How Blues Are Advancing Quality Measurement in Massachusetts & North Carolina

Apervita sat down with three industry leaders in the movement for value-based care to better understand their perspective and expertise in quality measurement, specifically as it relates to payment reform and the advancement of value-based models. The roundtable discussion, moderated by Apervita’s Stephanie Graham, Vice President of Payer Innovation, included:

James Colbert, MD
Senior Medical Director for Delivery System Innovation
and Analytics at Blue Cross Blue Shield of Massachusetts

Troy Smith
Vice President of Healthcare Strategy and Payment Transformation
at ‎Blue Cross of North Carolina

Qi Zhou
Vice President of Quality and Healthcare Delivery
at Blue Cross Blue Shield of North Carolina

Colbert, Smith, and Zhou shared with Graham their thoughts about the current state of quality measurement and moving the needle in value-based care.

Describe the quality initiatives happening within your organizations today.

Jamie Colbert (JC): We’ve been pushing on quality improvement for decades with the providers in our network, and we formalized that work a decade ago with a global risk model called Alternative Quality Contract (AQC). It’s one of the first value-based payment models developed in partnership between a commercial plan and large provider groups where providers earn quality incentives by improving their performance on quality measures across ambulatory care, acute care, and patient experience. Those three segments come together to create an overall quality score where providers can achieve payments and earn incentives based on how they perform relative to other providers in Massachusetts. It started with the HMO population but has expanded to include PPO and self-insured employers who may even have employees outside of Massachusetts, where we partner with Blues plans in other states to offer value-based arrangements.

How is North Carolina thinking about quality measures?

Troy Smith (TS): Our version of the AQC is the Blue Premiere Contract (BPC), which is our way of integrating quality in the total cost of care incentives for our provider base. We’ve done tiered benefit programs for provider systems and specialties in the past, but our philosophy is that we always want quality first. Quality has to be at the forefront, and the total cost of care will follow.

Qi Zhou (QZ): All of our value-based programs address two components: quality and affordability. What separates BPC from other value-based payment initiatives is the fact that we include value payments for targeted specialty care under Blue Premier. Those performance measures follow the National Quality Strategy established by HHS. We’ve also started to work on social determinants of health and address health equity.

There are so many quality measures across all sorts of payers. Is there a need to simplify or condense measures across payers to establish a standard? Are you simplifying measures within your own organizations?

QZ: We need to have a seminal conversation about quality measure fatigue. There are more than 400 measures across various quality programs we are tracking today. It is impossible to make meaningful improvements on that many measures. We need to focus on a few important quality measures that matter most to consumers.

  • First, quality measures today are focused heavily on process measures, and we want to move toward health outcomes.
  • Second, we need to take affordability into account, and must have quality measures that address the cost of care overall.
  • Third, we need to start measuring the quality of the patient experience. What does quality mean to members? For some, it’s the relief of pain. For others, it might be the quality of conversation with their doctor.
  • Fourth, we need to think about how the community benefits from quality measurement and improvement. How do quality measures address health equity and racial disparities?

These Four Big Dots are very important for our quality measurement framework to support value-based payment and population health.

JC: I agree with Qi. There’s a lot more we’d like to be doing to push quality measurement further than what you can measure based on claims data and EMRs. What we’ve done is look at each of the individual measures in our quality contract to see which measures don’t have much room for improvement. At a certain point, it isn’t worth keeping the measure because it doesn’t differentiate between providers and the providers don’t need to strive for improvement.

We’re also putting in place a small incentive for our providers to start working on shared decision-making. How do you measure shared decision-making to know that a member has had a conversation with their provider around cancer screening? There may be a valid reason for them to not undergo cancer screening, but with the system, we have in place right now, there’s no way to know that. Improving this will help to inform a more national conversation on how we’re defining measures, what those specifications look like, and how to ensure the measures we’re incentivizing will get us closer to the outcomes we want for our members.

What metrics and programs are needed to address racial inequities in healthcare access and quality?

QZ: If we can find some silver lining from the pandemic, it’s that achieving health equity is possible in a short time frame. One of the positive lessons learned from COVID-19 is how we reacted, particularly around vaccinations in addressing healthcare disparity. Everyone consciously made health disparities in vaccinations a top priority. Improving health equity is a must, and it is very possible as long as we have resources aligned and make it a top priority.

Because almost a quarter of residents in North Carolina are Black, our Health Care Equity Index initiative is to focus on improving black maternal health. Secondly, we’re focused on working with providers to improve data collection for our commercial population. And lastly, we’re working on quality measures for health equity and currently have 10 measures identified for the initial Health Care Equity index to support our valuable programs. This has helped us identify areas we need to focus on, and we’re beginning to make progress.

JC: Health equity is something BCBS Massachusetts is explicitly incorporating into our quality framework as well. The lack of data on member race and ethnicity has been a challenge. We want to incentivize providers based on their performance on health equity measures, but to do this, need to know which members belong to which racial and ethnic groups.

The approach we’re engaged with right now is asking our members for their self-reported race and ethnicity data. We are currently collecting race and ethnicity data from our members on a voluntary basis, via our app, and we will be offering our members’ additional ways to share their race and ethnicity with us later this year. On the physician side, providers vary quite a bit in how confident they are in the accuracy and completeness of the racial or ethnic information in their medical records, sometimes because it’s not clear who entered it. If the provider has a way for the patient to self-identify, that would be helpful.

The next step is working collaboratively with our provider partners to address those disparities. Once we have a better understanding based on baseline data, we’ll be able to work with our provider partners on closing some of those gaps.

If you had to pick your top priority for addressing quality measurement, what would you focus on?

QZ: The best return we can see is from interoperability. We need our members to tell us what their preferences are, providers, need to be upfront about their challenges, and health plans need to collaborate with members, providers, and communities to address bigger issues such as healthy people outcomes, affordability, and health equity.

TS: Communication is key. How robust we’re able to make quality and payments will always come down to how well we are communicating with providers. Unless we have that solid base, it’s hard for us to get to the next level. For North Carolina, the next year will be about refining our infrastructure. We already have the model, we already have the quality measures, we already have the vision. Now it’s about how we put it all together.

We should move from checking a box to measuring actual outcomes and the things that matter to our patients—things we may not be measuring today. This is where being able to get input from patients and getting them to participate more actively in quality measurement will get us closer to improving quality of life.

James Colbert, MD, Senior Medical Director for Delivery System Innovation and Analytics at Blue Cross Blue Shield of Massachusetts

JC: I think we’re still in the infancy of quality measurement in healthcare. If you really think about the measures we currently have in place in value-based models across the country, what we’re doing is still somewhat crude. Very few of those measures are really getting at the things that matter to members and providers.

We should move from checking a box to measuring actual outcomes and the things that matter to our patients—things we may not be measured today. This is where being able to get input from patients and getting them to participate more actively in quality measurement will get us closer to improving quality of life. Which providers can perform a knee surgery and get patients back in action faster? Which providers can treat a diabetes patients and get them feeling well enough to spend quality time with their families? These are the things that matter to our members. We’re at an inflection point. We can think about health equity, shared decision-making, and patient experience—components that are just entering the quality measurement discussion. It’s really an exciting time.


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