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providers recognize that reporting on quality and efficiency offers an
opportunity to demonstrate their value in a competitive environment and unify
their organizational leadership around common strategies.
highest level, metrics are a language that can unite both the clinical and
financial leaders within an organization,” says Mary Beth Briscoe, FHFMA, CPA,
MBA, FACHE, the CFO of UAB Hospital and UAB Medicine’s clinical
operations, Birmingham, Ala. “With clinical metrics increasingly impacting our
financial performance, clinical leaders and administration have an opportunity
to align their goals through education and collaboration.”
Yet at the
same time, providers are suffering from data-reporting overload. “Financial and
clinical leaders are overwhelmed by the number of metrics,” Briscoe says.
Clinicians are especially frustrated, says Emily Boohaker, MD, UAB’s
associate chief medical officer for quality and patient safety. “Providers across the country have
so many metrics but not enough resources to realistically meet many of these
metrics in our daily practice, whether it is in the inpatient setting or
outpatient setting,” Boohaker says.
metrics overload causes confusion at the front line. Medical groups may track
dozens of metrics at once, and subtle variations can bump that number into the
hundreds. “The same metric might be in two different contracts, but even then
they might have slightly different definitions and different targets, so you
are still running slightly separate strategies even on the same metric,” says
Andrew Snyder, MD, FAAP, executive vice president and chief clinical
integration officer, Mount Sinai Health System, and president, Mount Sinai
Health Partners (MSHP), New York City. Each variation of a metric definition requires
separate coding and reporting, Snyder says, increasing the resources and time
needed for providers to receive credit for their efforts.
the system’s clinically integrated network, participates in everything from
upside-only to full-risk arrangements and tracks 94 ambulatory metrics on its performance
scorecard. No single metric
is common in more than two-thirds of its 15 to 20 contracts. Some payers ask
for a few metrics, while others require more than 25 to be reported. This
multiplicity has a huge effect, Snyder says.
Sinai’s experience is not unique. In a 2013 study,
Bailit Health Purchasing, LLC reviewed 48 state and regional measure sets and found
that only 20 percent of 509 measures appeared in more than one set.1
Of the common measures, approximately a quarter were slightly modified in some
way from one set to another.
report also found that states and regions tend to use non-standardized
measures. In addition to frustrating providers, this lack of alignment inhibits
direct comparisons across patients, institutions, and geographies in the era of
Micklos, executive director of the Health Care Transformation Task Force, Washington,
D.C., says the group’s provider members have been drawn to the idea of a more
cohesive set that might be based on government measures, in part because the
Centers for Medicare & Medicaid Services (CMS) has already established
value-based metrics through the Medicare Shared Savings Program (MSSP) and the
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
the other hand, there is less homogeneity on the payer side. “Sometimes payers
just think differently both on value and quality measurement,” Micklos says.
“Or they may capture the metrics slightly differently, which calls into
question whether you can compare them from one plan to another.”
to whether commercial contracts could simply follow the lead of CMS’s value-based
initiatives, Micklos does not think that is realistic. “Providers should not
expect a cookie-cutter approach between commercial plans and the
Medicare/Medicaid programs because metrics are driven by the specific needs and
demographics of a particular community,” he says.
commercial health plans developed sets of measures that were important to their
member populations, which led to the lack of uniformity. “Neither the
government nor the commercial side exist in a historical vacuum,” says H. Scott
Sarran, MD, chief medical officer for government programs, Health Care Service
Corporation (HCSC), Chicago. “Our commercial side has been using quality
measures in contracts for the past 30 to 40 years, while the use in our
government programs has been more recent.”
parallel histories mean that metrics are not always in sync. What’s more,
Medicaid programs increasingly are adding regulations that differ by state. This
variability is an issue for health systems and health plans that span multiple
states. For example, the Medicaid program in New Mexico has 14 quality measures;
only some are shared by the Medicaid program in, say, Illinois, and only some
are common to Medicare.
“We try to
align as best as we can with the ongoing work that has been done on our
commercial side, but it is very clear on the government side that we have to
focus on the quality metrics that are important to our government partners—for
example, the Star measures for our Medicare populations,” says Esther Morales,
division vice president, government programs and quality, HCSC. Medicare Star
Rating measures, which include metrics focused on prevention and chronic
disease management, often align with commercial agreements. But measures in
government plans that are not common in commercial plans should not be ignored—they
help managed care organizations (MCOs) identify noncompliant beneficiaries so
providers can deliver needed care, Morales says.
The Nuances Within Quality Metrics
of a unified set of value-based metrics does not necessarily mean providers
lack a roadmap for enhancing the value of their care. For example, diabetes and
hypertension measures are common across both governmental and commercial
programs and are important for accreditation by the National Committee for
Quality Assurance (NCQA). Population heath management strategies targeting patients
with these chronic diseases will help providers do well on their
pay-for-performance contracts with MCOs, Morales says.
also can focus on preventive health by making sure they are performing well on
pregnancy measures and various screening measures—such as cervical cancer
screenings and mammograms—that are important for performance in Medicaid and in
Affordable Care Act marketplace plans.
who is putting money on the line in a pay-for-performance approach is incenting
preventive care and chronic care,” Sarran says. To succeed, providers should
follow recommendations from the U.S. Preventive Services Task Force and capture
the NCQA’s HEDIS measures, which are used to measure health plan and provider
years, Briscoe says, payers and providers have been moving away from measuring
quality with process measures to using outcomes measures such as
hospital-acquired conditions. She believes value-based care metrics will
continue to evolve in terms of quantity and depth of measurement, perhaps
changing dramatically over the next five years. “As measurement efforts in our
industry mature, metrics, definitions, and interpretations will continue to
evolve,” she says.
with room for improvement in the coming years is MACRA. UAB
reports metrics in the Physician Quality Reporting System—now a component of
the Merit-based Incentive Payment System in MACRA—under a single tax
identification number, so metrics apply to everyone in the organization’s provider
group, regardless of specialty. Boohaker says one issue with MACRA is that
definitions of metrics can vary depending on whether providers report as a
group or as individuals. In addition, MACRA measures may differ from MSSP,
Star, and commercial metrics.
performance under multiple contracts that are not well-aligned remains a
challenge that UAB shares with other provider organizations. Every year, UAB leaders look at
inpatient and ambulatory care metrics and prioritize where they have the
greatest opportunities to prevent harm and improve care, Boohaker says. Often,
they start by focusing on the metrics that are shared by most of their payers,
such as central line-associated blood stream infections and body mass index.
At Mount Sinai, a quality work group that includes
contracting experts, data analysts, finance leaders, care managers, and medical
directors prioritizes which 20 to 25 metrics will have the greatest impact on the
organization’s patient population and which it is best able to address.
Currently, Snyder and his colleagues are focusing on diabetes measures, which span
all their contracts. To support their efforts, they have more than doubled their
number of diabetes consults using telemedicine and enhanced their care
coordination across the system, among other tactics. “For any measure to
improve, you probably need four or five different strategies running in
parallel to influence large populations of patients,” he says.
influence the alignment of metrics, some providers are being more proactive in identifying
their own set of metrics based on the Triple Aim and in negotiating with health
plans to use those metrics, says Jim
Dietsche, CPA, executive vice president and CFO, Bellin Health, Green Bay, Wis.
Bellin Health currently tracks more than 600 measures, although leaders focus
on only about 30 at a time.
payers often ask providers to pull from measures created by the Wisconsin
Collaborative for Healthcare Quality, which publicly reports more than 40
ambulatory performance measures. Those involved in vetting the measures at
Bellin Health include primary care physicians, medical informaticists, quality
leaders, and managed care/contracting professionals. They make their selections
based on which metrics will have the greatest impact on their population as
well as the potential financial opportunities, Dietsche says.
is intrigued by the idea of a universal set of metrics for both professional
and technical services to help reduce the administrative burden on providers
and make a meaningful impact on patient populations. “What ends up happening is
that we build our own common set, and we have to vary the reporting and tracking
of information for different payers,” he says. If a universal set of metrics were
adopted, it should be based on evidence and developed with provider input. “The
measures would need to be current with the times and technology, and our
clinicians need to buy into them,” he says.
next few years, Micklos predicts, many providers will try to enhance their
market position to strengthen their negotiating position on performance metrics.
Larger providers that are well-positioned in their markets will have more
leverage to influence the metrics in their commercial contracts. For example,
national or large regional health systems may be able to create more
consistency in the markets they serve, not only in approaches to payment but
also in quality measurement overall.
The problem with having organizations pick their
own metrics is that providers may not always be in sync and may not choose the measures
that make the most difference to a large population of patients, Snyder says.
“We might focus on 20 metrics that reflect our patients the best, while another
provider organization near us might pick another 20,” he says. “We’re all
living in the same communities, but the different foci prevent us from truly
achieving population health.
“It would be much better if we all dealt with
aligned metrics, understanding that if you pick 20 metrics, you’re not going to
be touching every specialty, but at least it’s a start. And as three or four
metrics improve and the health of the community improves, you move on.”
Tracking Metrics Across Payers
there are no easy solutions for standardizing metrics across the industry.
Until there is more consistency, experts offer the following advice for health
plans and providers on aligning value-based care metrics to improve clinical
and financial performance.
Find resources to help define
measure sets. A tool
like the one developed by the Robert Wood Johnson Foundation (buyingvalue.org)
can help state agencies, employers, and other healthcare purchasers align their
quality metrics to federal, state, and commercial standards.
Choose metrics that make a
says the test of a meaningful metric is whether it reflects the Triple Aim:
better population health, an improved patient experience, and lower costs.
Create a culture of improvement. “Leaders are focused on ensuring
their organizations are learning from the data collected to achieve continuous
improvement of the delivery and associated outcomes of patient care,” Briscoe
says. In addition to technology, a culture focused on improvement requires
accountability at all levels of the organization—C-suite, middle management,
and frontline staff.
Such an effort
also entails communicating which metrics are essential to improve performance. At UAB, leaders have developed
physician and administration education materials that illustrate the linkage
and associated impacts among various measures. This methodology focuses on
improving patient outcomes while also explaining why select measures enable the
organization to meet both payer and patient expectations.
example, clearly demonstrating how reducing readmissions affects Medicare
Spending per Beneficiary (MSPB), commercial contracts, other programs, and
patient satisfaction can coalesce the organization around working toward a
common goal. Seeing how movement of a single metric improves organizational
performance in various programs helps financial and clinical leaders to
prioritize immediate efforts and to agree on which measures both improve
patient outcomes and accomplish strategic and operational goals.
Be open to new ways of sharing
outcomes data with payers.
Some measures, particularly the Medicare Star Rating metrics, are more
outcomes-based and cannot be mined from claims data. MCOs such as HCSC have
created portals that allow providers to submit a standard supplemental data
file from their electronic health record each month. In return, Morales says, providers
receive information on which members are noncompliant so they can focus their
efforts to meet specific measures.
recent years, the industry has made some progress to align metrics used by CMS,
state Medicaid agencies, state insurance departments, employer coalitions, and
other stakeholders. In 2015, the Institute of Medicine (now called the Health
and Medicine Division of the National Academies) released a report that
proposed a streamlined set of 15 standardized measures.2 The metrics
were developed by a consensus committee representing health plans, providers,
government agencies, and other stakeholders.
set to watch may be the core measures developed by the Core Quality Measure
Collaborative, led by America’s Health Insurance Plans. The measures were
developed by health plans, physician organizations, employers, and consumer
groups that reviewed measures that are currently in use by CMS and health plans
and that have been endorsed by the National Quality Forum. In March, the
American Academy of Family Physicians (AAFP) wrote a letter urging CMS to adopt
the core measure sets developed by the collaborative, which includes the AAFP.
common set of metrics works only if it is universally adopted by the diverse
group of stakeholders involved in purchasing and delivering health care—from
national government agencies to local providers.
transition to value-based care moves forward, providers will continue to
explore ways to optimize their performance under multiple contracts that are
not well-aligned. “It’s not easy, but it’s what they have been doing for
years,” Micklos says. “I don’t think we’ll ever get to a one-size-fits-all
scenario. But my hope is that moving to more outcomes-based measures should
help winnow down the measures to a more realistic number and make each of the
measures more meaningful.”
Ramos Hegwer is a
freelance writer and editor based in Lake Bluff, Ill.
Interviewed for this article: Emily Boohaker, MD, associate CMO for quality and patient safety, UAB Medicine, Birmingham, Ala.;
Beth Briscoe, CPA,
MBA, FHFMA, FACHE, CFO, UAB Hospital and UAB Medicine clinical
operations, Birmingham, Ala.; Jim Dietsche, CPA, executive vice president and
CFO, Bellin Health, Green Bay, Wis.; Jeff
director, Health Care Transformation Task Force, Washington, D.C.; Esther
vice president, government programs and quality, Health Care Service
Corporation, Chicago; H. Scott Sarran, MD, senior vice president and
chief medical officer, government programs, Health Care Service Corporation,
M. Snyder, MD, FAAP, executive vice president and chief
clinical integration officer, Mount Sinai Health System, and president, Mount Sinai Health Partners, New
1. Bazinsky, K., and Bailit, M., “The Significant Lack of Alignment Across State and Regional Health Measure Sets,” Bailit Health Purchasing, LLC, Sept. 10, 2013.
2. Blumenthal, D., Malphrus, E., and McGinnis, J.M., “Vital Signs: Core Metrics for Health and Health Care Progress,” Institute of Medicine of the National Academies, 2015.
Grant Thornton: Facilitating EAM
Priority Advantage: Helping Organizations Optimize Their Medicare Advantage Plans
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