The U.S. Department of Health and Human Services (HHS) Office of the Inspector General issued a report of its review of the Centers for Medicare & Medicaid Services’ (CMS) management of the Quality Payment Program and cited specific concerns regarding the need for more specialized technical assistance for clinicians and program integrity efforts.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted clinician payment reforms designed to promote quality and value of care. These reforms, known as the Quality Payment Program (QPP), are a significant shift in how Medicare calculates compensation for clinicians and require CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care. The first performance year began on January 1, 2017.
The recent report is a follow-up an early implementation review that OIG conducted of CMS's management of the QPP in 2016.”
In that review, OIG concluded that while CMS had made significant progress in developing the QPP, OIG identified two vulnerabilities that were critical for CMS to address in 2017: “(1) providing sufficient guidance and technical assistance to ensure that clinicians were ready to participate in the QPP, and (2) developing information technology (IT) systems to support data reporting, scoring, and payment adjustment.” “OIG conducted this follow-up review to assess CMS's progress in mitigating these potential vulnerabilities and to identify emerging risks,” OIG stated.
For this recent review, OIG interviewed CMS staff and reviewed internal CMS documents as well as publicly available information and conducted qualitative analysis to identify key milestones, priorities and challenges related to QPP implementation.
During 2017, CMS made significant efforts to address the two vulnerabilities that OIG identified in its 2016 management review-developing IT systems and preparing clinicians to participate in the QPP, according to the OIG report. With regard to IT, CMS appears on track to deploy the systems needed for data submission by January 1, 2018.
With regard to clinician readiness, OIG also concluded that CMS has conducted outreach, awarded technical assistance contracts, communicated eligibility information, issued sub regulatory guidance, and established a Service Center to respond to question. “However, clinician feedback collected by CMS demonstrates widespread awareness of the QPP, but also uncertainty about eligibility, data submission, and other key elements of the program. With regard to emerging challenges, we found that CMS has not yet developed a comprehensive program integrity plan for the QPP,” OIG stated.
Overall, OIG identified two vulnerabilities that are critical for CMS to address in 2018 because of their potential impact on the program's success. Clinicians require more technical assistance, and if they don’t receive sufficient technical assistance, they may struggle to succeed under the QPP or choose not to participate, the agency report stated.
OIG found that CMS carried out an extensive outreach, yet the majority of efforts have been directed toward general awareness rather than specialized technical assistance designed to meet practice-specific needs. CMS staff indicated that as implementation continues, clinicians—particularly those in small or rural practices—will have a greater need for customized assistance to support successful QPP participation.
Secondly, if CMS does not develop and implement a comprehensive program integrity plan for the QPP, the program will be at greater risk of fraud and improper payments.
"If clinicians do not fully understand how to participate in the QPP, or if they lack the tools and support to make the practice changes necessary to respond to QPP incentives, the program may have limited success.Additionally, without adequate program integrity measures in place, the performance data submitted may not reflect the true cost or quality of care provided, similarly compromising the QPP’s ability to achieve its goals," the OIG report stated.
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