Quality measures have been around for a long time. Before the move towards global payment, most contracts in the “Pay for Performance” era included both ambulatory and hospital-based quality measures. As provider organizations and ACOs transition to global payment, quality measures are certainly here to stay. Though we all agree that the quality measures as currently organized really only reflect a small fraction of the total care rendered by a group of providers, they serve as an important proxy for an organization’s ability to use data and IT to analyze their own variation in quality and improve the underperformers.
Key Strategic Decisions for a CMO
Challenges: multiple quality measures
One of the ongoing challenges and frustrations for CMOs is having to deal with different sets of quality measures from different payors. A sublevel of that frustration occurs when different payors use measures that are similar, but not exactly the same.
For example, one payor may set a diabetic hemoglobin A1c target at <8, where the next payor sets it at <9.
Another example would be where one payor sets a blood pressure target at <140/90 and the next payor sets the target at <130/90.
Given this headache, provider groups often entreat payors to use the same measures. This is usually met with limited success. Ultimately, CMOs need to make difficult decisions about where to set the bar on similar quality measures, often opting for the more inclusive choice – such as the lower hemoglobin A1c — so all patients are included.
This conflict about similar measures does not occur for federally distributed quality measures such as HEDIS based measures as they are, by definition, the same around the country. But, commercial payors are not under the same constraints. Sometimes, payors actually prefer to use different measures in their desire to differentiate themselves one from another, to the consternation of CMOs and providers.
CMOs may adjust their overall quality program strategy based in part on themes of quality measures that cut across several of their contracts. Health plan Medical Directors well understand the conflict around multiple and disparate quality measures, and are usually very sympathetic to the concerns of the providers, but may not be able to single handedly change the measures to conform with other quality measures in their catchment area.
It is also worth mentioning that the quality measures can have a major financial impact on an ACO or other provider group. In some contracts, there is a range of PMPM payments tied to quality measure performance. In other contracts, the aggregate performance on the quality measures increases the potential end of year surplus if an ACO comes in under budget, or mitigates a potential end of year loss if the TME target is exceeded. Some contracts use both methods for quality measure adjudication and reward.
Solutions: governance and staffing
Though data aggregation, analysis and presentation is a key to success with the quality measures, physician and other provider governance and organization is also critical. In my experience, the office practices that employ a dedicated “quality person” to review the registries and do the outreach to patients in need of certain quality services, always have the best performance.
ACOs often hire a physician or other person trained in quality and systems performance to help organize and run their “quality program” at the system level. In addition to having dedicated staff in each office available to run these quality measure programs, local physician leadership is required to bring the importance of this work home to the providers.
Appealing to physicians’ belief and hope that they should provide the best quality care possible to their patients is always a good place to start. In addition, the ACO leadership should have a financial system in place that rewards high scoring providers vis-à-vis the quality measures with direct financial reward.
Moving forward with multiple quality measures
MIPS and MACRA, the federally based programs that will measure physician success in the quality arena starting in 2017, will only accelerate the need for high functioning quality programs along with the attendant need for efficient data aggregation and analysis.
The most successful ACO quality programs will take advantage of EHR data as well as claims data to ensure quality “gaps” are closed. These highly efficient data and IT based programs work best in an environment where leadership has made success in the quality measures a high priority, and has consequently provided adequate resources in terms of IT and staff to get the job done.