Contributor: Beyond a One-Size-Fits-All for Managed Care Plan Benchmarks

Every year, managed care plans (MCPs) in California take a test, so to speak.

This test involves being compared and evaluated with other health plans across the nation using several quality domains, including patient experience, prevention, equity, and treatment. But the current evaluation system is based on inequitable benchmarks and policies that could put the most vulnerable among us at risk.

Think of plans as students in a class who are all taking the same test. The underperforming students would have their pencils, iPads, and computers taken away, yet are asked to outperform the other students the following year.

When it comes to health care quality, the stakes are high, and the stakes are real.

In their purest form, comparisons can be useful. They can motivate improved performance. They can guide our decision-making. They can even help us identify risks or downsides. However, when we’re comparing performance among groups with common goals but distinct challenges, we should question whether a one-size-fits-all model is the best approach.

California MCPs are being evaluated against national benchmark standards and policies that do not consider all the unique challenges and needs of the diverse populations and demographics within their regions. These regions require tailored solutions that national benchmark standards do not adequately recognize.

Poor performance against these national standards and benchmarks are used to deliver penalties, such as fines and sanctions. Better performance against these national standards and benchmarks can lead to incentives, such as more member assignment.

Benchmarking should be done with as close to apples-to-apples comparisons as possible to ensure fairness in the evaluation process. | Image Credit: © vivekFx - stock.adobe.com

The Trouble With Apples-to-Oranges Benchmarks

Essential in any benchmarking effort is ensuring that organizations collect valid, reliable, and useful data. Benchmarking should be done with as close to apples-to-apples comparisons as possible to ensure fairness in the evaluation process. Comparing plans with similar characteristics, such as size, geographic location, or demographics served, allows for more meaningful insights and improvement opportunities.

California MCPs should not be benchmarked against national quality standards and policies because the state’s health care landscape is unique in its demographic diversity, socioeconomic factors, and regulatory environments. Although these standards and policies are well intentioned, they do not take into account a few notable examples:

1. Variations across state policies

Although holding health plans accountable to national benchmarks helps provide visibility of performance, it cannot assess health plans fairly. One reason for this is the wide variations in state policies. For example, some states like California do not require certain vaccinations, such as the human papillomavirus vaccine, prior to entry into the seventh grade. However, other states like Rhode Island do. This difference in statewide policy could both directly and indirectly impact the willingness of a member to receive this vaccine, thus impacting performance on the national Adolescent Immunization measure.

2. Structural network differences

As the health care industry continues to find ways to provide better care to members, one structural component to this is the electronic health record (EHR). Some provider networks have the luxury of being on a single EHR system, whereas others like ours have over 100 different EHRs. And while the industry pushes toward leveraging entities like a data aggregator to address this, there are clear advantages, both from a clinical and quality performance perspective, that those on a single EHR system have. Yes, it would be ideal to transition all providers in our network to a single system, but this is just not realistic.

Other factors unique to California include redetermination policies, the annual process Medicaid beneficiaries must go through to renew their eligibility. This process impacted over 15 million residents during June 2023 through May 2024, and the large transient population across the state. Variation on timing of the redetermination process across states can have big impacts on quality measure populations.
 

A Path Forward

One way to address these issues is through maintaining a focus on improvement standards. For example, by focusing on year-over-year improvement, California MCPs can address the unique health care challenges in their specific regions with more innovative, collaborative, and transformative improvement activities. This fosters genuine improvements, targeted strategies for progress, and best practices that are directly applicable and actionable. In fact, the reason local health plans were created in California was to address the unique variation of needs across our vast state.

Driving meaningful outcomes

Without apples-to-apples comparisons, discrepancies caused by differing contexts and conditions can result in misleading conclusions, causing plans to compete with each other and potentially skew decisions that could negatively impact member outcomes.

As we strive for equity in health care, it’s imperative that our standards for comparison and governing policies for success reflect the diverse realities of all communities. Otherwise, we risk perpetuating a cycle that undermines the very essence of quality care.

One of the ways we have partnered with our state regulators is through an open dialogue and discussion of looking at national quality standards and policies. Some additional considerations could be to:

• Further strengthen mechanisms to support locally nuanced challenges.
• Enhance patient access and work to expand provider networks within managed care plans, particularly in underserved areas.
• Provide more opportunities for a meaningful comparison among relevant factors to enhance patient outcomes.
• Develop policies in better collaboration with the MCPs to benefit the member.
• Avoid relying on national or state comparisons to dictate penalties and develop them from a contextual and improvement perspective.

As MCPs prepare to “take our exams” this year, we’re reminded that no matter the outcome, our goal will always be to do what’s best for our members. And perhaps, someday, we will strike that balance to appropriately redefine how we measure and drive meaningful quality outcomes.