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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. 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. 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
  1. Supplemental Material to the CMS MMS Blueprint Legislative Mandates for Quality Measurement and Reporting. https://www.cms.gov/files/document/blueprint-legislative-mandates.pdf
  2. 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
  3. 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
  4. 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
  5. 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
  6. CDC - Health Department Resources - STLT Gateway. www.cdc.gov. Published March 9, 2020. https://www.cdc.gov/publichealthgateway/healthdepartmentresources/index.html
  7. 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
  8. 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 
  9. 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 
  10. 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…
  11. 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
  12. 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
  13. 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
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. 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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