How is the government driving greater accountability in healthcare? What types of clinicians are impacted?

Answer: The Affordable Care Act (ACA), which is built on a foundation of improving the quality of care for all patients, includes a number of provisions to help consumers make decisions about where to receive their care as well as how to increase the transparency of services through value-based purchasing efforts and private sector programs. Four years after the ACA was passed, these programs are still thriving. While the provisions differ in design, they share common elements like rewarding providers based on adherence to practices, achieving cost savings, improving clinical outcomes, and advancing a patient’s experience.

There are currently nearly 30 quality reporting programs under Medicare or Medicaid that capture over 600 unique performance measures.¹ Of these programs, a handful of programs have an impact on physicians and other health professionals, specifically, the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VBPM). Under PQRS, Eligible Professionals (EPs) are required to report on a set of nine measures (covering three National Quality Strategy domains) to report. In 2015, if an individual EP or group practice does not satisfactorily report or participate while submitting data on PQRS quality measures, a 2 percent negative payment adjustment will apply in 2017. These EPs are truly starting to understand the impact of failing to report given this payment adjustment. As quality reporting programs start to trend more toward value-based systems (i.e., rewarding EPs for showing actual performance on measures versus just reporting), physicians and other healthcare professionals will need to focus on outcomes versus processes and start to address patient experience, care coordination, and patients with co-morbidities.

Under the PQRS and VBPM, eligible professionals include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such professionals. The Centers for Medicare & Medicaid Services (CMS) may consider expanding the definition of an EP in the future.

As patients continue to use online tools to select where they receive their care, sites like Physician Compare, maintained by CMS, will be pivotal in consumers’ decision making. Physician Compare currently displays a subset of measures from the PQRS reporting programs. At this time, stars are used as graphical representations of the percent. Each star represents 20 percent; 100 percent is equivalent to 5 stars while 80 percent is equivalent to 4 stars and so on. Transparency of how providers are performing on these measures should have significant impact on performance.

What challenges do physicians face to meet the requirements of new quality reporting programs? What is being done to alleviate some of these challenges?

Answer: In 2015, CMS released a PQRS Experience Report² that noted a 47 percent increase in PQRS reporting between 2012 and 2013. Yet, this increase only represents 41 percent of total EPs eligible for PQRS. This lack of participation is likely due to the overwhelming reporting requirements, the administrative burden, and the lack of meaningful measures in the program.

CMS acknowledges a significant administrative burden of the proliferation of reporting programs and requirements resulting in the lack of measure consistency and wasteful redundancy. In 2015, CMS released the “National Impact Assessment of CMS Quality Measures,” which was mandated by Section 3014(b) of the ACA, and it noted that less than 50 percent of the quality measures reviewed under this report were aligned with reporting requirements of other state and federal programs.³ The report also reviewed 700 measures across 25 CMS reporting programs. This statistic alone points to the fact that there is a tremendous burden on providers to adhere to various requirements and monitor changes in programs, all while providing excellent care across various patient populations. Although CMS continues to align many of its major quality programs, the need to align the private sector and state programs is still needed.

Stakeholders in the quality debate (plans, providers, employers, and consumers) agree that current quality measures are not achieving their potential in improving quality of care. They continue to advocate for a core, consolidated set of outcomes-based quality measures that can be used across payers. However, achieving this alignment has proved extremely difficult, despite the best of intentions, because individual stakeholders have generally failed to achieve consensus around which measures should be prioritized and how they should be used.

One such example of a group of entities coming together to achieve consensus is the Core Quality Measures Collaborative Workgroup. In 2014, America’s Health Insurance Plans and its member plans’ chief medical officers convened leaders from CMS, the National Quality Forum, and national physician organizations to create a set of core quality measures. The Collaborative Workgroup represents approximately 70 percent of the combined population of health plans’ enrollees and fee-for-service Medicare beneficiaries.⁴ The goal of the collaborative is to promote a consistent process across public and private payers by reducing the total number of measures, refining existing measures, and relating measures to patient health.

“This effort represents a historic level of collaboration on quality measure alignment, which should benefit the whole health system. This work is essential to improve health and healthcare and enable a shift towards a healthcare system of improved outcomes and higher value.” – Collaborative Workgroup

Without question, there will never be a perfect set of measures in which there is universal consensus. However, today’s healthcare delivery models are moving forward at an unprecedented rate, and failure to reach consensus will not slow these models although they could discourage provider involvement. They will continue to move forward with the current patchwork of measures, which are administratively burdensome to providers, have significant information gaps, and lack consistent transparency.

What’s on the horizon for physician quality measurement in the next few years?

Answer: The recently-passed Medicare Access and CHIP Reauthorization Act (MACRA) legislation of 2015 consolidates PQRS, the Electronic Health Record (EHR) Incentive Programs, and Value-Based Modifier into a single system that reduces conflicts and streamlines the reporting process into a new program called the Merit-Based Incentive Payment System (MIPS) program. MACRA also includes requirements for the Secretary of Health and Human Services to develop, publish, and report to Congress on a quality measure development plan for provider participation in the MIPS and qualifying Alternative Payment Models (APMs). It also extends funding for quality measure endorsement, input, and selection at $30 million for fiscal years 2015 through 2017.

CMS currently has an open request for information to provide input on the MIPS and APMs for implementation. Based on input from this Request for Information (RFI), CMS plans to release a proposed rule on the MIPS and APMs in spring of 2016. More information regarding the RFI can be found here. Comments are due November 17, 2015.

“These new programs afford providers the opportunity to be rewarded for providing high-quality care at lower costs, and our goal is to help providers be successful while reducing administrative burden. Together, we can create a healthcare system that delivers better care and healthier people and spends healthcare dollars more wisely.” – Patrick Conway, CMS

In addition to all the exciting developments occurring under MACRA, opportunities for increased measure selection under the MIPS are forthcoming. As noted previously, quality measures under the MIPS will consist of those currently used in the existing quality performance programs (PQRS, value-based modifier, and EHR) with additional measures solicited by the Secretary of Health and Human Services from professional organizations and others in the healthcare community. Measures used by qualified clinical data registries (QCDR) are also being considered for use. Professional societies are currently working closely with CMS to align QCDR requirements with existing registries (those that have not been registered as a QCDR). To the extent possible, quality measures selected for inclusion under the MIPS (from QCDRs) final list will address all five of the following quality domains: clinical care, safety, care coordination, patient and caregiver experience, and population health and prevention. QCDRs pose an opportunity to meet existing measure gaps, especially for specialties where known measures are limited.

What tools are available to continue to track existing measures and changes to physician-based quality reporting programs?

Answer: There are a number of tools that are available in the public domain, as well as tools that can be purchased to better monitor the quality measure environment. A few are listed below for your reference, however, note this is not an exhaustive list.

National Quality Forum’s (NQF) Quality Positioning System (QPS)

QPS is a web-based tool developed by the National Quality Forum (NQF) to help people select and use NQF-endorsed measures. It allows a user to search for NQF-endorsed measures in a number of ways, export search results, and create and view types of measures.

CMS Measures Inventory

CMS Measures Inventory is a compilation of measures used by CMS in various quality, reporting, and payment programs. The CMS Measure Inventory also includes Pipeline/Measures under Development (MUD), which are measures that are in progress but are not fully developed.

CMS Fact Sheets

Fact Sheets provide information regarding program changes, release of federal rules, and implementation of new models of care. Fact sheets often reference specific changes to measure inclusion and/or payment changes for physicians.

Avalere’s Quality Measures Navigator™ (QMN) -A first-in-class resource, QMN organizes the quality measures chaos in seconds, by disease, condition, and program in one comprehensive, web-based tool. Rapidly search, synthesize and summarize over 6,000 versions of quality measures used in 40+ quality programs. There is a fee associated with the use of this tool.

As new value-based programs continue to be implemented, tools and resources for physicians to better understand the quality measure environment will be essential to help consumers assess what, how, and why quality is being measured. These tools will also help streamline existing measures and ensure that they are meaningful and capture what matters most to the patient.

To learn more about existing quality measures that impact providers, please contact Nelly Ganesan at Nelly Ganesan@avalere.com.