In the New Healthcare, Payers and Providers Look to Redefine Quality | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

In the New Healthcare, Payers and Providers Look to Redefine Quality

May 30, 2018
by Rajiv Leventhal
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Outcomes measurement regimens and new value-based incentives are changing how hospitals, physician groups, and integrated health systems operate and work to satisfy purchasers’ and payers’ quality demands

In the new and constantly shifting healthcare landscape, one in which policymakers are funneling hospitals, physician groups, and integrated health systems into a world in which they will need to take on more risk for their patient populations, the pressure is mounting on providers to deliver better outcomes.

Indeed, over the past several months, federal health administrators have made clear that the healthcare system, in both its current and projected cost state, is not sustainable, as Medicare actuaries have predicted that U.S. healthcare spending will leap from $3.5 trillion in 2017 to $5.7 trillion in 2026—a 62.8-percent growth over nine years. But at the same time, they have also stressed the need to reduce the burden that quality measures put on providers, since industry observers believe that many of these government-oriented measures have little value to clinicians or patients. As such, moving forward, federal leaders must strike a balance between being able to measure outcomes while not overburdening providers even more.

One way in which the federal Centers for Medicare & Medicaid Services (CMS) will aim to do this is through its new “Meaningful Measures” initiative. Announced last October, the new approach to quality measurement “will involve only assessing those core issues that are most vital to providing high-quality care and improving patient outcomes. The agency aims to focus on outcome-based measures going forward, as opposed to trying to micromanage processes,” CMS stated last fall. “We need to move from fee-for-service to a system that pays for value and quality—but how we define value and quality today is a problem,” CMS Administrator Seema Verma stated at the time. “We all know it: Clinicians and hospitals have to report an array of measures to different payers. There are many steps involved in submitting them, taking time away from patients. Moreover, it’s not clear whether all of these measures are actually improving patient care.”

As Verma alluded to, the lack of quality measure alignment across different value-based purchasing programs can be quite frustrating for providers, as a payer in one reporting program might have a different quality requirement than a payer in another. And even in the same program, such as the Quality Payment Program (QPP), under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, a lack of measure alignment creates complexities.

For instance, Kate Goodrich, M.D., CMS' director of the Center for Clinical Standards and Quality and the agency's chief medical officer, said at a meeting earlier this year in Washington, D.C, as reported by the Healthcare Financial Management Association (HFMA), that the lack of that quality measurement alignment has hindered quality reporting during the first years of the MACRA law. “The measures are basically the same, but what people have to do—the rules of the road, if you will—on the scoring are very different between the two,” Goodrich said, referring to hospitals and their employed physicians. “And that creates problems for health systems that use a single [electronic health record (EHR)] to report on behalf of clinicians and to report on behalf of hospitals,” she said, as reported by HFMA.

The notion of harmonization and alignment across quality measures is hardly a new concept, asserts Jeff Smith, vice president of public policy for the Bethesda, Md.-based AMIA (the American Medical Informatics Association). “This is [something] that has been out there for a decade or even more. So, the real question is, how do you get alignment on those measures?” he asks.

Smith believes that quality measures are a microcosm for a much larger issue inside medicine—defining what value is among different physicians. “Let’s say you are asking two different cardiologists what they value. The 80/20 rule is solid in this space; 80 percent of cardiologists would agree on a certain small set of measures that they see as important for most of their patients. But then going from cardiology to another specialty, or certainly in family medicine, measures matter to different people for different reasons. And we have been on this 10-year journey, especially when you think about the electronic environment that is everywhere now, so it’s a large task to figure out if there are measures that can be meaningful across specialties and settings,” Smith says.

Payers and Providers Working Together

Most industry stakeholders believe that payers and providers need to be on the same page when it comes to agreeing on a common set of measures, but to date, this has been tough to achieve. One reason why is that a lack of shared financial risk between payers and providers could lead to more misalignment. For instance, if a payer is assuming all the financial risk in a given value-based contract, its goals will be different than the provider that is in that agreement.


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