none

INTRO

Today’s healthcare provider reimbursement rates are tied closely to CMS (the Centers for Medicare & Medicaid) quality measures, specifically found in PRQS and they are prevalent in the reports throughout healthcare providers and payers circle, both commercial and government payers. For the early adopters, the ACOs (Accountable Care Organizations) contracts pivot around whether they have met the selected quality measures. For those with Medical patients, Under MACRA, performance measurements for new payment models begin in 2017, which makes it vital that physicians begin learning the definition of these quality measures and learn how to improve performance and avoid payment penalties under MACRA such as,

• Develop and monitor more performance measurement.
• Develop more complex governance models
• Adjust to more data sharing across the care continuum

This blog will be focusing on Item 1. We will follow up with blogs on Item 2 and 3. We will alert those who responded to our ACO Survey

Many of these ACO measures are part of the PQRS. Given the time and efforts devoted in tracking these quality measures, the “800-pound gorilla in the room” question is how effective these measures are at establishing MEANINGFUL quality measures for helping ACOs to achieve the Triple Aim of Healthcare (Care, Health, cost)?

At first glance, there is some evidence that quality measures have been successful. This is indicated by the improved quality of healthcare and the reduced number of unnecessary treatments seen in select reports. ACO Quality Measures and Guideline have demonstrated:

Declined Hospital-Acquired Conditions (HACs)

• HACs were reduced nationwide by 17% from 2010 to 2013
• This decrease in HACs saved approximately 50,000 lives
• The financial savings in health costs equates to about $12 billion
• Total patients experienced 1.3 million less HACs between 2010-2013 when compared to 2010 reports

Improved Average Performance Scores

• From 2013-2014, patient and caregiver experience scores increased in five of the seven measures
• Pioneer ACOs had improvements in 28 of 33 quality measures from 2013-2014
• Shared Savings Program ACOs improved in 27 of 33 quality measures from 2013 -2014

Increased Savings

• 37% of the MSSP (Medicare Shared Savings Program) ACOs increased their savings by 8% between 2013-2014
• 20 Pioneer and 333 Shared Savings ACOs generated $411 million in savings for 2014 (*119 of the 333 Shared Savings ACOs are in Track Year 1.

It should be also noted that for the 2016 reporting year, ACOs will be measured against 34 quality measures instead of the previous year’s 33. The new measure, Statin Therapy for the Prevention and Treatment of Cardiovascular Disease, became effective January 1, 2016. According to the Accountable Care Learning Collaborative’ s 2015 Policy Brief,

CMS will increase the size of the oversample for this measure from 616 to 750 to account for reporting on multiple denominators. The new measure will be added to the Preventive Health domain and will be pay-for-reporting for all three years. “

However, despite CMS’ efforts to align physicians with standard reporting guidelines, improve healthcare quality, and reduce total costs, there is substantial work needed from all stakeholders to align and create best practices. The current standards in place have not been successful as indicated by:

1. Disagreement On The, “WHY?” Between Stakeholders

While providers must follow the measures set forth by CMS, those are not the only guidelines that must be adhered. There is no consensus about why reporting should be done (i.e. improved patient care, Improved outcome, reimbursement, access to information for better decision making) or what factors should be reported despite agreement by stakeholders (providers, planners, employers, and patients) that there needs to be a set standard of quality measurements.

There is also fundamental disagreement across the board as to whether or not the quality measure achieves its goal (i.e. patient satisfaction). For example, quality measures generally measure primary care physicians. However, 26% of physicians are specialists. The measurements for specialists are narrowly focused on their process instead of outcomes like other quality measure programs. This lack of relevance is reinforced by the fact that Electronic Health Record systems must have an exclusion option, so specialists do not have to apply nine of the quality measures which are not applicable to them.

2. The Proliferation of Quality Measures

In 2013, one study reported that of 23 commercial health plans there were 546 “distinct” quality measures with minimal overlap with CMS guidelines. Another report touts an additional 1,676 reporting measures for 2014 among Medicare programs. This doesn’t include standards set by other regulating organizations. A separate research study released in 2015 also indicated 48 state and regional measurements, but, “only 20% of the measures used in more than one program and not a single measure common across all programs.”

Providers experiencing, “measurement fatigue” may become discouraged and perceive the plethora of reporting requirements as a hindrance to providing affordable, quality patient care. Organizations may find other ways to adapt their business model long-term to reduce reliance on Medicare reimbursements if all stakeholders do not quickly adhere to a consistent standard of quality measurements and core values.

CONCLUSION

The jury is still out on whether the ACO quality measures are really effective. There is no definitive evidence that the ACO quality measures are more effective than other healthcare measures to help to achieve the trip aims (patient experience, treatment outcome and cost).

Although ACOs continue to improve the quality of care for Medicare beneficiaries while generating cost savings, there is still room for all stakeholders to improve measurement guidelines and report measurements consistently nationwide. Stakeholders need to agree on a set standard of quality measurements and their purpose for each. Until consensus is achieved, it will be difficult to create a system that will truly change provider behaviors.

The balance between the comprehensiveness and usability of the quality measures is really the key for the continuous improvement of adoption rate.

The consolidation and standardization of these quality measures, apart from the CMS mandated ones, is most likely been driven by the bigger, more successful ACOs’ selected quality measures as their success to achieve the payer set goals is the strongest argument that the quality measures they adopted are the more, “meaningful” ones that leads to, “bottom-line” impacting transformations.

TAKE AWAY

If you would like to read more about this kind of practical assessment on the what works/what does not work around deployment of MACRA, MIPS, PQRS, APM, ACO and challenges of compliance to these programs, please take a short survey so we know which distribution list to add you on for the specific content/series we will distribute around this topic.

SOURCES