Email Updates
Health Plan Patient Safety Initiatives
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
When we think of improving patient safety, we often think of strategies that can be implemented at the health care organization or health care professional level. However, improving patient safety is a multifaceted issue, and health plans play an important role in monitoring and improving patient safety.
In the United States, insurance status can determine a patient’s access to safe, high-quality health care. The Patient Protection and Affordable Care Act (ACA), established in 2010, sought to improve access to care by expanding coverage through Medicaid and reforming the private insurance market.1 The ACA specifically sought to improve patient safety by establishing quality reporting programs and pay-for-performance initiatives that tied reimbursement payments to quality measures and patient safety indicators. It also mandated funding for patient safety initiatives and research and highlighted the role of health plans as critical players in patient safety.
Health plans have a unique position in addressing patient safety, as their covered services can impact patient access to care. Although there is extensive published literature on the health plan’s role in monitoring and improving healthcare quality, a limited body of work specifically examines the health plan’s role in monitoring and improving patient safety. However, health care quality and patient safety are closely intertwined, and patient safety events often overlap with quality issues.2,3 This essay explores ways that health plans are currently monitoring patient safety and discusses opportunities and initiatives at the health plan level to improve patient safety.
Monitoring and Measuring Patient Safety
Monitoring and measuring patient safety, including the occurrence of adverse events, is a critical first step in determining priority patient safety areas for improvement and designing improvement strategies. Health plans have access to large amounts of administrative, claims, and cost data. By monitoring and analyzing these data, plans can see the bigger picture of patient care across multiple healthcare settings in a way that is not always possible within a single healthcare organization. This access to data across entities allows plans to identify trends and patterns that can indicate potential safety issues.4 These trends can be shared with healthcare organizations and professionals and can inform targeted patient safety interventions and quality improvement initiatives.
In addition to monitoring patient safety events and analyzing data at the plan level, patient safety and quality measurement initiatives are in place at the federal and state levels.5,6 Health plan quality measures reported out to consumers typically include a combination of clinical quality data and member experience data, and focus on topics such as patient safety, healthcare effectiveness, and access to care. Two such examples of measures sets that assess health plan quality and patient safety are Healthcare Effectiveness Data and Information (HEDIS) measures, managed by the National Committee for Quality Assurance (NCQA); and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey measures, maintained by the Agency for Healthcare Research and Quality (AHRQ). These measures can help consumers make informed decisions when selecting a health plan through public reporting, such as through the Centers for Medicare & Medicaid Services (CMS) Quality Rating System (QRS) for qualified health plans or Medicare Star Ratings, which are published on the CMS Care Compare website.7
In addition to their use for consumers, these measures can help plans determine priority quality and patient safety areas for targeted quality improvement efforts.8 NCQA also manages health plan accreditation programs that establish baseline requirements on quality, safety and experience of care for health plan members. Employers often look to NCQA accreditation status when determining which health plans to offer to their employees/members. Many states also specify accreditation requirements for the managed care organizations that receive state government contracts.
Another example of a federal quality and patient safety monitoring initiative is the AHRQ Quality and Safety Review System (QSRS), which is a national surveillance system that identifies adverse events using clinical data abstracted from inpatient Medicare discharges and administrative data.9 Additionally, AHRQ’s patient safety indicators (PSIs) are a set of measures that use hospital administrative data to identify complications and adverse events that represent opportunities for improvement in the delivery of care. Health plans use patient safety indicators to compare performance among hospitals to understand the safety, quality, and affordability of the care that their enrollees receive. CMS, which is the largest payer of health care services in the United States, uses a subset of the AHRQ PSIs for the CMS Patient Safety and Adverse Events Composite (CMS PSI 90). The CMS PSI-90 summarizes patient safety across multiple indicators, monitors performance over time, and facilitates hospital-level comparative reporting and quality improvement. CMS uses the CMS PSI 90 in several federal programs, including the Value-Based Purchasing Program.10
Improving Patient Safety: The Health Plan’s Role
In addition to health plans’ focus on quality, health plans can play an important role in improving patient safety. Health plans offer a means to finance healthcare expenses, and the plans determine which healthcare services (e.g., tests, medications, treatments) to cover based on their understanding of patient needs.11 Because the health plan determines the type of care that patients can access and which healthcare organizations they contract with, health plans have an opportunity to positively impact patient safety.
Health plans can have a significant impact by considering patient safety when they contract with healthcare organizations. By regularly monitoring the safety of health care facilities in the health plan network, health plans can ensure members have access to facilities delivering safe care. There are also federal requirements around the health plan’s role in incorporating patient safety into their contracting processes. CMS’s Health Insurance Marketplace Quality Initiatives (MQIs) collect and report quality data for the Health Insurance Exchanges. One of these initiatives is CMS’s patient safety standards, which require that Qualified Health Plan (QHP) issuers verify that the hospitals they work with meet quality and patient safety requirements. They also require that QHP issuers confirm that the hospitals they contract with have patient safety programs in place that focus on reducing the risk of patient harm, engaging patients and families, improving care coordination between providers, and monitoring performance on patient safety events.
Plans can additionally impact patient safety through reimbursement and payment policies that incentivize healthcare professionals’ continued focus on quality improvement and patient safety by tying a portion of reimbursements to quality metrics related to patient safety outcomes. CMS has several quality reporting and value-based payment initiatives designed to improve care quality and patient safety through payment incentives, payment reductions, and public reporting.12 These existing value-based payment initiatives could set the foundation for additional value-based programs specifically related to patient safety.
By collaborating with healthcare professionals to determine best practices, health plans can implement system-wide policy improvements to improve patient safety. A study conducted in Massachusetts highlighted the important role that health plans play in medication prescribing and medication-related adverse events. The health plan conducted an analysis of pharmacy claims data and other data sources to understand prescribing rates and adverse events related to opioid use. The plan then collaborated with a network of nurses, physicians, pharmacists, and other stakeholders to develop and implement a comprehensive opioid utilization policy that led to a significant decline in monthly opioid prescribing rates. When changes to policies are made at the plan level, it can have important downstream impacts for patient safety.
Another study discussed the role of the insurer in preventing adverse events in maternity care.2 The study found that insurers can improve patient engagement and promote collaboration among healthcare professionals by serving as a bridge linking a patient’s health care services. The study recommended that insurers incentivize hospitals to provide training programs for healthcare professionals, and fund patient safety research.
Conclusions and Future Directions
While the ACA increased the number of insured individuals and there are several strategies that can be implemented at the health plan level to improve patient safety, differences remain in care quality and patient safety across health insurance programs. One study, which analyzed hospitals from 11 states, found that the quality of care for patients within the same hospital varied by insurance status. Medicare and Medicaid patients had significantly higher risk-adjusted rates of adverse events for a majority of the examined patient safety indicators than privately insured patients. Another national study that examined in-hospital mortality rates for myocardial infarction, stroke, and pneumonia patients found significantly lower in-hospital mortality rates for privately insured patients compared with patients that were insured by Medicaid or uninsured.13 Further research is needed to explore mechanisms for differences in health outcomes and safety events among patients with different types of health insurance.
Another promising avenue for future research is developing a better understanding for how we can best measure and report patient safety indicators in a way that is actionable to health plans. While there are currently several robust pay-for-performance programs related to healthcare quality, further research is needed to determine whether these types of programs can be leveraged to specifically focus on patient safety.
References
- Supplemental Material to the CMS MMS Blueprint Legislative Mandates for Quality Measurement and Reporting. https://www.cms.gov/files/document/blueprint-legislative-mandates.pdf
- Unruh L, Lugo NR, White SV, Byers JF. Managed care and patient safety: risks and opportunities. Health Care Manag. 2005;24(3):245-256. doi:10.1097/00126450-200507000-00009
- Yount, N., Zebrak, K. A., Famolaro, T., Sorra, J., & Birch, R. (2022). Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting. Journal of Applied Gerontology, 41(1), 73-81. https://doi.org/10.1177/0733464820969283
- Draycott T, Sagar R, Hogg S. The role of insurers in maternity safety. Best Pract Res Clin Obstet Gynaecol. 2015;29(8):1126-1131. doi:10.1016/j.bpobgyn.2015.07.002
- Radley D, Baumgartner J, Collins S, Zephyrin L. 2023 Scorecard on State Health System Performance. www.commonwealthfund.org. Published June 22, 2023. https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance
- CDC - Health Department Resources - STLT Gateway. www.cdc.gov. Published March 9, 2020. https://www.cdc.gov/publichealthgateway/healthdepartmentresources/index.html
- Rowan P, Hsu R, Masaoay T, Parver S. Quality Rating Systems in Medicaid Managed Care Final Report. Mathematica; 2021. Accessed March 18, 2024. https://www.macpac.gov/wp-content/uploads/2021/03/Quality-Rating-Systems-in-Medicaid-Managed-Care.pdf
- Kaitlyn Whiton Esselman, Ciemins EL, Donckels EA, Barbera C, D’Andrea G, McBride T. Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations. Published online November 8, 2021. doi:https://doi.org/10.1089/pop.2021.0197
- Classen DC, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3):e234-e240. doi:10.1097/PTS.0000000000000322
- Quality Measures Fact Sheet CMS Patient Safety Indicators PSI 90 (NQF #0531) National Quality Strategy Domain: Patient Safety BPCI Advanced and Quality Background on CMS Patient Safety Indicators 90. https://www.cms.gov/priorities/innovation/files/fact-sheet/bpciadvanced…
- Keisler-Starkey K, Bunch L, Lindstrom R. Health Insurance Coverage in the United States: 2022 Current Population Reports. U.S. Census Bureau; 2023. Accessed March 18, 2024. https://www.census.gov/content/dam/Census/library/publications/2023/demo/p60-281.pdf
- Centers for Medicare and Medicaid Services. CMS Quality Reporting and Value-Based Programs & Initiatives. Last modified January 2024. Accessed March 18, 2024. https://mmshub.cms.gov/about-quality/quality-at-CMS/quality-programs
- Hasan O, Orav EJ, Hicks LS. Insurance status and hospital care for myocardial infarction, stroke, and pneumonia. J Hosp Med. 2010;5(8):452-459. doi:10.1002/jhm.687
Editor’s note: Amy Helwig, MD, MS, FAAFP, is the Chief Quality Officer at Commonwealth Care Alliance. We spoke to her about the health plan’s role in monitoring and improving patient safety.
Sarah Mossburg: Thank you for joining us. Could you tell us about yourself and your current role?
Amy Helwig: I am the chief quality and population health officer at Commonwealth Care Alliance, which is a mission-driven healthcare services organization that offers innovative health plans and care delivery programs designed for individuals with the most significant needs. We serve more than 100,000 individuals across Massachusetts, Rhode Island, Michigan, and California.
Sarah Mossburg: What do you see as the health plan’s role in improving patient safety, and how do you think that role has evolved?
Amy Helwig: Health plans, like all other stakeholders in health care, are invested in the best care and outcomes for our members. We are interested in whole healthcare, quality of life, patient experience, and prevention of patient safety events and adverse events such as medication issues, falls, pressure ulcers, and infections. When these things happen to our members, they end up in the hospital. Our members want to be with their families and friends in the community setting for as long as they can.
When I think about how the health plan’s role has evolved in the last 15 years with respect to patient safety, similar to the provider side, there is more emphasis on quality variances, total cost of care, and health outcomes. As we all experience healthcare, we consider how we can minimize unplanned care and maximize prevention and quality improvement.
Sarah Mossburg: What are some ways that health plans can impact patient safety?
Amy Helwig: One example is having strong credentialing programs in place. To be credentialed as a provider in our network, there are committees making these determinations, and providers must submit licenses, background checks, and references. For facilities, we conduct certain safety checks using publicly reported data. Before a provider is included in the health plan network, we are screening for quality and safety.
Once providers are in the network, we have requirements around reporting critical events. When we become aware of these events from various sources, we have mechanisms to ensure these are reported to the appropriate authority and investigated.
Another example of the impact of the health plan is through policies on what we include in our benefit coverage, especially as it relates to new technologies, new drugs, any other types of interventions and treatments, and making sure that these are reviewed from an evidence base on improvement in outcomes and safety. We look for any safety risks, especially when new drugs and devices first come out. We also monitor for product and device alerts, like recalls.
Sarah Mossburg: What unique advantages do health plans have in addressing patient safety?
Amy Helwig: I don’t know that we have a lot of advantages because, at the plan level, we are a few layers removed from the patient and provider. However, we do have access to claims data across time and health systems. Encounter and claims data indicate if a health plan member is seen in a clinic, a hospital, or even if they get discharged from the hospital and then get admitted a month later to a hospital on the other side of the country. We see claims across healthcare settings, such as emergency departments, pharmacies, and specialists, whereas the individual hospitals or clinicians may not see that level of claims data. We often see a different picture of care in a way that individual providers may not.
If you think about medications and side effects, the health plan sees every medication refill claim no matter where or how frequently it was refilled. Because of this, the plan can often determine if health plan members are on redundant medications. The plan may also learn a provider issued a prescription that was not picked up at the pharmacy by the member, as claims data indicates pre-authorization and a final claim. The provider generally sees that they prescribed it in the electronic health record [EHR]. Whether prescriptions got picked up, the number of refills actually filled over time, or whether another provider prescribed the same medication are things that providers may not always directly see.
Sarah Mossburg: That is potentially very powerful to see that bigger picture in terms of taking a patient or population-focused view of care. What are some of the biggest patient safety priorities for health plans today?
Amy Helwig: Patient safety priorities will always be driven by the population that plans insure. The health plan that I work for specializes in patients with multiple chronic diseases, who are elderly, have behavioral health needs and substance use disorders. As the majority of members are over age 45, our patient safety priorities are much different than, for example, another plan that specializes primarily in young adults or a plan with a large number of pediatric members. It really comes down to, when you look at your population, what are the most common conditions that are present?
Sarah Mossburg: That makes sense, and then considering what are the potential adverse events associated with those common conditions. What are some ways that health plans monitor patient safety? Is that data-focused as well?
Amy Helwig: It is data-focused but may be different data than what providers see in their routine business operations. Hospitals have their own patient safety event reporting systems with real-time data. At the health plan level, our data is claims-focused. We follow claims data and complications as they're coded, as well as unplanned care and admissions into the emergency department or urgent care.
Sarah Mossburg: Are there any standard types of information you share with hospitals or providers?
Amy Helwig: Our quality improvement programs usually specify the health conditions and their associated key quality measures. We provide feedback to providers on these quality measures as it relates to the care of members seen in their respective setting at both the physician group level as well as at the hospital level.
These quality measures change every year, and it often reflects trends happening at the state and federal levels. For example, if a state health department indicates lead screening as important for the state, they may require that all the managed care companies conduct lead intervention programming. A health plan may then build that into quality improvement programs with network providers.
At the federal level, the Center for Medicare & Medicaid Services’ (CMS’) Medicare Star Ratings is a public reporting program with about 30 to 50 measures that change every year, including the weights and targets. This annual change contributes to quality improvement by focusing on measures that need improvement.
Most health plans provide monthly or quarterly feedback to providers to support local quality improvement implementation programs.
Sarah Mossburg: It sounds like, when you're developing quality improvement programs, you're considering federal priorities, state priorities, as well as your own population needs. You touched a little on specific health plan measures of patient safety. Are there any other specific health plan measures of patient safety that you want to call out?
Amy Helwig: We often refer to these as quality measures rather than patient safety measures. The National Committee for Quality Assurance (NCQA) has a standard set of Healthcare Effectiveness Data and Information Set (HEDIS) measures that we use, including chronic care prevention measures, diabetes measures, cardiac disease measures, and the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey measures. These measures are similar to those used by providers.
Sarah Mossburg: Do you have an example of something that health plans are able to directly impact for patient safety?
Amy Helwig: One example is prescription drugs. Many health plans have pharmacists who help support patient safety functions, such as medication reconciliation. Another example is access to care. Health plans can improve access by adding more providers to their network or implementing programs that encourage members to contact a triage nurse to help determine the best place to access care, for example emergency or urgent or next day appointments that are appropriate depending on their condition.
Sarah Mossburg: Earlier, you mentioned the CMS Star Ratings program and publicly reported data. What are your thoughts related to the benefits and challenges of making some of that performance data publicly available?
Amy Helwig: I think it's appropriate to make performance data publicly available. Every year, all of us must choose a health plan, and I think it's important to have data available to inform how we choose.
Sarah Mossburg: Are there other measures or tools that you would look at to help complete the picture?
Amy Helwig: There's been a push for more patient-reported outcomes and functional outcomes measures. Hearing directly from consumers themselves and their own lived experiences in the healthcare system will help other patients make informed decisions, and also ensure that more quality measures are actually based upon the outcomes as reported by the patient.
Sarah Mossburg: Could you talk a little bit about example initiatives that you've seen health plans use aimed at improving patient safety?
Amy Helwig: One example is medication reconciliation post discharge and working to ensure that within days of a member getting home, a healthcare professional such as a home health nurse or pharmacist is reaching out to them to go through their medications. Sometime, this occurs with home visits. This helps prevent readmissions.
Sarah Mossburg: What factors do you think separate a successful patient safety initiative from an unsuccessful initiative?
Amy Helwig: It is important to have a strong partnership with providers to have successful patient safety initiatives. Good data, aligned focus on high quality of care, and shared patient outcome goals are also key to successful patient safety initiatives. It’s also important to minimize administrative burden and ensure the feedback data is timely.
Sarah Mossburg: What do you see as next steps on the horizon for health plan patient safety initiatives?
Amy Helwig: There is definitely a desire to move towards more patient-reported outcomes data and more quality of life and functional status measures. We're also moving toward more digital quality measures that allow you to look at all different aspects of data and the actual outcome, rather than just whether someone had a vaccine or a specific screening.
Whole-person care and health equity are important aspects of quality improvement. We are rapidly improving data analysis around disparities and stratifying data by race, ethnicity, language, geography, etc., to understand differences in outcomes across different sub-populations. We want to make sure that we’re taking care of all patients and drilling down into the data to see barriers in care that vary across those different groups.
Sarah Mossburg: Thank you for your insights. I really enjoyed this conversation.
