Toward a Common Vision for Value Based Care Metrics
Providers say reporting dozens—maybe even hundreds—of potentially conflicting metrics from government and commercial payers is a burden. The idea of a one-size-fits-all, universal set of metrics may be unrealistic, so how can stakeholders find common ground?
Healthcare 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.
“At the 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.
The 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.
MSHP, 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.
Reasons for Overload
Mount 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.
The 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 big data.
Jeff 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).
On 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.”
As 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.
Historically, 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.”
These 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
Prioritizing Metrics for Performance
The absence 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.
Providers 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.
“Everyone 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 performance.
In recent 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.
One program 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.
Optimizing 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.
Gaining Greater Leverage
To 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.
In Wisconsin, 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.
Dietsche 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.
Over the 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
For now, 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 difference. Dietsche 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.
For 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.
Fewer, More Meaningful Measures Ahead?
In 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.
Another 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.
A 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.
As the 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.”
Laura 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.; Mary 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 Micklos, executive director, Health Care Transformation Task Force, Washington, D.C.; Esther Morales, division 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, Chicago; Andrew M. Snyder, MD, FAAP, executive vice president and chief clinical integration officer, Mount Sinai Health System, and president, Mount Sinai Health Partners, New York City.
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.