The following is a Q&A with Cary Sennett, M.D., about the avalanche of new reporting requirements mandated by the health reform bill and CMS initatives. Dr. Sennett is the chief medical officer at MedAssurant Inc., a Bowie, Md.-based performance improvement company.
There’s a lot of new reporting requirements in the pipeline. Which datasets will be the toughest to compile? Are there any quirky requirements that most organizations aren’t aware of?
In the last five to 10 years, hospitals have been expected to report clinical and performance metrics to CMS that are then rolled up into a rating system that CMS uses to rank hospitals. Similarly, health plans have faced requirements from NCQA, and many of those who serve Medicare patients have reported data to CMS to be used for a similar rating system for managed care plans. While it is currently voluntary to report performance metrics, these reporting requirements will most likely be mandatory in the next five to eight years. More than that, they are rapidly becoming “de facto” requirements, in that more and more compensation is being linked to them—not only to the reporting of them, but to the actual performance reflected by them. The issue is then not really about ‘new’ reporting requirements, but rather that current requirements will become increasingly significant.
In terms of healthcare reform, it is clear that the government is investing a substantial amount of money (around $300 million) in the development of more robust and more capable quality measures that will increasingly prioritize clinical and quality outcomes. Most likely, these measures will be more focused on issues that are important to consumers and buyers (both the public sector and private sector). Right now, many of the measures that are reported do not resonate particularly well with those groups. It is also clear that the government intends to use these measures in a wide variety of “value-based” purchasing programs—so that the financial success of hospitals, other institutions and health plans will depend even more on their ability to produce (and to improve) these new metrics.
Of course, many of the details have yet to be defined in regulation, but reporting accurate and comprehensive performance metrics will challenge those who manage health information both to collect data efficiently and to maintain the integrity of the collected data.
The health care reform bill contains a passage about Medicare Advantage Plans that could significantly increase reimbursements if certain quality measures are reported. Can you explain what that means to our audience? Are their potential goldmines hidden in here?
When the system takes effect in 2012, Medicare Advantage (MA) plans will be eligible for a 1.5 percent bonus when they achieve four or five stars for high performance in the CMS star rating system. This reimbursement will increase to 3% in 2013 and 5% in 2015. And, for MA plans in certain parts of the country, that bonus can double. This isn’t a hidden goldmine—it’s right there at the surface.
So the message to MA plans is pretty clear: measures that improve your Star Rating should be a priority. Plans will be asking themselves, “How are we doing with respect to the measures that define the Star Rating— what do we need to improve in order to reach the four Star level— and where are the most important areas to put our focus, in terms of their impact on our Star Rating?” Very few MA plans are there right now, so the vast majority have some work to do. And there’s no time to waste—the 2012 payment will be based on 2011 results.
Pressure is therefore going to intensify on the IT part of each organization with the expectation that there will be more data, better data and more integrated data that can be used to create information that is useful to management, and that can drive effective response to improve quality (and quality-based reimbursement).
Let’s switch from reporting to the actual quality standards. What deficiencies in care are most common industry wide?
A major issue right now in the quality world is the coordination of care. When care is poorly coordinated, patients are at risk, and waste is everywhere. The tip of the iceberg is redundancy when tests are done twice because two doctors aren’t able to share information. More serious issues occur when patients fail to receive follow up after a hospital stay, and who then end up back in the hospital because the baton slips when it’s handed off to the ambulatory care provider. There are just too many examples of patients whose health has suffered, because adjustments to medications made by two (or more!) physicians were poorly coordinated—and patients ended up on drugs that interacted in a way that caused a serious complication.
Consequently, there is certainly a growing interest in metrics that can begin to open a window on coordination, and there is an increasing commitment to investing in systems to improve coordination of care. While we have seen more attention to this in the private sector, these issues are called out very directly in the health reform act.
The CMS PQRI program has been around a few years. Some providers have found that the costs of creating an infrastructure to report quality measures is not worth the increases in reimbursements. What’s your take?
Ten years or so ago, there was a pilot program by a hospital system called Premier, together with CMS, to reimburse hospitals incrementally for better quality: The National Voluntary Hospital Reporting Initiative (NVHRI). At the outset, reimbursement was simply for reporting, hoping to avoid anyone feeling threatened by reporting measures of performance. Pay-for-performance was introduced in the third or fourth year, at which point reporting was no longer voluntary. This system, which is five to eight years old, is one in which the winners do better and the losers lose.
Three years ago, CMS introduced the Physician Quality Reporting Initiative (PQRI), which offered up to a 2 percent increase in Medicare reimbursement for physicians and eligible professionals who reported a limited set of metrics. In the early years of the program, most doctors did not participate. According to some, the cost of producing the metrics was more than the 2 percent reimbursement benefit.
I think that it is likely to change. First of all, the health reform act suggests that the future of PQRI will model that of the NVHRI; that is, that PQRI will move from an elective bonus payment only to a bonus payment for those who report and a penalty for those who do not. Second, more and more organizations that represent and/or work with physicians—organizations like the specialty societies of which they are members—are offering products and services that make it easier (and less costly) for physicians to report PQRI measures to CMS. MedAssurant, for example, has worked with the American Gastroenterological Association (AGA) to develop a Digestive Health Outcomes Registry available at very low cost to AGA members. Participation in the Registry enables very cost effective PQRI reporting. Other societies—and other organizations that work with physicians—are doing similar things.
Is this new heap of reporting requirements too much? Too little? Too late? How prepared is the industry to handle reporting of this magnitude?
It is certainly not too late—but neither is it the time to sit and watch. The economic consequences of quality measurement, reporting and improvement have reached a point where healthcare organizations can no longer wait. While there is a lot to manage, the new reporting requirements aren’t more than organizations can handle if they make it a priority and approach the new requirements strategically.
That begins with a focus on the core of their business and where they excel. The tracking of quality metrics—what’s new, what’s changed, what’s important—is a surprisingly complex undertaking and not something that is at the core of most healthcare organizations. Fortunately, there are a number of companies that have real experience and expertise in this domain and that can help providers, hospitals and health plans meet these new requirements and improve their quality of care.
Outsourcing this type of work to a company which focuses on the analysis and reporting of outcomes data, and which can leverage information to drive improvements in quality, will help everybody win. The patient and the organization overall will both derive value financially and in higher quality from accountability and better, more coordinated care.
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