Synchronizing Anthem QHIP and CMS Quality Programs for Unified Improvement


Get Personalized Hospital Specific Presentation on Unified AI Quality, Safety, Risk & Incident Software


This article is part of the Dexur Insight, which is focused on Hospital Quality and Safety topics and is read by CEOs, CMOs, CNOs, CQOs, Quality, Safety, Compliance, Analytics & Performance teams. Please email dexurqualitysights@dexur5.com to join this newsletter and receive updates (not more than once per week).

Anthem Quality-In-Sights Hospital Incentive Program (QHIP) and CMS's Star Rating and Hospital Readmission Reduction Program (HRRP) have designed several measurement programs with commendable intentions, the measures frequently result in hospitals addressing them in isolation, potentially due to varied reporting requirements and benchmarks. Herein lies the opportunity for creating a system that unites these common measures to optimize efforts, resources, and ultimately, patient care. Some common measures and thier groupings among Anthem QHIP, CMS Star Ratings and HRRP include:

Implementing technological solutions that incorporate artificial intelligence (AI) and data analytics can help merge the approaches towards these shared measures. By systematically analyzing data across these common metrics, healthcare providers can identify patterns, predict outcomes, and derive insights that drive unified and impactful improvement strategies across all related measures, ensuring that efforts are not duplicated and resources are utilized effectively.

Keeping a synchronized focus on multiple program metrics is paramount. For example, a hospital grappling with Heart Failure (HF) readmission rates and Catheter-Associated Urinary Tract Infections (CAUTI) Standardized Infection Ratio (SIR) serves as a prime example, where cohesive improvement strategies are essential. Anthem's QHIP targets necessitate a CAUTI SIR of less than .66. Concurrently, an under-50th percentile performance in HF readmissions is equally critical, given Anthem's benchmarks and the broader implications it holds for CMS HRRP penalties. The distinct targets across these two examples underline the imperative for an interconnected approach in managing quality improvement efforts, considering both Anthem QHIP and CMS programs.

Dexur’s AI Advisor can seamlessly blend these two seemingly distinct challenges into a unified quality improvement strategy by providing an Early Warning for metrics like HF readmissions, ensuring that healthcare providers are immediately alerted when performance falls below the requisite percentile. Meanwhile, in managing CAUTI SIR, Dexur’s intelligent simulations can help hospitals to navigate through various improvement strategies, visualizing their impact on Anthem’s benchmark and also understanding how enhancements in CAUTI SIR reflect positively within CMS's safety group score.

By coalescing Anthem's targets with the broader ramifications within CMS Star Ratings and HRRP, Dexur facilitates a comprehensive view that is crucial for prioritizing interventions, allocating resources, and streamlining improvement efforts in a way that is mutually beneficial for compliance with both Anthem and CMS. Hence, not only does the healthcare provider elevate the quality of patient care, but it also simultaneously enhances its financial and reputational standing across multiple platforms.