Quality in healthcare has always been a top priority for providers, but the definition of quality and how it is achieved has been elusive. Now, one of the greatest forces driving change in the industry is the aim to measure outcomes and reward providers for value over quantity. Joe Rubinsztain, MD, founder and CEO of gastroenterology-focused EHR and practice management company gMed, gives an expert look at how this trend is impacting reimbursement, ambulatory surgery centers, physician practices and healthcare as a whole.
How outcomes measures are created
Primary care has a number of metrics used to measure outcomes and subsequently determine the quality of care provided, but identifying these metrics becomes more complex at the specialty level. "Outcomes measures in various specialties are being defined right now. For example, GI measures, such as adenoma detection rate are now defining that path," says Dr. Rubinsztain. "Evidence-based medicine is one half of the equation, and the other half is interacting with patients and understanding how different treatments impact their day-to-day lives."
How reimbursement is changing
The heightened focus on defining quality is not only reshaping how care is delivered, but also dramatically impacting the way providers are compensated for that care. Healthcare leaders have been forecasting the demise of fee-for-service reimbursement for quite some time, and now it appears that time has finally come. In January, the Obama administration announced plans to shift Medicare away from the fee-for-service and toward a value-based model over the next four years. By next year, 30 percent of Medicare payments will be funneled through alternative payment models, and that percentage will leap up 50 percent by 2018. Right now, roughly 10 percent of Medicare payments are made through these alternative models. This plan is ambitious in scope, but perfecting the definitions of quality and value remains a work in progress.
How quality reporting affects providers
These dramatic changes to Medicare may be in the not so distant future, but outcomes and quality are already affecting reimbursement. Penalties for not participating in the Physician Quality Reporting System are coming into play and will only increase as time goes on. From the specialty standpoint, not all PQRS measures are applicable. Key stakeholders are joining together to have a hand in naming the metrics and measures that demonstrate quality for a particular field. "In the GI field, the professional societies, payers and technology providers are working together to build a common framework," says Dr. Rubinsztain. For example, gastroenterologists can submit outcomes data for PQRS through platforms such as the GI Quality Improvement Consortium and the AGA Digestive Health Recognition Program.
How the value trend is pushing providers to accept risk
Beyond PQRS, value-driven initiatives like accountable care organizations and population health are also playing a role in healthcare's transformation. The call for value and measurement of physicians' ability to achieve it, places a large responsibility on physicians' shoulders. With this responsibility comes risk, particularly as providers are expected to demonstrate quality and outcomes while containing costs. Bundled payments, for example, present both an opportunity and risk for providers. Procedures such as colonoscopy and total joint replacement are frequent choices for this payment structure. "Larger groups have the ability to gather large amounts of data and manage it," says Dr. Rubinsztain. "They are able to assess the risk they are taking with bundled payments." While many value-based initiatives have yet to come fully into play, bundled payments are happening today.
How physician practice structure is changing
As healthcare undergoes these dramatic alterations, it is becoming clear that larger groups are better equipped to handle the demands. Many physicians are banding together or opting for hospital employment. "Hospitals are acquiring groups, however GI is lower on the pecking order for reimbursement, therefore not a top hospital priority," says. Dr. Rubinsztain. Solo practitioners and smaller physician groups will find it difficult to handle the risks of bundled payment arrangements, as well as the financial demands of meaningful use and quality reporting. As a result, Dr. Rubinsztain predicts that smaller GI groups, as well as groups in other specialties, will begin to merge with one another or seek to become part of a larger health system.
How ASCs will be impacted
The ASC industry was built by independent physicians, but now larger organizations like hospitals and healthcare systems are expressing growing interest in the low-cost, high-quality structure surgery centers offer. "ASCs have been traditionally seen as a separate care delivery location, but the shift toward population health makes location irrelevant," says Dr. Rubinsztain. "From a logistical perspective, ASCs will become much more integrated into the care chain." Hospitals and health systems are actively acquiring ASCs and partnering with physicians to build their own. National ASC companies, such as Regent Surgical Health and United Surgical Partners International, focus heavily on structuring three-way joint venture ASCs with health system/hospital and physician partners.
As data grows to become even more of a premium commodity, ASCs will by necessity become more integrated into the chain of healthcare delivery. Even those ASCs that remain independent will need to work more closely with physician offices, while ASCs that are part of a larger organization will contribute to and benefit from a system-wide data pool.
How health IT companies are playing a role
The outcomes measures and quality revolution in healthcare has sparked an enormous response from the health IT sector. Companies are offering everything from data management to population health support. On the specialty level, gMed is working to build an easily visualized, common framework to help gastroenterologists gather, understand and put to use quality data. Health IT companies, like gMed, are an important piece of the healthcare value puzzle that continues to fall into place. "The way we measure and reimburse for quality is limited, but it is starting to move toward something more meaningful," says Dr. Rubinsztain.