Drew Borland, Manager at Wellcentive outlines the overarching trends among clinical quality programs and where you can expect them in the coming years.
A quality program (or Clinical Quality Improvement program) is a collection of healthcare quality measures/metrics grouped together and applied for a meaningful purpose, to evaluate and/or incentivize an entity to improve clinical and/or financial outcomes. These entities are typically providers, provider groups (IPAs, PHOs, ACOs), and payers. The main purpose of a healthcare quality program is to assess performance as it relates to controlling costs, and to create an environment that incentivizes participants to adhere to the quality standards.
Over the past few years, healthcare professionals have gone from marginally understanding these quality programs, to now barely being able to keep up with them. Incentive-based payer-driven quality programs are quickly becoming the modern day ‘tax code’ for the healthcare industry. Keeping that in mind, I will focus on identifying the overarching trends among the quality programs and shed some light on where you can expect them to be in the coming years.
The Clinical Quality Program Landscape
From a landscape perspective let’s take a look at the main quality programs that exist today (many of these were covered in previous blog entries, so descriptions will be abbreviated):
Meaningful Use (MU) — Incentive based program for healthcare professionals created by CMS. There are currently two outstanding specifications; Stage 1 and Stage 2.
Medicare Shared Savings Program (MSSP) — Performance based program for provider groups created by CMS.
Healthcare Effectiveness Data and Information Set (HEDIS) – Benchmark based evaluation tool for comparing health plans created by NCQA.
Pay for Performance (P4P or PFP) — Payer-specific preventive care and chronic disease management programs with metrics often based on national standards, such as HEDIS.
A typical healthcare provider will most likely be involved with several concurrent quality programs, each with its own deadlines and year-to-year program specifications. While vendors, including Wellcentive, help insulate quality program participants from some of the intricate details, it is very important to understand that the programs are rapidly evolving. As a result, how providers are being measured as well as reimbursed is fundamentally changing. In the following sections, we’ll look at some of the main trends that we have noticed on the vendor side over the past few years.
Pay For Performance is replacing Pay-For-Reporting
In order to receive an incentive payment, several quality programs initially only required that the providers report their data. The actual numbers that they reported (their underlying quality scores/metrics) had no effect on their corresponding incentive payment. At the time, this was beneficial because this approach helped garner participation in the program and minimized the effect on a provider’s clinical workflow. Today, with quality reporting becoming more mainstream and refined, this model has largely been phased out. More modern quality programs like the MSSP are changing their models to pay based on performance (the quality scores). While some programs still only require reporting, soon all quality programs will force providers and eligible professionals to improve their quality, or leave a significant amount of money on the table.
When Claims-Based PQRS (then known as PQRI) started in 2007, there were only 74 measures from which to choose. For the most recent 2012 program year, there are 210 measures from which to choose. This trend has increased the pool of eligible professionals that can participate in the program, expanding to even more specialists. It is extremely important that providers continue to track their eligibility for these quality programs, because programs they could not participate in yesterday may be available to them today.
More Types of Measures
One of the main reasons that the number of quality measures is growing is that the types of data that is accessible for measurement is expanding. Some of the early quality programs focused primarily on paper and electronic claims data. Today, almost any structured data that can be found in an EMR, EHR, PMS, Registry, or HIE is fair game for use in a quality measure. This expansion of available data has led to the creation of sub-groups (or types) of quality measures, including:
- Preventative Health Measures
- Patient Satisfaction Measures
- Care Coordination Measures
- Patient Safety Measures
- Chronic Disease Management Measures
- Meaningful Use ‘Best Practice’ Measures
- Cost and Utilization Measures
More Complicated Measures
Early quality measures (circa 2008) targeted ‘low hanging fruit’ and focused on specific quality actions on very simple and straightforward populations. For example, NQF 0056: Foot Exams in Diabetes Patients, concretely measures what percentage of an adult diabetes population has had a foot exam in the last 12 months. The numerators, denominators, and exclusions for these early measures were reasonably comprehensible. Over time, as the number of quality measures increased, so did the complexity. This led to more detailed measure specifications, which in turn added more challenges to healthcare organizations and vendors to support these measures. Below is a snippet for a newer measure, NQF 0659: Endoscopy/Poly Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps- Avoidance of Inappropriate Use (circa late 2011), which demonstrates the increase in complexity:
From the measure above, it is quite evident that the age of understanding and measuring simple clinical quality metrics has passed. More and more healthcare organizations are understanding that the expansion of data that is in the purview of clinical quality measures combined with the increased complexity is quickly exceeding their technical capabilities. From the Wellcentive perspective, every single customer is leveraging our abilities to aggregate and normalize the data that is spread over their entire organization to solve their data management needs. This is the essential first step in satisfying any quality or incentive program requirements.
Patient-Level Data Reporting is replacing Aggregate-Level Data Reporting
The emergence of advanced EHRs and EMRs empowered providers to calculate the aggregate totals of specific patient populations required by the early quality programs. As HIT has continued to improve, quality programs have begun to require more detailed patient-level data in favor of the aggregate data of yesteryear. This patient-level data is granular, much more precise, and allows for more advanced auditing capabilities (traceability). As quality programs evolve towards Pay for Performance, watch for them to similarly require patient-level data as a reporting and participation requirement.
Quality Results are going Public
Another growing trend among quality programs is the publishing of provider quality metrics. While most providers are not in favor of this concept, it is creating a much-needed non-financial incentive to help increase participation and adherence to the program. Originally pioneered by HEDIS to publicly compare health plans, other provider-centric quality programs are following suit and allowing consumers to perform an online ‘Physician Compare’-style provider evaluation, a term coined by CMS.
Group Reporting Replacing Individual Reporting
As mentioned in some of the trends thus far, quality programs are not only changing, but also changing quickly. As a result, they are getting increasingly complex. While PHOs and POs have been around for quite a while, there has been a huge uptick in the formation of Accountable Care Organizations (ACOs) to work on behalf of a group of providers. One of the main drivers here is that single providers and small clinics are realizing that they simply cannot sustain the burdensome requirements of all of these programs. This natural progression from individual to groups has its advantages and disadvantages, but we’ll leave that subject for another blog post.
Payment Model Experimentation
As we’ve seen from a myriad of P4P programs that are largely backed by payers, the models for reimbursement vary greatly. Each program is potentially different. While we know that most of them are focusing now on paying for ‘good’ performance, the payment mechanism and/or model is a mixed bag at best, with no clear progress towards any kind of standardization or trend. This trend (or lack thereof), however, is not only specific to private payers. CMS has created the Innovations Center, which is dedicated to researching and experimenting with various payment, and incentive models to ultimately identify the models that provide the highest clinical quality at the lowest cost.
Clinical Quality Program Evolution Trends
At a high level, improving clinical outcomes is a core tenet of Responsible Population Health Management (PHM). The financial implications of quality programs shape our industry more than any other external force. Therefore, tracking the evolutionary trends of such programs helps us design the tools and products of tomorrow to best meet our customers’ needs.
From a provider standpoint, understanding these trends is not simply academic. These programs have an influential impact on future clinical workflow. Knowing the predicted path clinical quality programs will take is also critical when choosing an effective PHM platform. Using a PHM system that is tuned for clinical quality improvement, manages your quality/incentive programs, and most importantly, does not impede core productivity are all important requirements. Understanding these trends in the evolution of clinical quality programs will help you to ask the right questions of your organization and empower you to plan accordingly to maximize any potential or unrealized future gains from these programs.
Drew Borland is the Manager of Architecture and Research at Wellcentive where this article was first posted.