Why Digital Quality Measurement Will 'Materially Change' How Payers Operate

Don Rucker and Joe Gagnon detail the power of computational quality for the NCQA's new pilot and far beyond.

How much could and should we have done without a pandemic to spur us?

For years to come we'll be asking ourselves that question about everything, from personal choices to industry practices. Sometimes, however, change does require a confluence of innovations—that "perfect storm," in the words of former ONC chief Dr. Don Rucker—to transform the slow, fragmented, and undiscoverable into the real-time, unified, and actionable.

The nascent field of digital quality measurement (dQM) is now harnessing that storm, which combines cloud computing, new FHIR-based API requirements (Fast Healthcare Interoperability Resources), and more modern data storage and transmission formats.

The NCQA is leveraging these advances for its Digital Quality Solutions (DQS) Pilot, which will convert the agency's printed quality measures into a software solution. In the second of a three-part series on DQS (part one here), HealthLeaders spoke in depth with Rucker—an executive lead for the pilot and now chief strategy officer for 1upHealth—and his colleague CEO Joe Gagnon about the coming dQM transformation.

Related: Early Updates from the NCQA Digital Quality Solutions Pilot

Using a screwdriver instead of a hammer

With FHIR, says Rucker: "For the first time ever, payers and providers can have a formal computational discussion about performance." He adds two related firsts: the ability to "compare providers and patterns of care robustly, rather than doing a specific study" and the ability to "match up computationally what you're paying for, which amazingly enough has not really been possible in a robust way."

Robust is the key word.

"We want to look at populations and performance. Modern medicine should be able to pull out data on a population of patients, not just one at a time," says Rucker.

By leveraging FHIR for dQM, he adds: "We'll be able to look at populations in a computational apples-to-apples type of comparison. Historically, all we've ever had in American medicine or any other medicine, is apples to oranges."

Those apples and oranges are the clinical and claims data that have been firewalled, preventing the optimal integration and use of both.

"Almost all health services research is done on claims data while trying to answer clinical questions. It's like using a hammer instead of a screwdriver," says Gagnon.

Achieving terminal velocity

Rucker notes that 1upHealth has "built a FHIR-native architecture that we think will perfect for complex performance and quality measurements benefiting from both clinical and claims data that is provided by both providers and payers in varying combinations." 

Aiding this data integration is more automation.

"The challenge of quality measurement over the last 20 years is that for every single program, we've had to manually curate data," says Rucker.

Gagnon also notes: "The thing that's different now are these sort of real-time protocols. Healthcare has a lot of very important decisions to make about quality, cost, and value, and when you're doing things more manually, that is a very long distance in the rearview mirror."

The CEO adds: "Allowing for computation in near-real time has, in every industry, changed the dynamics of those industries … We've hit a point where I think the terminal velocity is going to increase at a rapid rate. This is the sort of transformation that healthcare needs to go through because we can't accept how the performance and cost structure is anymore. I think everyone is for that."

Linking real-time data with long-term strategy

The NCQA pilot includes two payer organizations: Aetna, a CVS Health company, and Health Care Service Corporation. Rucker notes that FHIR and dQM will "materially change" how these and other payers operate.

"Payers have been really a more claims processing type of operation that now are effectively supervising clinical care," says Rucker. "Historically, they've had to rely on claims data, and it's been a very jury-rigged system," adding that "the way payers manage care through a combination of network contracts, network contract incentives, quality measures, and prior authorization … has been a huge dissatisfier."

So what will early transformation look like and how will it evolve?

Through FHIR and dQM, says Rucker: "We anticipate early payer analytics will be around typical questions such as risk management, patterns of care, network design, and various other forms of cost management.

He notes, and Gagnon agrees, that these will "soon involve richer calculations supporting appropriate care, personalized prior authorization, and digitally native quality measurement. Eventually the ability to power real-time analytics and APIs will allow more direct communications between providers, patients and payers that are possible today."

Gagnon agrees.

"The environment has not been pro-sharing and consumers aren't ultimately in control" as they are in other industries. "We don't need to accept that a proprietary focus is the best we can get, which is what we've been stuck with in healthcare for so many years."

The CEO adds: "How we use the data is where the difference is made and that's where a market economy can really make strides on behalf of both innovation and consumerization."