Problem: The definition of quality is complex, constantly evolving, and varies by industry sector and by organization. This lack of consensus creates inconsistency in how organizations set and assess quality goals. Commercial health plans and public payers often have different reporting measures they hold provider organizations accountable to. This adds to the lack of consistency and overlap. And without clearly defined and mutually agreed-upon goals, progress is limited.  

How healthcare leaders can respond: Large health plans are well-positioned to convene cross-industry stakeholders to level-set on quality definitions. For example, Shatterproof, a nonprofit organization dedicated to transforming substance use disorder (SUD) care, recognized the impact the lack of standardized, evidence-based practice has on SUD outcomes. Shatterproof convened representatives of the major national health plans and clinical subject-matter experts to articulate eight principles of high-quality care (and associated metrics of success), which both providers and plans agreed on. The organization was then able to build a digital platform that publicly tracks provider performance across each metric, raising the bar for provider organizations and enabling health plans to build high-quality, performance-driven networks. This collaborative approach not only promotes consistent and accountable substance use treatment but also serves as a model for other areas of healthcare to follow. 

Problem: Payment structures as they stand today often do not provide enough incentives to prioritize and improve quality. In fee-for-service (FFS) models, providers are reimbursed based on the volume of services they deliver, rather than the quality or outcomes of care. This can create a challenging situation for provider organizations as they strive to balance the delivery of high-quality care with the need to meet their financial obligations. Furthermore, the penalties for poor quality in healthcare may not be substantial enough to incentivize providers to shift their focus away from other priorities that contribute more significantly to their margins. As a result, the attention and resources needed to drive significant improvements in patient outcomes may not always be adequately allocated to quality initiatives.

How healthcare leaders can respond: Meaningful movement toward industry-wide value-based care requires behavior change across sectors. More provider organizations must be willing to enter into uncharted territory, and that requires significant upfront investment in population health capabilities. This includes the realm of commercial risk, as the major commercial health plans have the potential to tip the scales of the industry if they act in concert. To that end, health plans need to ensure it’s as easy as possible for provider organizations to make the leap, including building trust between partner organizations, mutually defining quality in value-based contracts, minimizing the administrative burden of data collection and technology implementation, and designing payer-provider partnerships custom to the market dynamics at hand.   

Problem: Care complexity is increasing due to three key trends:

1. Patients with unmet non-clinical needs are increasingly presenting with complex conditions. Adverse social determinants limit patient access to high-quality care due to financial constraints, transportation issues, and inadequate healthcare infrastructure. Treating a complex patient population with social and economic disadvantages requires intensive care, making it challenging to meet quality goals.
2. As the population ages, the prevalence of chronic diseases increases, and the delivery of high-quality and safe care becomes more complex. The complexity of managing multiple chronic conditions, medication regimens, and coordinating care across different providers can lead to fragmented and suboptimal care.
3. The shortage of qualified behavioral health practitioners, the high cost of behavioral healthcare, and the cultural stigma surrounding behavioral health conditions all contribute to delays in accessing quality care for behavioral health patients. These delays not only increase the complexity of patients' conditions but also pose significant challenges for providers in delivering high-quality care to this population.

How healthcare leaders can respond: Across the industry, provider organizations play the most direct role in navigating this rising complexity. They can develop scalable chronic disease management programs that provide wraparound clinical and non-clinical care for polychronic patients and integrate behavioral health into primary care to expand access. It is crucial for healthcare leaders of all sectors to devote efforts to advocating for structural change within how we pay for and provide healthcare. This is especially needed in behavioral health and senior care, where current payment models contribute to worsening workforce shortages and access barriers. 

Problem: Industry-wide workforce shortages can create an environment where overworked clinicians are unable to achieve quality goals. In understaffed facilities, clinicians must see more patients, work longer hours, and take on additional responsibilities, fueling clinician burnout. Burnt-out clinicians have limited capacity to learn evolving best practices and implement new quality standards. A shortage of healthcare professionals can also lead to increased wait times, delayed treatment, and decreased communication with patients, negatively impacting patient satisfaction and worsening health outcomes.

How healthcare leaders can respond: Tapping into the potential of technology is one underutilized option for provider organizations to mitigate industry-wide workforce shortages. Technology can offload some burnout and moral distress-inducing responsibilities that take clinicians away from direct patient care. It can automate repetitive and mundane tasks to extend clinician reach and allow clinicians to deliver top-of-license care. Technology can contribute to a work environment where clinicians feel equipped to deliver high-quality care.