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The Problem with Poor Quality of Care

Poor quality of care, particularly in oncology, continues to impact health plans and their efforts to control costs for their members. It’s estimated that 30 percent of healthcare spending in the U.S. is wasted on inappropriate care, administrative complexity, and other inefficiencies. Poor quality of care is a significant portion of waste, estimated to range from $75 billion to $101 billion yearly. It’s also suggested that more than 40 percent of Medicare beneficiaries receive poor quality of care each year.

As health plans struggle to keep oncology costs from ballooning in an era of new therapies and an aging U.S. population, health plan leaders continue scrutinizing their procedures and practices, looking for ways to target poor quality of care. Here are seven strategies health plans can use to try to (or attempt to) mitigate the effects of poor quality of care on their business.

First, a definition and several examples of poor quality of care.

What is Poor Quality of Care?

Poor quality of care care refers to any medical tests, treatments, or procedures that provide little or no benefit to the member compared to their costs and potential harm. These treatments could also be considered unnecessary or not evidence-based and, as a result, could lead to increased costs and member harm.

Examples of Poor Quality of Care in Oncology

Several examples in oncology can be found in healthcare today.

For example, the U.S. Preventive Services Task Force (USPSTF) does not endorse colorectal screening after age 85. A recent JAMA study found that in members older than 75 years, a large proportion of screening colonoscopies were among those with limited life expectancy and were associated with an increased risk of complications, and colorectal cancer was rarely detected and rarely treated. This lapse in treatment is poor quality of care.

It can also occur when members are subjected to unnecessary imaging tests, such as routine whole-body PET scans for early-stage breast cancer members without a history of metastasis. These tests can be very expensive and not indicated.

Another example revolves around radiation therapy. Poor quality of care can occur when members receive high doses of radiation that are not endorsed, which can lead to harmful side effects and decreased quality of life. An example is when members with low-risk prostate cancer receive radiation therapy which may lead to a higher risk of rectal or bladder complications.

A final example is the use of inappropriate or non-endorsed chemotherapy for advanced-stage cancer members with no record of responsiveness. Chemotherapy is a very effective treatment for cancer patients. However, for patients with poor performance status, the treatment may not be endorsed or efficacious.

Reasons and Causes of Poor Quality of Care

What explains the amount of poor quality of care in healthcare? The reasons vary, but here are four:

  1. Lack of evidence-based guidelines or protocols for treatment. In some cases, providers rely on their judgment or experience rather than following established best practices and evidence-based standards.
  2. Financial incentives surrounding healthcare. Providers or healthcare facilities may receive higher reimbursement rates for specific treatments or procedures. This can create a financial incentive to provide unnecessary or poor quality of care.
  3. The “shotgun” approach. A provider orders all possible tests during a medical visit, often using this approach to ensure that they do not mis a potential problem or to avoid possible litigation.
  4. Member requests. Providers may provide additional tests because they fear they have to appease members, a bigger concern in the last several years as member ratings have been used in new payment models and public reporting of healthcare rankings. Interestingly, a recent study by the University of Chicago and Harvard Medical School found no relationship between favorable member ratings and exposure to a poorer quality of care.

Impact of Poor of Quality of Care on Health Plans

Poor quality of care can have significant implications for health plans in several ways. First and foremost, it can increase healthcare costs, which can be passed on to members through higher premiums or out-of-pocket expenses, and reduce profitability.

In addition, poor quality of care can decrease member satisfaction and cause mistrust. Members may become dissatisfied with their health plans and providers if they believe they are being charged for poor care or if they experience adverse outcomes due to that care.

Another potential impact is legal action. Health plan companies may face litigation from members who believe they have been harmed by poor quality of care or believe they’ve been overcharged for unnecessary care. Poor quality of care may also lead to additional regulatory scrutiny, including CMS and other health plans not reimbursing for adverse events.

Seven Strategies for Mitigating the Impact of Poor Quality of Care

How can health plans reduce the impact that poor quality of care has on their organization? Here are seven strategies that could be deployed.

  1. Implement evidence-based guidelines. NantHealth’s Eviti Connect platform, for example, electronically connects health plans and providers to verify evidence-based cancer treatments in real-time.
  2. Deploy value-based payment models. These models may reduce the existence of poor quality of care.
  3. Establish guidelines for routine imaging and surveillance.
  4. Use data analytics to identify areas of high spending on poor quality of care.
  5. Develop member education programs that inform members about the risks and benefits of different treatments and encourage them to choose high-value care.
  6. Establish and maintain provider performance metrics and incentives based on high quality of care (E.g. Gold carding).
  7. Conduct ongoing evaluation of interventions to ensure care is effective and sustainable.

Poor quality of care is a significant concern in cancer care, with potentially serious consequences for health plans. By understanding the specific examples and the reasons for occurrences, health plan leaders can develop effective strategies for reducing its impact on their business. Implementing value-based payment models, evidence-based guidelines and protocols, member and provider education, and other strategies—health plans can promote high-value and quality care, and improve member outcomes—a winning combination in this era of higher cancer care costs.

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