Making the Case for Payer Digital Quality – How to Build a Business Case and Communicate with Your Senior Leadership

Health plans that are building their digital quality programs are looking to gain a first-mover advantage – leveraging this new technology to maximize their HEDIS^® rates and incentives while transforming their quality operations and their ability to impact member health and engagement. Like other disruptive technologies, digital quality measurement requires substantial supporting infrastructure. Getting in early lets you integrate smoothly rather than playing catch-up.

But before you can start on this journey, you need to make the business case for new resources – both for the technology and for the clinical data that is needed. How can you make the most effective argument for these resources before it’s too late?

Focus on Strategic Alignment. Digital quality measurement has transformational impact across a health insurer. It affects all lines of business, with the strongest impact on Medicare Advantage, Medicaid, and SNP populations. It also crosses functional areas, impacting finance, network and provider engagement, care management, and marketing. Digital quality is also a key foundational infrastructure for population health. Focus on the strategic alignment to your company’s mission and vision.

Highlight Competitive Advantage. Emphasize how and why adopting digital quality will help you compete in current markets and gain a better footing in new markets. With a fixed pie of incentives and the retirement of the hybrid methodology, your ability to obtain and analyze clinical data will be your main forward-facing advantage.

Address Risk Reduction. We’ve seen many surprises in MA and Medicaid with the new administration, and we are likely in for more including potential changes to Stars measures and methodology. Digital HEDIS^® operations enable you to respond quickly to these surprises, reducing the risks to your business.

Explain Operational Benefits. Explain how digital quality can improve operations and reduce costs. For example, you can show quantitative data describing how prospective review with NLP can blunt the impact of the hybrid method retirement (contact me if you want to know how). Or you can describe the reduction in costs produced by a more streamlined digital operation that automates repetitive tasks and reduces audit risk.

Leverage Case Studies and Professional Contacts. Use data from other payers to help extrapolate the value to your health plan. Astrata has a number of quantitative case studies available on our website. Often, healthcare organizations prefer ROI data collected within their own organizations (see pilot programs below). However, with new technologies, waiting for organic data can also hold you back. Instead, use your professional network to learn more about how the technology has worked in a similar setting and gain the benefits of lessons learned from your peers.

Demonstrate Qualitative Analysis. The retirement of the hybrid methodology provides the most potent quantitative analysis for the need for digital quality measurement. You can extrapolate from your past hybrid seasons to show why inaction is so dangerous. Calculate the impact of each hybrid measure retirement and evaluate it against your ability to use other supplemental sources. Demonstrate that even just staying where you are will require transformation.

Establish Pilot Programs. Some aspects of this transformation are easier to quantify in pilot programs than others. We’ve found that use of unstructured data with NLP is well suited to an ROI analysis on a smaller number of measures, if those measures are carefully selected. Programs can be scaled up from there. A similar approach can be taken with FHIR/CQL-based digital engines. But be careful to design your pilots to collect the necessary data for ROI analysis, and ensure that there is sufficient buy-in from all parties.

Address Scalability & Future-Proofing. An important aspect of the new digital quality technologies is that we see massive gains in scalability over current HEDIS^® technologies and operational processes. As more and more data must be utilized, scalable systems and processes tend to pay for themselves quickly.

In summary, securing the resources needed to make this transformation requires a multifactorial approach. What works for smaller, more incremental investments may not work here. It’s all about shifting the conversation to broader business impact, long-term gains, and strategic necessity.