Navigating the Shift to Quality-based Healthcare

Create an Organizational Culture of Quality

A quality-based model requires health plans to be accountable for the health of their member populations, and many HEDIS measures are designed to urge health plans to focus on prevention and early detection of chronic disease. To improve quality, health plans must focus on maintaining the health of their populations, in addition to effectively treating those with acute or chronic conditions.

Focus on Disadvantaged Populations

CMS has proposed changes to the Medicare Advantage risk adjustment model that could take population characteristics, such as dual eligibility for Medicare and Medicaid, into account. Regardless of how the risk adjustment model changes, focusing quality improvement initiative on lower income segments can help health plans address significant gaps in care and improve star ratings.

Focus on Improving Performance for Specific Measures

The changes that the Affordable Care Act has made to reimbursement models has encouraged health plans to be honest about their shortcomings and to work rapidly to address them. Plans that allocate resources to measures with the highest potential for improving overall quality ratings can see significant gains in a short amount of time.

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