Employers want the workforce to be as healthy as possible—but health doesn’t always seem like something the American healthcare system is set up to provide.
Everyone is using a different definition of quality, and nobody is communicating about how to coordinate care.
We recently interviewed Paige Cooke, Assistant Director of Customer Engagement at NCQA (National Committee for Quality Assurance) in Washington D.C., about healthcare delivery and finance—and how employers can navigate this intricate system.
Paige has been with the NCQA for the last seven years and has an educational background in health communications. “In my role, I support a wide array of healthcare organizations in understanding the value of adopting NCQA’s evaluation surveys to demonstrate their commitment to continuous quality improvement and the way they’re supporting today’s healthcare system,” Paige said.
Regarding the Patient Protection and Affordable Care Act, Paige said it has done right to put a greater focus on a whole person and primary care in particular. “We’ve been working with a very fragmented system,” she said.
The NCQA is a nonprofit organization whose mission is to improve the quality of healthcare through measurement, transparency, and accountability. But beyond that triple aim is an emphasis on the providers themselves, making it a fourth aim to ensure that providers have the ability to meet the demanding needs of taking care of today’s consumers.
The Fourth Aim
Many of us can relate to the experience of having primary care in one area, secondary care in another, social supports and mental and behavioral health resources in yet more separated arenas.
The ACA has done a lot of good for healthcare to bolster the primary care industry and providers by incentivizing more practitioners to go into that realm, Paige observed.
“Restructuring the importance and the value of primary care in the last 20 years has been a step in the right direction.,” she added. “The advancements in technology and understanding the value that it has and improving efficiencies and stemming fragmentation have all been excellent.”
Of course, healthcare still struggles with transparency of cost—as well as the cost to be able to support today’s health complex healthcare system.
“I think we all agree that we have a long way to go in terms of insuring that our most vulnerable populations, which happens to be the most high risk and high cost populations, are getting the needed services that they deserve across the United States,” Paige said.
The Importance of Primary Care
One solution is more time with primary care physicians (which, if it happened, would create an instant shortage of primary care physicians).
Speaking personally, Paige is an advocate for the patient-centered medical home model (PCMH), which delivers care through a patient’s primary care physician. Recent legislation called the Medicare Access and CHIP Reauthorization Act (MACRA) supports this model.
“My mother was diagnosed with metastatic cancer. It really enabled me to see the need to engage families and caregivers when you have a loved one dealing with a chronic disease who needs to work with multiple specialists,” Paige said.
Best case scenario, primary care serves as that hub to ensure the care that is being delivered at the specialty level is all being collected in one centralized location.
If you’ve got a primary care physician being on the front lines of providing care, that person will engage with the patient as a whole person—primary, secondary, social, mental and behavioral health, and family engagement all in one.
“We still have a long way to go to financially support what role primary care really has in today’s healthcare system,” Paige said.
The misconception about the importance of primary care lies with consumers, too, who only think of them for coughs or headaches, not necessarily for anything more than a referral to a specialist.
Unfortunately, the economics of healthcare puts an economic value incentivizing providers to gain specialty expertise in a particular area, to the detriment of the primary care model.
“Primary care really should be managing the whole person together as part of a collective care team,” Paige said.
A Patient-Centric Viewpoint
The best way to engage all stakeholders to improve the healthcare system as a whole is to renew a focus on the patient.
The number of moving parts is incredibly complex: standards and guidelines for a healthcare institutions, health plan accreditation, complex case management, the appeals process, clinical outcomes, patient satisfaction, credentialing for providers, and the list goes on.
“My perspective on ways in which stakeholders can come together is to take a look at the spectrum,” Paige said.
There’s a measure fatigue on quality measures that gives different standards to different institutions. “But, there’s an opportunity when you look at the various aspects of the delivery system holistically and you keep the patient at the center of it,” she said.
When you’re in a specialty world, it can be hard to find your way back to patient-centeredness. “If stakeholders could really start looking at it solely from the patient and then building out their network from there, this is how these institutions can operationalized the way they work with each other to support a shard patient population,” she said.
NCQA standards and guidelines helps create a language and a way of understanding quality. For example, if something is a patient centered medical home, they’ll have a formalized process for care coordination.
“Because it’s so much, it can be very challenging to step out of your box and be able to really look at the healthcare system as a whole and really work to understand your role in the entire, connected network,” Paige said.
The more there’s a common language in terms of how we define quality, how we operationalize the way we engage with patients, we’re making strides forward to stem that fragmentation and come together as a group of stakeholders to serve a common purpose to support all of us.
On a member level, it can be hard to accept and understand that some prescriptions are $2.00 per month and others are $1,200.00.
“It is a tangled web when it comes to understanding the financial implications of healthcare and I don’t believe providers are clear on it—and that’s the challenge,” Paige said.
Providers can’t provide education to their patients when they don’t understand themselves what the real cost of specific healthcare services are.
Frankly, consumers are frustrated and confused. Especially for those of Paige’s generation who are caregivers to their children and their parents both, navigating the confusing waters of healthcare costs is more essential than ever.
NCQA is the only accrediting body that employs research scientists to develop clinical quality measures, as well as accreditation of case management for long-term services and supports.
“It is important that there are a set of baseline standards that ensures that organizations, healthcare organizations as well as those that are delivering social supports, are not operating in silos,” Paige said.
Measuring and Reporting Outcomes
Every medical institution needs to have fundamental quality standards in place. And since NCQA’s mission is to improve the quality of healthcare through measurement, transparency, and accountability, they’re encouraging the tracking and analysis of data reporting.
“In order to improve clinical outcomes, you have to measure them first,” Paige said.
The more organizations that track reporting, the greater chance we have of identifying what’s working and what’s not.
Consistent Engagement Practices
Without a patient-centric model, quality will be all over the place. “You need to be consistent in the way in which you engage with patients, understanding what their needs are, how they define quality so that their voice is being heard,” she said.
The NCQA has launched a patient-centered connected care program to support on-site employee health clinics, retail clinics, and urgent care sites. The more these standards are implemented in practice and the more coordinated these services become, then you’re avoiding doing duplicative services because everyone’s talking to each other.
Employers can take advantage of this knowledge by advocating for uniform quality standards and the emphasis on primary care physicians to provide whole person care.
“I would encourage employers to consider the holistic opportunity of making sure that your private payers are being held accountable to the needs of your population as an employer,” Paige added.
Contact Paige Cooke on LinkedIn or by email at pcooke@NCQA.org. And tune in to every episode of Healthcare Simplified by subscribing on iTunes or your favorite podcast player.