RISE Radio
Join the RISE team as we chat with industry leaders and explore ever-changing policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health. Produced by RISE, the number one source for information on all things Medicare Advantage.
RISE Radio
Episode 34: The health care quality shift: Always-on, digital, and connected
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
The rules of health care quality are changing fast, and the biggest shift is simple to say but harder to execute. Our latest episode focuses on this fundamental shift in health care quality performance, the future of digital quality, and the multi-pronged approach organizations need to stay ahead.
Our guest, Shariff Baseer, vice president of product, quality, at Optum, unpacks what the CMS and NCQA digital quality roadmap really means for health plans, especially as STARS and HEDIS performance becomes more dependent on interoperable clinical data, eCQMs, dQMs, and IDSS total-population reporting.
About Shariff Baseer
Shariff Baseer is the vice president of product, quality for Optum and has almost a decade of industry experience building health care products. He specializes in quality and member engagement. Prior to his current role, he has spent time enhancing risk adjustment products focusing on advanced analytics in this area. Baseer has an MBA degree from Indiana University of Pennsylvania and engineering from VTU, India.
About Optum
Optum is a trusted information and technology-enabled health services business dedicated to helping make the health system work better for everyone. With more than 315,000 people worldwide, Optum delivers intelligent, integrated solutions that help to modernize the health system and improve overall population health. Click here to learn more about its risk and quality solutions.
Welcome and the new quality stakes
Ilene MacDonald, hostHello, and welcome to the latest episode of RISE Radio. I'm your host, Ilene MacDonald. Today we will be discussing the fundamental shift in health care quality performance, what plans are grappling with today, and the multi-pronged approach organizations need to stay ahead. My guest is Sharifff Baseer, vice president of product quality at Optum, a trusted information and technology enabled health services business. Sharifff will help us understand the market forces reshaping STARS and HEDIS performance. Thank you for joining me today, Shariff.
Shariff Baseer, guestThank you, Ilene.
Ilene MacDonald, hostTo start, can you give listeners a high-level view of what's changing in the quality landscape right now?
Digital quality roadmap and 2030 target
Shariff Baseer, guestAbsolutely. The biggest shift in terms of what's happening in the quality landscape right now is our digital transition. CMS and NCQA have announced the digital quality roadmap. It's been there for a couple of years now, but then now it's getting to that phase of reality where 2030 is approaching and all of the organizations are marching towards that. And just a little bit of reference in terms of history, right? Quality programs were built for retrospective reporting and hybrid measures and annual submission cycles. Now, today we're moving towards this digital measurement, which focuses in on interoperability and data collection through clinical data and electronic data. And one of the other aspects of this, as we're moving away from hybrid, is the fact that there is focus on IDSS submissions rather than hybrid submissions. So we're moving from sample reporting to total population reporting. Now, when we go into this, quality becomes a strategic operating discipline rather than just a regulatory requirement. Organizations are being asked to measure to help improve quality across their total population, then the sample. At the same time, quality metrics are also being tied to their value-based care contracts, financial performance, member engagement, or the member experience and provider performance as a whole. So organizations that succeed are the ones moving to reporting quality actively and every day rather than keeping it a seasonal activity.
Ilene MacDonald, hostWhy would you say CMS and NCQA changes are creating such an urgency for health plans around quality measurement and reporting?
Shariff Baseer, guestI think it is clear from CMS and NCQA standpoint that they're signaling that the future of quality is digital. We're seeing increased emphasis on clinical outcomes, chronic condition management, patient experience instead of purely admin measures. The move towards ECQMs and DQMs requires organizations to collect, validate, and exchange clinical data differently than they have done in the past, right? So what this means is essentially having access to that clinical data becomes critical. Having the ability to validate this clinical data and additional sources becomes critical for the organizations. And organizations that delay this modernization may really find themselves trying to build a digital infrastructure under tight regulatory guidelines deadlines. And the industry challenge is no longer understanding that the change is coming, it's determining how quickly we can operationalize this change within their own ecosystem today. So with CMS and NCQA right now have not given us any clear indication that the 2030 data is going to shift. So right now we're marching towards that. So it's not a matter of when, it's a matter of how you adapt to the change.
Ilene MacDonald, hostIt sounds like a challenge because the industry is moving away from this hybrid retrospective measures towards that IDSS reporting. You said leveraging ECQMs and DQMs.
Why CMS and NCQA have raised the urgency
Ilene MacDonald, hostWhat does that shift mean in practical terms?
Shariff Baseer, guestPractically speaking, organizations can no longer rely on end-of-free chart reviews and hybrid methods alone. Instead, they need to be able to access more complete clinical data sets through the year. It increases the importance of the EMR connector with the FHIR resources so that's a significant operational and cultural change for most organizations that we're seeing today in the market.
Ilene MacDonald, hostSo historically, quality improvements have been treated as sort of end of year or retrospective.
Making quality a year-round habit
Ilene MacDonald, hostSo why would you say the approach is no longer enough?
Shariff Baseer, guestAbsolutely. Now, when we talk about retrospective of hybrid reporting, right? Like we're talking about a sample population. Now, when we move away from sample-based or hybrid reporting, this means organizations are now accountable to for quality performance across their entire population, their total population. And waiting until the second half of the year, which they traditionally do, is not often not going to leave too much time to identify, to prioritize, and to address these care gaps in the last half of the year. High performing organizations are bringing quality activities forward and making them a part of everyday operations. They are monitoring the performance continuously rather than through this periodic seasonal aspects of things. They're also integrating provider engagement, member outreach, the analytics, the care management, all into one continuously automated, connected workflow. And quality improvement right now is becoming proactive rather than reactive the way it used to be in the past.
Ilene MacDonald, hostSo, how would you describe what it's like for a health plan to manage quality from day one instead of waiting until the retrospective season?
Shariff Baseer, guestOh, this is this is a very interesting question, right? Like for me, I think it starts with near time near real-time data access for clinical data and claims data, having the ability to actually build a workflow and the technology setup through which we are able to get the data near real time, have access to clinical data is going to be critical. Organizations identify likely quality opportunities earlier in the measure year. Analytics will help them prioritize these members and who are likely to influence the quality performance. Care gap identification and closures become ongoing instead of seasonal. Providers receive additional information early, and this additional information is also going to be actionable for them. So we're not just making the data visible to them, we're also making it actionable to them. And the outreach program, which will obviously help with the member experience, becomes more targeted and personalized rather than generic one -size -fits -all solutions that we do today. The primary goal is to have like a continuous improvement cycle rather than an annual quality sprint. Because that's what we do today.
Ilene MacDonald, hostYes, yes.
Data foundations that power performance
Ilene MacDonald, hostI know earlier, prior to the actual recording of this podcast, we talked about quality depending on the several upstream data sources, like eligibility, enrollment, claims, EMR data and FHIR resources. Why would you say that data foundation is so important?
Shariff Baseer, guestOh, this this is definitely a topic which we can double-click on and go into more details and further discuss it. Quality performance is only as good as the data supporting it. So when we talk about eligibility, enrollment, claims, EMR data, and FHIR resources, each of them provide a different piece of the quality story. Now, better clinical data access allows organizations to identify these conditions, care gaps, and intervention opportunities sooner and in a much more clearer way. Now, the strong data foundation can definitely help with FHIR provider collaboration because data completeness means better quality of data, better analytics. And at the end of it, all it's a better member experience and provider experience, right? And that's what we are all striving for in today's environment. And with all of these things in mind, one of the key aspects of this will be for us to be able to validate the data coming into our systems and doing the data quality checks and making sure that the data is pristine before we are taking an action on it. So, along with you know, just dependency and making sure that the data is foundational, the data quality also becomes a key empirical factor in terms of how we can measure quality performance, improve member experience, and provider performance.
Barriers to automation and EMR data
Ilene MacDonald, hostWhat would you say are the biggest barriers that organizations face when they move from manual reporting to the automated reporting?
Shariff Baseer, guestAbsolutely. The first and biggest challenge or the barrier what we are all running into is access to digital data. This remains one of the biggest challenges. Many organizations have, you know, still operate in fragmented systems, disconnected workflows, and access to EMR data is not currently available. So being able to connect with the HIEs, connect with EMR connections, and actually having FHIR resources available for us to be able to measure quality or you know to utilize for quality measurement is currently missing. And along with that, data must often be aggregated, standardized, and validated to help transform it before we can actually utilize it. So that is a key thing. And the key aspect of this is how can organizations also have to, you know, this they should start thinking about the long-standing operational processes built around this with regards to the manual chart retrieval and abstraction. As I stated before, right, like with hybrid moving away and the dependency on the last half of the year and how much of manual short retrieval and abstraction can you actually do. So that's the place where, again, access to EMR data and having that real-time connectivity really helps. So the challenge isn't simply implementing technology, it's creating that ecosystem where we don't have fragmentation, we have real-time data access, we have access to EMR data, and there's not like a sole dependency on just chart retrieval and abstraction.
Ilene MacDonald, hostAnd how does automation change the way teams manage care gaps and quality performance throughout the year?
Shariff Baseer, guestAbsolutely. Now, in terms of automation, when we talk about quality, one of the things which is key, and I know the listeners here will also acknowledge this, that quality is not a simple one step one, step two, step three process. It takes quite a bit of joining the dots for us to be able to actually accomplish our goals for quality. And depending on the type of measures, depending on the type of goal you're after, your solutions differ. Now, if we have solutions which are daisy chained and which are connected, you know, in a very manual way, one, it is time consuming in terms of labor and resources you're spending. Two, there is always a risk you create for failure and you know things getting dropped. So what we've really tried to do with regards to the automation is it allows organizations to really move away from retrospective insights and get more into prospective action. Teams tend to spend less time gathering the information, more time focusing on the opportunities in terms of what the information is. So a lot more time analyzing insights rather than, you know, I need to get the source lined up and make sure that the source information is actually flowing in through the engine. And when we have the ability to automate all of these things, then we know for a fact that we can do a very targeted and efficient process in terms of an intervention, whether it is charge retrieval, whether it's member engagement, or whether it's gaps in care programs, it becomes very efficient and targeted, where now all of your upstream systems are connected through an automated fashion through real-time APIs. And then we are able to utilize that information and actually present the gaps in care where it matters the most, which is in the provider's office, in front of the member and the provider, and we are actually able to make a difference there. So ultimately, automation improves scalability and reduces the administrative burden, where clinicians and members are seeing the most important attributes and most important elements of quality when they are actually interacting with each other.
Ilene MacDonald, hostNice. I have heard you describe and advocate for a closed-loop quality strategy.
Closed-loop strategy for care gaps
Ilene MacDonald, hostCan you explain what that means exactly?
Shariff Baseer, guestYes. Oftentimes, you know, when we are doing quality initiatives and when we're going after care gap closures, there is a certain limit through which we actually do it. As an example, you know, without this ecosystem in mind right now, and you know, organizations are right now trying to do a member outreach campaign and trying to educate the member on the importance of why they need to get their colonoscopies done or the importance of breast cancer screening, that's step one, where we are able to basically take that step of educating the member and basically aligning with the member to say, here is the importance of breast cancer screening. Now, the step two is actually getting the member into the provider's office or getting the actual mammogram screening done or the colonoscopies done, right? And so when we look at the continuum of this, which is pre-visit, post you know, point of care visit, you know, prior to the visit itself, and then the pre-visit, the point of care and post-encounter, all of these things now need to be connected. If the data is not documented, and if that data which has been documented is not accessible, the care gap is still open. So that's the place where the closed loop follow-up comes in or the closed loop quality strategy comes in, where we begin with identification of the care gap. And then these opportunities first and foremost need to be made accessible and visible to the providers. And then the actions are taken in the provider's office with the member, whether it's picking up medication or whether it's getting through your A1C or tests done, whatever that action is, and having the ability to also, you know, talk about it in context of, you know, I've responded to a gap versus I've captured the evidence of a gap, both of these things become critical. Now, once the evidence is captured, validation of this evidence that it truly ended up closing the care gap is where the closed loop follow-up or like the closed loop quality strategy comes into play, where the results actually are able to flow back into the system. And through measurement and optimization, we're actually able to close these gaps. Definitely creates accountability on the technology teams, definitely creates accountability in terms of our workflows, our provider actions, our member actions, our data processes, all of these things. That's exactly how we can truly have that closed loop follow-up built out.
Ilene MacDonald, hostAnd
Linking insights to provider workflows
Ilene MacDonald, hosthow would you say analytics, care gap identification, provider workflows, member outreach and reporting need to connect to support that strategy you're advocating?
Shariff Baseer, guestYeah. One aspect of this is obviously any quality ecosystem definitely needs to have, you know, the certified measure engine itself. Now, obviously, we've, you know, we at Optum here are making quite a few strides in terms of making sure that we have the ability to run not just the traditional certified measure engine, but also the digital measure engine for what's required for us to generate these quality gaps. So the key aspect of this will be that the analytics which we're building is certified, has the ability to accurately identify these care gaps and these care opportunities, and then which are most and then further into that is what advanced analytics capabilities are you building to be able to precisely identify most likely to improve outcomes, right? Like how can we enhance and improve our member targeting to be able to invest the right time, resources, and energy on the right member at the right time to be able to influence or close these care gaps. So when we talk about this, point of care workflows will have to surface these insights directly within the provider workflows. You know, we cannot close care gaps and work on quality without a clear payer and provider collaboration along with the member. So having these point-of-care workflows to showcase these insights, to surface these insights directly within the provider workflow so that the provider does not have to look elsewhere, right, outside of the system. So that'll obviously ease accessibility of these care gaps to the provider, being able to build on smart and smart and FHIR applications and real-time integrations that can actually bring these quality opportunities into the clinical setting is going to be key for us. And when we're doing the member outreach programs, then having the ability to do this with understanding what the engagement preferences are for the member, what the SDoH factors are for the member, what are the prior interactions which have happened. And the accessibility needs are all need to be accounted for before even we trigger a member outreach program. So if I'm getting a phone call from my health care ecosystem, then I would definitely want it to be more feel more connected and to know it all on the fact that I've already scheduled my colonoscopies. Please don't give me a call back again, right? Or wait for a certain time period, like having that interconnected web of workflows, or probably there is a certain instance where you know we we found a member who has a behavior of visiting the emergency department rather than the PCP for smaller issues. And there is an active campaign happening with that member where we are talking to the member, trying to identify the PCP, and then imagine not having an interconnected workflow. And through a random mean, they also get notified that, hey, guess what? You also need to get your colonoscopies done. Now that disrupts the member experience. Now the member is basically left confused to be able to understand, okay, am I going to this PCP or do I have to figure out on my own and you know get the colonoscopy done? So those are the things which we essentially have to evolve quite a bit. And the only way which we can do this is through actual analytics, connecting it to provider workflows as well as member outreach and leveraging advanced analytics to do it. And the key out here is getting the right intervention to the right member at through the right channel at the right time. So channels matter, right? So just making sure that if I , I keep giving this example to folks where a lot of times, people have this habit of basically waiting till their birthday to schedule their annual wellness exam, right? And have you built analytics to be able to identify that pattern? Like if someone's birthday is happening in October, why are you starting to outreach to them in January to schedule their annual wellness exam when you've already seen this pattern behavior in the past five years that you know they will end up completing their annual wellness check in October and closing all of their care gaps in October? Is this even a member who we need to prioritize and outreach and probably not have the best member experience from more of a you know engagement standpoint? So those are the things which we need to keep in mind. And that's the reason why we we you know, we at Optum here are really stressing on the fact that it is key to get the right intervention to the right member through the right channel at the right time. This becomes very pivotal for us in terms of how we've built our analytic platform to enable provider workflows as well as the member engagement workflows.
Ilene MacDonald, hostChallenging, but worth it in the end, right? For the outcome, better for the patient.
A three-step modernization playbook
Ilene MacDonald, hostSo for plans that need to modernize their quality strategy, where would you suggest they begin?
Shariff Baseer, guestOkay, I'm gonna go through like a three-step process for this. The first step being building a trusted data foundation. Your quality is as good as the data is. We've spoken about this prior, right? Having the ability to build a trusted data foundation is going to be core for us to look at a modernized quality strategy in the new world of digital quality as we are transitioning away from hybrid. First and foremost will be to build that trusted data foundation. What I mean by that is improve your data acquisition strategies, focus on investing in interoperability and digital data access, having the ability to pull the data through the right EMR channels and the digital channels, along with your traditional admin sources today is going to be critical. And once you have the data access and you have the data in your hand, being able to build data quality and governance around it is going to be critical. Because one of the things I know we've not touched on it is when we talk about EMR data, one of the key aspects is the ability for you to go through a PSV audit and actually have audit-verified data for submissions. Now, when we talk about this digital data, that's one aspect and one element of it, which truly becomes a little bit of a challenge for health plans when they're trying to access this data. And that's the place where your data quality focus and governance can come in, right? Like, how are you going to introduce a new digital source into your quality ecosystem? What protocols, processes, data quality checks are you going to bring in? One of the things we are working on is you know, we're partnering with NCQA on the other digital data quality program, which is essentially certifying the data even before it hits the analytics. So that's one of the things what we are doing to be able to build on that data quality so that any downstream processes, PSV audit process or anything else downstream is easier for us to take care of and manage. So that's step one in terms of just being able to build a trusted data foundation. Second is creating actionable insights, right? Like moving beyond a dashboard, an Excel sheet is going to be critical. The amount of times I've basically interacted with folks in quality and they have you know hundreds of Excel sheets open, data dumps and CSV formats and everything, it's insane. And now we are in a world of AI and there's so much already happening. So it is important for you guys to have a user experience which is more inbuilt within the system rather than you know a system which forces you out of the application. So that's what we are focused on is having the ability to create actionable insights using AI, right? Like so pattern recognition, modeling in terms of projections, and being able to consolidate year over year, month over month, trend changes, showcasing these trends, showcasing these patterns in front of the users. So that's basically where we're moving, right? We're moving from measurement and reporting to insight and action. So we're going to be presenting these insights, which are actionable for the users to take, rather than here's what we measure and here's what a report on a dashboard is. And what this basically allows us when we move from insight to action is the fact that we are now we have the ability to prioritize these care opportunities and really focus in on these care opportunities in a way that going back to my example, right? Do I really need to push a priority list of members in the first half of the year if their birthday is in October and we've seen that pattern that you know they will end up closing these, all of these care gaps usually get closed in the month of October. So being able to utilize AI to identify these patterns is going to be critical. And having the ability to deliver these insights early rather than post an action is taken is going to be critical. And this is a place where you know one thing what we've been consistently doing here at Optum is we've been releasing our quality measures as and when they're certified through bi-weekly releases. So what that basically means is as of March, you have a certified version of these measures available. So rather than quality being a Q3, Q4 activity, our customers are essentially able to start off in Q1 on what these insights are. And they are able to drive that action, come up with a more of a strategic plan, and drive the interventions accordingly so that you know they can decide, okay, I want to be able to do member outreach and engagement campaigns for these members who've been hard to reach, who've been, you know, consistently not reactive to what we need. And then there are certain places where all you need to do is just make sure that the care gap is accessible and showcasing early the certified care gap becomes critical in that flow. So that's the step two, which is showcasing actionable insights which are driving the outcome. Finally, it's operationalizing quality improvement. You know, I spoke about this a little bit in my step two as well. Is how can we stratify these care opportunities, leveraging AI? How can we build a coordinated payer and provider workflow ecosystem which will provide a better member experience, which will actually be effective in nature, where we are able to have organizations, the payer organization and the provider organizations on the same system, talking to each other in the same way. And it doesn't require an urgent critical workflow for us to be, you know, having this engagement. So being able to build this out and like we say, meet the member where where they want to be met is the same thing with the providers, right? Like having coordinated payer and provider workflow ecosystems basically means if they are on a certain EMR and if they are already used to that EMR, how can we get access to their system rather than us switching the providers over to a brand new system where you know they they have multiple technologies to work with and showcasing what's most relevant rather than bombarding the providers with a lot more information, which might you know reduce the the effectiveness, the efficiency in terms of where we're going is going to be critical. And finally, having the ability to create this multimodal engagement strategy for members and providers is critical, right? Like where where we are saying there might be certain providers in rural regions who are not yet adopted into an EMR. Can we actually get the gaps in care and all relevant information sent to them via you know facts, via postage? Or if they are currently on a specific EMR, then let's use smart and FHIR systems or just within the EMRs organically to share the care gaps, whether it's risk gaps, quality gaps, or any other gaps which are present out there, right? Having the relevant SDOH information also showcased in that is going to be critical. So having this multimodal approach on the provider side is definitely going to be effective. And the same thing on the member front, where outreach to the member, leveraging text messages, emails, phone calls, IVRs, and having that determination of whether this should be a clinical outreach versus a generalist outreach is going to be critical. And also determining whether the when we talk about meet the member where they are at, one of the key things comes in. Is it going to be in the office or is it going to be an in-home assessment that we would like to do and where we are basically sending our house calls nurses and clinicians into the member's house to make sure that we are able to complete all of the care gap assessments out there, right? So that's the approach which Optum is taking. And having a multitude of interventions handy is always great. But backing that up with the right insights and the right data foundation. So the three steps to answer your question in terms of a modernized quality strategy would be build a trusted data foundation, create those actionable insights, and then operationalize quality improvement through this multimodal intervention method across the board.
Ilene MacDonald, hostWe've
Final takeaways
Ilene MacDonald, hostcovered a lot of ground today. And I wonder, I'm going to have you go back to a three. If you could take if our listeners were going to take away three things from our conversation, what should those be?
Shariff Baseer, guestFirst and biggest takeaway, digital quality is happening now. Organizations should start preparing today for the industry's digital future. As we are looking at what's coming our way, uh, so that'll be the biggest takeaway for digital quality is happening now. Takeaway two is turning insights into action. I've stated this in the prior as well. Like just data and analytics only matters if you're able to drive that meaningful intervention and outcomes, especially in the world of value-based care where we are in right now, and how outcome-driven the industry is getting to be. So looking at these insights and turning it into action is my takeaway too. And my takeaway three is quality is a team sport. You know, success requires connected workflows, automation, payer provider collaboration, and having that personalized approach for engagement with the member is going to be critical. So choose the right vendor partner, choose the right technology strategy, choose the right payer provider collaboration techniques, and that's how we can succeed in quality.
Ilene MacDonald, hostThank you, Shariff. I appreciate your time today.
Shariff Baseer, guestAbsolutely. Thank you, Ilene. It's been a pleasure talking to you.