CMS is continuing to request providers report more quality data. While healthcare can use the data to facilitate change that could drastically improve patient outcomes, the pay-for-performance system still has some kinks that need to be worked out before the medical community can see the benefits.
Tom S. Lee, PhD, founded SA Ignite in 2009 to help providers navigate the quality reporting process. "We are in the business of simplifying and optimizing value-based programs through automation and services," Dr. Lee says. "We help with quality performance management and reporting so that organizations are not bogged down by regulatory, administrative burdens."
Dr. Lee addresses the challenges many providers face as healthcare moves toward value-based payment systems.
Complexity
CMS requires providers to report a wealth of quality data in many different forms. In April 2015, Congress and President Obama repealed the Medicare Part B Sustainable Growth Rate reimbursement formula, replacing it with the Merit-Based Incentive Payment System.
"CMS has different programs that all have separate sets of rules, making it challenging for providers to maintain compliance," Dr. Lee says.
CMS calculates a provider's MIPS score based on four performance categories, which determines a provider's payment for that year. While MIPS reinforces Medicare Meaningful Use and Physician Quality Reporting System payment adjustments, MIPS does not influence Medicare MU incentives.
To add another layer, CMS also rewards providers who participate in alternative payment models like accountable care organizations. CMS will give providers an automatic 5 percent bonus for participating in an eligible APM such as ACOs and certified patient-centered medical homes which accept downside financial risk. However, providers risk reimbursement if they do not meet metric standards.
Quality reporting causes many providers anxiety as CMS makes the scores available to consumers, which may impact a provider's reputation and patient base.
Resources
ASCs often have limited resources, especially when it comes to staff. To obtain optimal quality scores, reporting is essential and centers have to allocate staff toward compiling the quality data CMS requires. "It's hard to find enough of the right staff at the right price," Dr. Lee says. The 'right' staff includes people with an extensive knowledge about the many reporting requirements because a lapse could result in a hefty pay cut.
Physician engagement
CMS' quality reporting requirements often do not incite physician engagement as measures may not directly pertain to specialty providers. Dr. Lee explains CMS designed most quality measures to assess the mass of providers, rather than a particular specialty.
A Health Affairs survey found primary care providers spent four hours each week on quality reporting, while multispecialty practice physicians spent three hours per week on reporting. Orthopedic surgeons spent merely 1.7 hours per week on quality reporting.
"There are not a lot of quality measures that are optimized for ASCs," Dr. Lee says. "So, you may have surgeons being measured on quality measures that have nothing to do to their workflow."
With great risk come even greater rewards
Value-based payments pose a significant risk for physician who could lose capital due to insufficient reporting. In CMS' value-based payment program, 5,477 physician groups will experience a 2 percent payment cut this year for poor performance or non-reporting in 2014. Groups receiving the payment cut will pay for those 128 physician groups receiving a bonus for superior performance. While the small percentage receiving bonuses proves the system can work, it also indicates the system has room for improvement.
Providers, as a whole, are optimistic about the transition to value-based payments. A Fidelity Investments and the National Business Group on Health survey found providers feel "cautiously optimistic" about pay-for-performance payment models. Respondents felt the model will deliver better quality of care, more efficient medical practices and overall improvements in patient health. Of physicians under 35, only 28 percent believe the fee-for-service payment model is ideal for obtaining good patient outcomes.
"Every provider inherently wants to be better from a quality standpoint," Dr. Lee says. "Value-based systems allow you to align financial incentives with the desire to be a high performing organization. That was never the case with fee-for-service payment."
Combating the challenges
Using its cloud-based provider platform, SA Ignite is simplifying the quality reporting process. The program combats the reporting's complex nature by featuring the latest government rules, and allowing providers to regularly monitor where they are trending throughout the year and improve before the year ends.
Through automation, SA Ignite can reduce the number of staff allocated toward managing quality reporting, allowing staff to put time toward other strategies. "Our system allows staff members to operate at the top of their licenses," Dr. Lee says.
Thirdly, SA Ignite works to engage providers through sending them performance cards to their mobile phones. Physicians can see their scores on a daily basis, and can assess how their quality scores compared to yesterday. Through physician engagement, SA Ignite is "making physicians a part of the solution, rather than the barrier."
Pay-for-performance is the way of the future with the United States spending nearly $15.4 billion annually on quality measure reporting for orthopedics, cardiology, primary care and multispecialty practices. As healthcare prioritizes this pay-for-performance system, the medical community has to push on to understand the system and use it to enhance patient care.
"We have to stay vigilant as theory doesn't always match reality," Dr. Lee says. "All facets of healthcare — providers, patients, payers — have to make our voices heard and work to improve these programs so we can make theory more relevant and useful in the real world."
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