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In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives

Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024 
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Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.

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Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.

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.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.

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