“Gaps in Care” is a term you’ve almost certainly heard tossed around the healthcare industry in recent years. For those really paying attention, you may feel that it’s more of a chasm than a gap when it comes to quality care. The good news, however, is that the right type of technology — applied at the right time and place — can help close this growing divide.
First, we must understand that “Gaps in Care” is a term used to describe the delta between the average rate of care received by members of both commercial and government payers and the members receiving care at the 90th percentile. Historically, there has been a delta greater than ten percentage points between the average and the excellent!
To address this, the National Committee of Quality Assurance (NCQA) created a set of clinical measures to monitor and close what is referred to as “Gaps in Care.” The measures are collected and reported to the Healthcare Effectiveness Data and Information Set (HEDIS), which NCQA describes as a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of health care plans.
As a result of the NCQA’s HEDIS measures, insurance payers have built programs specifically to alleviate these concerns. To demonstrate how technology can help, Workpath partnered with a regional payer struggling to manage its state’s Medicaid population (and its Medicaid-Medicare dual eligibles). Workpath technology helped close 20% of the payer’s gaps in care and at the conclusion of the pilot, the payer surpassed their goal of securing a neutral rating and unlocking previously unattainable reimbursements from HEDIS and STARS.
Here’s how the pilot worked.
Workpath, the makers of an award winning technology platform used by healthcare organizations across the country, set out to help the payer improve the way it closes the gaps in care identified from HEDIS reports. Payers routinely wrestle with managing the care of their members to the 90th percentile, resulting in direct and indirect costs of patient mismanagement that adds to their health plans.
In this pilot study, Workpath and the payer focused on diabetic patients because every year there are 4,300 to 9,600 preventable deaths due to poorly managed diabetes. In addition, one out of every three inpatient days for patients with cardiovascular, neurological, and renal conditions are due to patients battling diabetes. To make matters more difficult, the prevalence of diabetes in America continues to rise.
More Americans battling diabetes relates directly to the increased investment payers make to disease management programs. While payers clearly understand the downstream costs of poorly managed diabetic members, the average rating of comprehensive diabetic care amongst health plans is 3.01–4.0. Member education, operational costs for payers, and member non-compliance are preventing payers from delivering the care they aim to provide.
With proper diabetes prevention and management, however, the US healthcare system could dramatically change this trend. In fact, we could save $570 million per year by avoiding unnecessary medical procedures related to diabetes. And most importantly, if all diabetics received the best care available, nine cases out of ten could be prevented.
To make this a reality, Workpath and the payer turned to Comprehensive Diabetes Care measures for the pilot, to include: Hemoglobin A1c (HgA1c), Urine Microalbumin, Retinal Eye Exam, and Blood Pressure.
And here’s where technology comes in.
Workpath was leveraged as a tool for effective management of the critical labor required to make this testing possible. Collection specialists responsible for HbA1c, blood pressure, retinal exams, and various other metrics were organized and digitally dispatched using Workpath technology. The payer used the platform, and its integrated API, to strategically deploy the right labor to the right place at the right time. By organizing and dispatching a network of specimen collectors through Workpath technology, the payer in the pilot was able to achieve their goals.
Some considering this approach may stop here, pause, and say, “Wait, I don’t have the labor in-house to pull this off.” But here’s the catch, healthcare labor, in general, across the US is often under-utilized and inefficiently managed. If healthcare organizations take a step back and realize the healthcare labor that is available to them — employed and contracted — gaps in care can be addressed. There is a stigma among healthcare organizations that additional labor resources mean additional management requirements. However, with technology, you can automate the management without additional operational burden and gain value insights throughout the patients care continuum.
Such was the case in this pilot. Workpath offered the payer in this case study the ability to determine the members with gaps in care for specific measures, the projected earnings per member if the incentives are achieved, and the costs per collection by utilizing contracted labor. With the combination of Workpath’s seamless online ordering system and its compliance messaging system, the payer’s HEDIS team was able to deploy on-demand collectors, working as independent contractors, to close the necessary gaps in care. As a result, Workpath provided the payer with ability to optimize operations and outreach, enhance their patient outcomes, and the ability to improve STARS/HEDIS reimbursements.
At the conclusion of the pilot, the payer surpassed their goal of securing a neutral rating and unlocking previously unattainable reimbursements from HEDIS and STARS. Workpath drove 90% compliance through its patient messaging platform. Workpath technology provided patients the opportunity to easily and seamlessly reschedule their appointments. In addition, the system sent reminder messages through a variety of channels in order to meet all communication preferences.
By leveraging the Workpath platform to manage and dispatch their on-demand workforce, the health system was able to deliver a mobile, flexible collection solution for closing gaps in care in one of America’s densest metropolitan statistical areas that was both convenient for the patient and compliant with the system’s laboratory protocols. The result of the Workpath implementation was a projected net-HEDIS rating of 94.96%, nearly four points above the neutral rating. The average incentive payment from NCQA to payers for closing gaps in care for A1c collections averages $120.00 per member. It is projected that the payer actualized a potential revenue of $180,000 — much of which was previously unattainable.
By using Workpath’s technology to manage an on-demand network of healthcare labor, payers can reduce costs, increase quality, and improve outcomes, as proven by Workpath’s case study. In this pilot, Workpath was able to unlock incentives for the payer previously thought to be unattainable — and is projected to be a key operational tool in their upcoming year.
So, what’s next?
Tell us how you would use technology like Workpath — or other solutions — to improve gaps in care in your area. Send us your story ideas, partnership proposals, and other ways to collaborate: firstname.lastname@example.org. Together, we can dramatically improve care and patient outcomes for everyone.