QUALITY IMPROVEMENT
AND MEDICAL POLICY

Optimize management of quality programs (Stars, HEDIS, etc.) purpose-built to line of business performance demands, and supported by medical policies that are grounded in evidence-based medicine and aligned to performance outcomes

Quality and medical policy functions are key foundations of effective health management and optimal working models between payers and providers.

Payers must develop competencies across variety of levers to drive quality performance including:

Optimizing medical and provider policies
Partnering with network providers to identify and drive clinical quality initiatives for the point-of-care
Executing LOB specific quality programs in line with market best practices (e.g., Stars, NCQA, HEDIS)
Deploying a rigorous continuous improvement process to quality and clinical policy programs to keep up with the rapidly evolving evidence-based medicine and care delivery practices

Quality programs have a positive impact on long-term medical cost performance and can drive favorable economics; however, quality programs require thoughtful strategies to balance investments across staffing and operating models and intervention with the desired quality outcomes.

Common issues we help our clients solve

How can we evaluate the efficiency and effectiveness of quality functions?

What opportunities are there to improve our team, staffing model, and key roles and skills within the organization to better address clinical quality?

How can we drive improvements in our clinical quality programs?

How can we better engage our provider partners in quality initiatives?

What is the business case impact of implementing quality program changes and of revising Medical Policies?

How can we optimize our Stars, NCQA, and HEDIS performance?

Key enablers of successful quality programs

Develop robust analytic framework to evaluate Stars and HEDIS performance across geos, populations, and provider partners; analytic outputs drives strategy for overall program, continually highlights areas for improvement, informs interventions, incentives and network engagement efforts.

Develop an integrated measure-level return on investment model in order to balance investments with impact on measure outcomes to inform an efficient and effective portfolio of quality programs.

Improve efficiency using digital tools that allow for system/data integration (e.g., EMRs) or automation of data capture and validation tasks.

Deploy robust member and provider communication and experience campaigns to inform the importance of gap-in-care closure and approaches to address them.

Ensure clear accountability for quality program strategy, design and development with robust service level agreements for critical execution teams across the enterprise.

Quality initiatives

Best-in-class provider quality initiatives follows three steps:

Identify high-priority areas for provider quality initiatives

Create robust analytics to identify hot spots and areas for further exploration
Assess in-flight initiatives or priorities from provider network and partners

Collaborate between provider clinical leadership and payer clinical SMEs to stand-up new quality initiatives

Use evidence-based medicine and the latest clinical research, to define and agree upon a set of actionable best practices to implement in the care setting as part of the quality initiative
Identify and facilitate any additional tools, capabilities, or process changes required to meet the best practices

Continuously monitor program outcomes

Define KPIs and reporting cadence for each quality initiative
Track and monitor physician actions to determine adherence with initiative and quality improvements from initiative actions
Use outcomes data to iteratively adjust clinical protocols in care setting

Oliver Wyman has successfully partnered with our clients to drive improvements in clinical quality and optimize medical policy.

Conducted a side-by-side evaluation of leading clinical criteria vendors aligned to specific client parameters, including future savings potential, degree of automation, and ease of staff use. Read more

Developed a robust Stars strategy including member and provider interventions, vendor selection, and development of an analytic model that allowed for measure-level ROI and optimization of quality program portfolio; allowed the plan to move from 3 Stars to 4 Stars. Read more

Performed analysis of historical and current performance to identify key opportunities to improve Stars performance which would result in $35M in bonus payments and developed the foundational building blocks required to improve and maintain Stars performance. Read more

Redesigned provider incentives to increase focus on quality performance and identify $70M worth of improvements; drove alignment on near-term priorities across the enterprise to ensure successful implementation. Read more

Assessed likelihood of receiving an improved Stars score based on improvement activities and provided support for advocacy efforts with CMS to adopt a different approach for their COVID-19 response. Read more

Developed a roadmap and blueprint to shift a plan’s Stars program from a start-up like structure to a mature program and help ensure a consistently high Star rating and potential gain of $200M+ net profit. Read more

Behavioral Health

Care Delivery

High Cost Claim and Member Management

Medical Cost Action Planning

Member Advocacy and Concierge

Network and Product Design

Pharmacy Management

Population Health Management

Provider Performance Management and Risk Enablement

Quality Improvement and Medical Policy

Social Determinants of Health

Utilization Management