Measuring Quality: Where is Health Care Headed?

There is widespread agreement on the importance of measuring and optimizing the quality of medical care; however, controversy exists around the best ways to achieve this. During the 57th American Society of Hematology Meeting & Exposition, 3 experts explored the opportunities and debates around quality measurement in health care with a focus on pay-for-performance.

National Quality Strategy 

The Patient Protection and Affordable Care Act required the development of the National Quality Strategy (NQS) to provide guidance on a nationwide effort to coordinate public and private efforts to improve the quality of health and health care for all Americans. 

The National Quality Forum (NQF) worked with the federal government to come up with the NQS. Helen Burstin, MD, MPH, FACP, chief scientific officer, NQF, said the collaboration identified 3 core aims: (1) better care, (2) healthy people/healthy communities, and (3) smarter spending. These core aims are advanced through 6 priorities: (1) make care safer by reducing harm, (2) strengthen person and family engagement as partners in care, (3) promote effective communication and coordination of care, (4) promote effective prevention and treatment of chronic diseases, (5) work with communities to promote best practices of healthy living, and (6) make quality care affordable. 

She acknowledged tension at the national level and among individual practitioners around quality measures. For example, there is a lot of interest with moving to outcome measures for accountability and yet process measures are still the basic tool used to provide improvement. Why focus on outcomes? “Outcomes are the reasons patients seek care and why providers deliver care,” Dr Burstin explained. “Measuring performance outcomes encourages a systems approach to providing and improving care.”

She also identified challenges with outcome measures such as persistent measurement gaps and potential for unintended consequences. “We don’t want people feeling like they have to blindly go down a path for the sake of improving a performance score for the sake of payment.” 

Physician Quality Reporting System

Currently, the Physician Quality Reporting System (PQRS) is the main platform through which quality is being measured and evaluated, said Andrew Ryan, PhD, MA, associate professor, department of health management and policy, University of Michigan School of Public Health. 

Value is a ratio of quality and cost, he explained, noting that quality is being measured for hematologists by 4 clinical process measures in the PQRS. “This represents a very narrow scope of activities that is being considered quality for hematology.”

Dr Ryan said there has been impetus around pay-for-performance and value-based purchasing. “We have seen a lot of the quality indicators we look at moving in the right direction. However, at the same time, we don’t see evidence that the programs that are trying to improve these outcomes are associated with incremental benefits.”

MACRA and Medicare

The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is an effort to improve the quality of care patients receive by moving Medicare compensation from volume-based fee-for-service to merit-based incentives. MACRA, which replaces the Sustainable Growth Rate payment formula, changed the physician fee schedule giving a stable 0.5% annual update during the transitional period from 2015 through 2019, explained Lemeneh Tefera, MD, MSc, medical officer, value-based purchasing and Merit-Based Incentive Payment System (MIPS) program, Centers for Medicare & Medicaid Services (CMS).

MACRA ends separate application of payment adjustment under the PQRS, the value-based payment modifier program, and the electronic health records (EHRs) meaningful use program as of December 31, 2018.

Two models providers can follow to increase Medicare payments begin January 1, 2019—MIPS and Alternative Payment Model (APM)—at which time CMS will be required to assess 4
categories of performance under MIPS: (1) quality, (2) resource use, (3) clinical practice improvement activities, and (4) meaningful use of EHRs. These are weighted 30%, 30%, 15%, and 25%, respectively, as components of the MIPS score of 0 to 100.

MIPS incentive payment formula is structured for participants to receive positive or negative payment adjustment depending on performance score. MIPS can see up to a 4% increase or cut in payment beginning in 2019. This percentage can increase or decrease up to 9% by 2022.

Beginning in 2019 and for 6 years, providers qualifying for APM and who meet specified payment thresholds will be eligible for a 5% incentive payment; payment is made in a lump sum based on the previous year’s Part B expenditure. In 2019 and 2020, eligible providers must have 25% of Part B payments for covered professional services furnished by an APM that meets the criteria of  an eligible
alternative payment entity. This will increase to 50% in 2021 and 2022, and 75% in 2023 and thereafter, explained Dr Tefera.

CMS expects the majority of professionals in the first year will be in the MIPS program “because there are not enough APMs out there, even if there was demand from professionals to participate,” he said.

The published draft plan for development of quality measures for MIPS and APM is expected this spring with the final rule published in the summer or fall of 2016.—Eileen Koutnik-Fotopoulos