The Impact of COVID-19 on Quality Measures

COVID-19 impacted healthcare quality measurement and reporting at a level never seen before, as healthcare organizations responded to the health crises by addressing access to care, care allocation, and even health equity issues brought on by the pandemic.

As clinicians focused their efforts on combating the virus, the Centers for Medicare & Medicaid Services (CMS) loosened reporting requirements by making substantial changes to collecting and submitting data for quality programs during the heart of the pandemic. Since then, lessons learned from this emergency have led to permanent policy change, which may impact quality measures in the years ahead.

For payers, the pandemic brought on much uncertainty related to plan management and balancing the hills and valleys of care provided during the worst of the health crisis. For example, at the start of the pandemic, services were halted to slow the spread of the disease, then several months in, as patient volume spiked, health systems remained all hands-on deck to respond to overflowing patient needs. These stagnations impacted health plans as much as they did health systems.

Payers initially saw cost reductions and savings. They then experienced a subsequent increase in operating expenses because of the growing volume of COVID-19 patients and, later, the resumption of deferred health services. Compounding matters, on the member side of the business, many people lost coverage because of furloughs or job loss, which took an economic toll on payers and their health system partners.

While all these disruptions occurred, CMS exercised enforcement of benefit enhancements by Medicare Advantage organizations and other responsive policies.

Evolution Emerges in Care Provision

Responding to the marketplace and societal necessity, some private payers took independent action to address inequities, access, and care quality issues. For example, some developed a coordination function to match high-need patients with relevant community organizations. A few plans augmented financially strapped public assistance programs, such as enrollment help for Supplemental Nutrition Assistance Program (SNAP) benefits, and offered support for community organizations working on rapid rehousing solutions for the homeless population.

Others addressed challenges such as food insecurity by coordinating the home delivery of medically tailored meals and groceries during the pandemic, focusing on reaching high-risk and COVID-19-positive patients. Additionally, health plans tried to address mental health challenges for individuals during the pandemic by funding support programs (Crisis Text Line, domestic violence prevention programs) and coordinating virtual services for social connection in specific populations, such as older adults experiencing loneliness.

Telehealth also received its share of attention and use as a way to provide care remotely while quarantines were in effect and elective procedures were shuttered. However, despite substantial increases in telehealth use during this pandemic, quality performance measures that could determine the effectiveness of telehealth as a care provision tool remained lacking. For example, because of the relative newness of telehealth (as a mainstream care option), it is not yet clear what constitutes optimal "quality" for care delivered this way, though efforts are underway to remediate this.

However, having a quick way to identify and disseminate a standardized way of providing care and collecting data from these interactions potentially helped providers and health systems understand and improve performance.

Because of evolutions in care delivery (mainstream telehealth usage), a reduced measurement burden was needed. According to the American Medical Association, developing data collection systems from hospitals, other health care centers, and clinicians without extra effort ­­­­- along with data abstraction that does not require a manual chart - remains vital to establishing a baseline for future quality efforts.

"This would include building new data capture systems designed with quality measurement in mind and abstraction systems that can maximize the use of information technology. The government and other quality reporting organizations can play a key role in pushing the market in this direction by insisting that all new measures be electronic and even setting a timeline for phasing out manually abstracted measures," the AMA noted in its journal.

The National Committee for Quality Assurance (NCQA) states, "You cannot drive quality improvement if your measures don't consider what has quickly become the fastest-growing modality for providing healthcare services. We understand the important role telehealth has played in making care available amid an unprecedented national lockdown and that it will continue to be an important part of the health care system going forward."

And while fee-for-service remains the dominant form of healthcare payment in the U.S., evidence of cost savings before COVID-19 and growing interest in models such as capitation during the pandemic means health insurers may help accelerate the transition to value and quality across the system.

Understanding the Impact of COVID-19 on Quality Measures: QM Innovations

While telehealth proved an essential tool for patients who need safe access to healthcare, Manatt Health developed a federal and comprehensive 50-state tracker for legal changes, policies, and regulations related to telehealth during the COVID-19 pandemic.

Other individual innovation efforts included some organizations sending patients Cologuard through the mail when patients could not receive in-person colon cancer screening. Likewise, a rise in mail-order prescriptions spiked as patients opted to avoid visits to the pharmacy. Other healthcare organizations worked with NowPow, using its digital online directory for social services and social determinants that impact health. In neighborhoods with food deserts, NowPow assisted in locating community-based groups to add to the directory.

Some states have taken action to improve access to care and provide higher quality care:

• New Hampshire now requires healthcare providers using telehealth services to be registered, certified, or licensed with the state before providing services.
• Louisiana added addiction counselors, certified, licensed, or registered prevention specialists, and compulsive gambling counselors to its definition of "healthcare provider."
• Illinois now allows licensed non-residents to provide social services through telehealth to other non-residents of the state for up to five days a month and 15 days per year.

Payment parity issues are also being addressed for telehealth, which may impact the quality of care in the years ahead. Payment parity means healthcare providers' care is reimbursed for telehealth at the same rate as in-person visits, a hurdle that has long saddled the evolution of it as a care channel.

While some states implemented temporary payment parity earlier in the pandemic, many have now made it permanent. As of June 2022, 21 states require payment parity. Another five states have payment parity with caveats, but 24 states still have no payment parity requirements.

Digital Healthcare to Continue Quality Improvement

Virtual care will continue to increase over time, and while it is still novel to many, that will change. Quality of care tracking will continue to be of utmost importance regarding regulatory standards, patient selection, access, and addressing other limiting factors.

The explosive expansion of virtual health services and capabilities in the American healthcare system is the primary outcome of the pandemic, including modality changes for patient encounters (audio or video-enabled telehealth services) and new technology for supporting remote patient monitoring and chronic disease management. These channels will produce data outcomes that will drive future quality measures.

Payers' data collected during COVID-19 is helping inform plan design and evaluation of supplemental benefits for Medicare Advantage. In addition, data suggests financial incentives may reduce disparities and address social determinants of health challenges, which may positively impact quality outcomes in the coming years.

Lastly, COVID-19 exposed disparities in population health in the U.S. The virus disproportionately affects communities of color and low-income populations. Payers are committing to address inequities and patients' social needs during the pandemic. Still, long-term action across the sector is needed to support meaningful progress for health equity and improve care quality across the board.

¹ "The State of Health Care Quality Measurement in the Era of COVID-19: The Importance of Doing Better"; J. Matthew Austin, PhD, et al.; June 25, 2020; https://jamanetwork.com/journals/jama/fullarticle/2767747

² "COVID-Driven Telehealth Surge Triggers Changes to Quality Measures"; June 5, 2020; https://www.ncqa.org/programs/data-and-information-technology/telehealth/covid-driven-telehealth-surge-triggers-changes-to-quality-measures/

³ "Tracking Telehealth Changes State-by-State in Response to COVID-19"; Jared Augenstein et al.; May 5, 2020; https://www.manatt.com/insights/newsletters/covid-19-update/tracking-telehealth-changes-state-by-state-in-resp

⁴ "Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling Needs"; Mark McClellan et al.; May 17, 2021; https://nam.edu/health-care-payers-covid-19-impact-assessment-lessons-learned-and-compelling-needs/

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