Quality Performance Needs a Boost? You Have 500 Choices

Quality is becoming the bar against which all things are measured (and paid) in healthcare, but tracking the relevant data is exceedingly complex. In my days managing a three-hospital system, our team had over 500 quality-related metrics to track for several thousands of patients every year. Tracking such numerous quality metrics requires multiple teams of clinicians, administrators and support staff even in the presence of an electronic medical record. For example, not only is a quality team necessary but also pharmacy quality teams, surgical quality teams, medical quality teams, orthopedic teams et al. For investors or administrators focused on improving quality performance, it can be both exhilarating and overwhelming to sift through all of the possibilities and identify the right levers that will produce measureable improvement in patient outcomes. This process has also become imperative in order to maximize revenue.

Reporting Quality: Drowning in a Sea of Acronyms
The Centers for Medicare & Medicaid (CMS) is a driving force behind the emphasis on quality, appropriately initiating reimbursement programs that are forcing the industry’s shift toward value over volume. By the end of 2016, CMS plans to shift 85 percent of Medicare’s fee-for-service payments to value-based payment programs. Earlier this year, Congress passed legislation on the Medicare and CHIP Reauthorization Act (MACRA), green-lighting a new Merit-based Incentive Payment System (MIPS) to pay for physician services, which heavily weights quality.

Under MACRA, there are at least 60 new proposed quality measures—merely the tip of the iceberg for quality metrics that hospitals and health systems must track. There are quality elements tied into:
  • Medicare Advantage (MA)
  • Medicare Star Ratings
  • Bundled payment for care improvement metrics (BPCI)
  • Surgical care improvement (SCIP)
  • Inpatient quality report metrics (IQR)
  • Outpatient quality report metrics (OQR)
  • HIPAA compliance
  • Metrics unique to managed care contracts
  • State-specific Medicaid regulations
  • Varying clinical quality reports required by contracted private payers such as employers
  • Gainsharing metrics
  • Stark compliance metrics
  • Skilled nursing facility metrics
  • Home health/ Visiting nurse metrics
  • Ongoing professional practice evaluation (OPPE)
  • Initial professional practice evaluation (IPPE)
And that’s just to name a few.

How can providers improve quality in a meaningful way when the pool of requisite metrics can seem as numerous as the grains of sand on the beach?

Automation Helps You Breathe
Automating data collection is a necessity in today’s environment. But that doesn’t mean you “set it and forget it;” automated processes must be constantly evaluated and nimble enough to adjust to changing regulatory requirements. Automation also has the added benefit of minimizing errors and fraud, although skilled eyes should still be vetting the information.

Equally important are professionals skilled at analyzing data who can use the intelligence to inform an action plan for change.

Floating to the Top
Quality metrics are fed to a variety of masters, and it’s debatable whose opinion holds the most weight when it comes to judging quality. However, Medicare is a big influencer that is gaining more clout. Medicare’s Five-Star Quality Rating System is increasingly dictating payments to providers, ultimately affecting which providers sink or swim.

Providers argue that star ratings are over-simplified, distilling an ocean of data on quality, outcomes and cost into a single set of stars assigned to hospitals, nursing homes and home health agencies. The simple fact is that CMS star ratings are now the currency of the realm—and they are easily understood by patients. If private insurers follow the path blazed by CMS, as they often do, then soon the stars will influence a much broader scope of payments beyond Medicare.

Ready or not, quality is revolutionizing the payment system, and in turn, forcing long-threatened changes to healthcare delivery.