical homes, the coaches support data analysis, assist with setting improvement goals, and help select changes to test with Plan-Do-Study-Act cycles. Some state Medicaid agencies have also used this approach.
Other payers have taken more dramatic steps. For example, some insurers have led or supported large-scale quality improvement collaboratives in which providers have participated.
Inland Empire Health Plan: Supporting Behavioral Health Integration
Inland Empire Health Plan (IEHP) is a not-for-profit Medicaid and Medicare organization serving the residents of Riverside and San Bernardino counties in California. After finding that members with severe mental illness died an average of 30 years earlier than others — often of chronic diseases such as diabetes and cardiovascular illnesses — IEHP invested $20 million to advance behavioral health integration. Working with 13 local health care systems, IEHP provides funding so participants can offer behavioral health care and primary care in the same location.
IEHP coaches trained clinical teams to use the Model for Improvement and make workflow changes. IEHP also supports collaborative learning between health care systems and shares freely available resources.
Blue Cross Blue Shield of Michigan: Collaborative Quality Initiatives
Since 1997, Blue Cross Blue Shield of Michigan has convened hospitals and physicians in regional collaboratives to use registry data to improve the quality of care. They have so far launched more than 20 initiatives, in areas ranging from cardiac and bariatric surgery to trauma care and breast cancer.
Collaborative Quality Initiatives (CQIs) are partnerships between Blue Cross, participating hospitals, physicians, and the coordinating center (staffed by a participating hospital) that leads the program. CQIs have dedicated staff (including a physician-director, statistician, data analyst, quality improvement nurse, and administrator) to provide support. The plan offers the providers hospital- and physician-specific outcome data and benchmarks, and hospitals receive compensation for participation.
Five of the longest running CQIs have produced almost $800 million in statewide savings from decreased complications and improved outcomes.
By going beyond incentive payments, quality measurement, and small-scale quality improvement assistance, payers can play a major role in large-scale quality improvement. Regardless of the specific approach, they can support and even initiate collaborative-style learning that delivers results at scale.
Jeffrey Rakover is an IHI Research Associate and a member of the IHI Innovation Team.
Editor’s Note: Learn more from examples like these at the Learning Labs and workshops included in the new Health Plans & Insurers Advancing Improvement track at this year’s IHI National Forum.
