By comparing quality measures with what NCQA calls Relative Resource Use data—an evaluation of how extensively plans within a certain region leverage healthcare resources relative to the populations they serve—NCQA was ultimately afforded a glimpse into the value a health plan offers. In fact, it determined that more use of resources, such as inpatient bed days or procedures, is actually often associated with poorer quality, translating into a bad value for consumers and employers.
The report also had advice for health plans on what they can do to create better value for their members. Among other measures, improvements in the following areas will affect RRU scores:
1. Plan design and copays: Are copays set at levels that encourage preventive care? How does the plan design encourage employees to select cost-effective providers?
2. Appropriate levels of care: What are the recommended care standards for the most frequent chronic conditions? How is compliance monitored, and how well do providers meet expectations?
3. Overall utilization management: Are utilization trends monitored by provider and by patient details such as age, gender and chronic condition? What happens when outliers are identified?4. Local practice patterns: How does the health plan monitor providers' practice patterns and encourage providers to adopt cost-effective techniques?
5. Use of technology: What are the standards of use, and how are they monitored? How does the plan instruct providers about appropriate use?
RRU improvements also could be facilitated by encouraging high-volume providers to enhance continuity of care by creating incentives to adopt patient centered medical home (PCMH) and accountability care organization (ACO) care delivery models.
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