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PA OPINION

The stakes are high: how healthcare associations can facilitate quality reporting in 2018

Reimbursement for healthcare services is increasingly based on the value, rather than the volume of services delivered to patients. As more and more providers adopt value-based care models and are required to report quality of care and outcomes information to healthcare payers, healthcare associations are well placed to support these efforts.

Despite the quality of care benefit to patients, value-based reimbursement has resulted in increased administrative burden on clinicians. The Center for Medicare and Medicaid Services (CMS) has implemented specific policies to incentivize payers and providers to transition to a value-based payment model. The 2015 passage of the Medicare and CHIPS Reauthorization Act, also known as MACRA, established a quality reporting framework (known as MIPS) for providers who care for Medicare Part B patients. The quality measures in MIPS evaluate the quality of care that clinicians deliver to patients, based on data elements like patients’ health outcomes, patients’ experience of receiving care, and condition-specific outcome and process measures.

Many healthcare providers are required to report on the quality of the care they deliver: in 2018, healthcare providers who care for at least 200 Medicare patients and/or earn at least $90,000 of Medicare Part B revenues annually must report on quality either through MIPS or another qualified alternative payment model. The stakes for quality reporting are high. For the 2018 performance year, MIPS-qualified healthcare providers who do not submit a minimum amount of data to CMS will face penalties of up to five per cent of their Medicare reimbursement dollars in 2020, and the penalties increase in the future.

Despite efforts by CMS to make the reporting process easier through the 2017 addition of bonus points and simplified requirements, healthcare providers may not have the time, technology, or financial and human resources to meet the reporting requirements on their own. The process can be arduous, especially for small or independent medical practices that may not have extensive administrative resources to devote to reporting. Clinicians may report their quality data in a variety of ways, including: CMS Web interface; claims-based reports; electronic health record (EHR) systems; qualified registries; and qualified clinical data registries (QCDRs).

Each of the methods of quality reporting has advantages and disadvantages, depending on the size of the provider group, their EHR system, and the resources they have to devote to quality reporting. While the CMS web interface, claims-based reports, and EHR reporting all rely on individual clinicians to report their data to CMS, qualified registries and QCDRs are managed by entities like specialty healthcare associations that can provide extensive value to small and independent practices.

At PA Consulting Group, we have worked with numerous specialty medical societies on all aspects of QCDR operations – from developing a business case to selecting the right technology vendor and improving scalability of operations. In our experience, successful QCDR initiatives have the following attributes:

  1. Clearly articulated value proposition
  2. Defined business model
  3. Scalable operations
  4. Robust technology that is easy to integrate.

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How specialty medical societies can facilitate quality reporting with QCDRs

Specialty medical societies can assist small and independent healthcare provider groups with the MIPS quality reporting pathway by establishing a qualified registry or QCDR by which clinicians can report their quality data. To qualify, specialty healthcare associations must demonstrate to CMS that they meet the requirements for quality data reporting. The society then submits all registry data to CMS on providers’ behalf. Not all registries submit all quality measures to CMS, so it is crucial that providers are aware of the measures that their QCDR submits to CMS.

While QCDRs offer associations the opportunity to provide value to their members or to entice prospective member clinicians, building and operating a QCDR is its own challenge. It is clear that the healthcare system is moving toward value-based reimbursement, but potential policy uncertainty may make the business case for establishing a QCDR less clear, particularly in more risk-averse organizations. Here are a few key suggestions to consider before pursuing a QCDR:

  • Before pursuing a QCDR, associations must understand and agree to the business model of their registry. Registries can provide value, but they require significant resources to establish, strong financial commitment to hire or train staff to manage the registry and a time commitment to engage with technology vendors to build the QCDR
  • Societies should select a robust technology platform that can accommodate the challenges of data integration from a diverse set of billing and medical record systems across practices, and identifying such a vendor can require both time and expertise. To offer the best value to the society and its members, the society must establish scalable operations to accommodate future growth of the registry. Medical societies should be able to justify the ROI of the large upfront investment in time and human and financial resources to establish successful QCDR operations
  • Specialty healthcare associations must also identify for themselves and provide to clinicians the value proposition to encourage member participation in the QCDR. For example, identifying and reporting on a comprehensive and well-defined set of quality measures that are aligned to members’ practice will incentivize clinicians to contribute their data to the QCDR, rather than a competitor organization. When determining what set of measures to report, societies should select measures that achieve a balance between being comprehensive for quality measurement for the society’s clinicians, and being practical to implement from a technology and EHR perspective for the society
  • Data is the primary benefit of a QCDR to clinicians, healthcare associations and CMS. When creating or implementing a QCDR, organizations should consider how they plan to integrate the data that their members submit to the registry. The value of the integrated data can be enormous for societies that do it successfully. Data from thousands of patients related to several measures over millions of patient encounters can provide research and commercialization opportunities to benefit the society as well as clinicians and patients. Patients and clinicians can then benefit from improved care pathways and diagnostic power. Commercialization opportunities could include collaborating with research, pharmaceutical, or life science companies that require additional data on specific disease states. Specialty medical societies could also monetize their registry data by licensing the data to pharmaceutical or life science companies to support new product development by identifying high-need clinical areas. Furthermore, medical societies could use their registry data in collaboration with health insurance companies to design optimal care pathways or to establish care guidelines that could be distributed throughout their specialty.

As quality reporting becomes ever more present in healthcare reimbursement, small and independent clinical practices will have more regulatory requirements to grapple with. Specialty medical societies can offer real value to healthcare practices that must manage the quality reporting requirements associated with MIPS. By offering a QCDR to its membership, specialty medical societies can help clinicians to offload some administrative reporting tasks and to gain other benefits for their practices, ultimately improving patient care.

Contact the authors

  • Nilesh Chandra

    Nilesh Chandra

    PA healthcare expert

    Nilesh is a leader in PA's healthcare business focused on helping provider industry clients develop new business models for an industry shifting towards value-based payments.

    Insights by Nilesh Chandra
  • Mark Summers

    Mark Summers

    PA healthcare expert

    Mark has extensive experience helping healthcare organizations develop and implement winning business strategies

    Insights by Mark Summers
  • Jenna Phillips

    Jenna Phillips

    PA healthcare expert

    Jenna collaborates with stakeholders throughout the healthcare system to design and implement complex strategy initiatives

    Insights by Jenna Phillips
  • Meggie Hotard

    Meggie Hotard

    PA healthcare expert

    Meggie uses her expertise in performance improvement to enable healthcare organizations to achieve greater efficiencies.

    Insights by Meggie Hotard

Contact the healthcare team

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