Jennifer Searfoss, ESQ., CMPE

Jennifer is the Founder and CEO of SCG Health. Previously Jennifer was the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payer operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare. Prior to this, Jennifer served as the External Relations Liaison for the Washington, DC-based Government Affairs Department of the Medical Group Management Association (MGMA). As the External Relations Liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the Government Affairs Representative for the Eastern & Southern Sections. She began her work with MGMA in August of 2001. She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics In Context.

Tuesday, 13 December 2016 19:53

A Retrospective Review of Quality Reporting

Like tax folks in early April, we healthcare value improvement people, are entering the beginning of our busy season. We survived the first round of the eligible professionals’ appeals to the Centers for Medicare & Medicaid Services (CMS) regarding their 2017 penalty designations. These “informal reviews” aren’t up for second opinions, but through networking with CMS officials, we recognized that there were a number of glitches with the processing of the 2015 data – which greatly influences how we are advising clients for the 2016 data submission cycle. 

Is it too Late to Get Started?

This time of year, we get a ton of calls from frantic business managers in outpatient settings on whether or not they should just throw in the towel when it comes to quality reporting for 2016. It isn’t too late! 

While some quality data vendors may have closed their enrollment for 2016 submissions, that date is unique to each vendor. Vendors have until March 31, 2017 to get data to CMS. So you won’t have until March 31 to enroll, because it takes time to validate each provider and then upload data to CMS; some vendors will be accepting enrollment until early spring 2017. Why not get started now, and find your vendor partner!

Likewise, if you are reporting individually and worry that you don’t have enough data yet, the guidance from CMS is that you must address the quality metrics during the reporting year, which ends Dec. 31. It’s a great time to get your documentation completed and run audits while you may have fewer patients. And remember, double-check if one of the 25 measure groups makes sense for you (20 patients, and 11 or more must be traditional Medicare patients, with reporting done on a defined set of measures based upon the services you provide). Measure groups go away in 2017, so take advantage of them now. 

Stay the Course

For the sake of everyone’s sanity, let’s forget about the recent election and the new president and Congress convening in January. Instead, let’s focus on the fact that the quality reporting programs, electronic medical record mandate, and electronic prescribing requirement have been around for over a decade as either an incentive or penalty for eligible professionals billing Medicare.

And while the Merit-Based Incentive Payment System (MIPS) tweaks and streamlines the existing programs, the fundamental apparatus is still there. Even for those who are betting on Congress dismantling Medicare as we know it and implementing Medicare Advantage for all Americans by Feb. 1, I say if it ain’t broke, don’t change it. I counsel my friends, colleagues, and clients to keep doing what you are doing with quality reporting, electronic prescribing, and electronic medical record use. Let’s go for the gold and not rip up the railroad tracks of workflow that have already been laid, confusing medical assistants and support clinical staff on their roles and job expectations. And honestly, what’s the harm if I am wrong? 

Outsourcing Quality

The most important thing that we in our provider community needed to appreciate this year is that CMS has outsourced its quality evaluation to several contractors. That means we have run into numerous hurdles getting questions answered or problems fixed, because the government agency and contractors weren’t aware of some of the same information or able to access the same data. 

  • QualityNet (Ventech Solutions, Inc.) – This is the helpdesk for the majority of the congressionally mandated “value-based purchasing” quality programs, including the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM). However, they don’t process the data; they just host the helpdesk, also known as the Health Care Quality Information Systems (HCQIS) Infrastructure and Data Center Support (HIDS).

    We have found it best to submit emails (to This email address is being protected from spambots. You need JavaScript enabled to view it.) rather than spending hours waiting for your call to get non-answered. The email process auto-generates a processing number, which is crucial. It also allows for faster transfer of questions to the appropriate subject matter expert. Plus, you get wrong answers from the helpdesk in writing. Be sure to keep copies of these responses, because you may need them in the future. And currently allow a week (seven business days) for processing.

    We are aware of accuracy issues wherein QualityNet isn’t aware of announcements made by other parts of CMS or related subcontractors. For example, QualityNet wasn’t processing requests from organizations to change their Group Practice Reporting Option (GPRO) designation or reporting modalities that were due by Nov. 25, 2016 (there was no formal announcement made other than one directed toward data submission organizations). Likewise, QualityNet can’t answer questions about the 2017 program yet – those are transferred back to CMS for response.
  • PQMM (Signature Consulting Group) – This is the management arm staffed by Signature Consulting Group that oversees and maintains the PQRS measures (soon-to-be-called MIPS measures) through its Physician Quality Measure Management (PQMM). This is the correct group, other than the measure author, to contact for questions about measure specifications. They can be contacted through the QualityNet Help Desk – so be sure to note in your email that your question is a measure specification question and should be routed to PQMM.

    The number of 2016 measure specifications not easily understood by our clients is growing. And several of the measures proposed in 2017 do not reflect MIPS program changes. The 2017 measure specifications are available online at https://qpp.cms.gov/education (scroll down halfway to “Learn More About the Merit-Based Incentive Program,” and the measures are under “Measure Specifications Download”) on “preview” with “final measure specifications will be posted by Dec. 31, 2016.” Although a bit late, comments may be directed to this organization for requested changes to troubling and confusing specifications (along with the measure author).
  • PQPMI (Newwave Telecom and Technologies, Inc.) – This is the group processing the PQRS data (with a 2-percent penalty for failure to submit data on Medicare receipts two years after the reporting cycle; 2016 data affects 2018 payment). They process the quality data coming in from Medicare claims, registries, electronic medical record (EMR) vendors, QCDRs, and the CMS Web portal, then create the PQRS feedback reports, publishing them on portal.cms.gov. This contract is called the Physician Quality Programs Management and Implementation (PQPMI).

    NewWave has several contracts with CMS, including the Chronic Conditions Warehouse and Virtual Resource Data Center contracts. It is also the incumbent contractor for the CMS Enterprise Privacy Policy Engine.

    Two interesting items have come up regarding this. In the informal review process, we learned that the NewWave data processing platform uses the provider specialty off the National Plan and Provider Enumeration System (NPPES) (specialties are called “taxonomy” in this system) to determine the inclusion of that specialty to the PQRS program. Our clients often have differences between the PECOS and NPPES data, and for 2015 we had several instances in which the NPI taxonomy was not updated to reflect subsequent state licensure. Thus, our biggest advice in 2016-2017 for all professionals is to double-check your information in both systems for accuracy and consistency.

    Another concern is that NewWave doesn’t have access to the other reports available on the portal.cms.gov system. Basically, the two contractors administering the very related programs of PQRS and VBM can’t see each other’s reports. So far, we have had several instances where the PQRS feedback report didn’t match the Quality and Resource Use Report (QRUR) Table 7 Individual Eligible Professional Performance on the 2015 PQRS Measures.
  • Physician Quality Reporting System and Electronic Prescribing Incentive Program Data Assessment, Accuracy, and Improper Payments Identification System Contract – The 2013 award went to Arch Systems, Inc. (among other subcontractors for support of the contracts listed here). Arch is tasked with identifying gaps, data errors, and inconsistencies on how program data is being procured, translated, transmitted, and submitted to the PQRS and eRx incentive programs by registries and GPROs; validating and verifying the accuracy of GPRO and registry data submitted by or on behalf of eligible professionals; and supporting the development and implementation of a process to identify PQRS and eRx improper payments derived from registry and GPRO data.

    These will be the audit watchdogs that we likely will see more from as the program matures in 2016. We look forward to working with them in a more public role.

  • DECC (Computer Science Corporation, ViPS/General Dynamics Information Technology and 2020 – Business Integra) – This large collaboration is the IT backbone for the quality reporting programs. Noted in the contract these contractors (main awardee is Computer Sciences Corporation) under the Development Effort Consolidation Contract (DECC) is to consolidate and innovate four stovepipe applications onto the Oracle platform. The four applications we know and dislike are Hospital Reporting, Physician Quality Reporting System, End-Stage Renal Disease and Quality Improvement Organizations.

    Users already are experiencing some system pinches with these platforms as the consolidation and innovations move forward. A goal in this area is to have more frequent back-and-forth discussions between developers and system users. Personally, I look forward to more API integrations and the movement away from manual uploads of data.
  • Registration and Attestation System (R&A) – This is the meaningful use attestation site used by CMS and states for their Medicaid incentive programs. It’s currently unclear, but this federal contract may have been awarded to Xerox which provided states access to their own systems.

    The already bloated list of contractors is complicated by the integration of this system and its program into MIPS. Maybe the R&A will be added to the DECC?
  • CAHPS for PQRS Data Team (RAND Survey Research Group) – New this year, and buried in my spam folder, is the Rand Corporation taking over the reins and registration site for group practices’ and Accountable Care Organizations’ reporting data on patient satisfaction through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey-certified vendors.

    Despite the fact that PQRSCAHPS.org is hosted by QualityNet, the helpdesk this fall, even on the deadline day for specifying the chosen CAHPS vendor (Sept. 20, 2016), they didn’t know about the deadline or to whom to get the information. I was told that a different unit had that information and that the main line couldn’t help me. After separately reaching out to that unit (This email address is being protected from spambots. You need JavaScript enabled to view it.), I learned that an email was sent to the large GPRO organizations giving them information about the new RAND hosted portal https://cahpsportal.rand.org/. Thankfully, the invitation was dug out of the spam and everything was met on deadline. Imagine the number of folks who didn’t follow this route.

 Conclusion  

With this many actors and hands in the cookie jar can be messy, I can only think of President Eisenhower’s famous quote about the dangers of a military industrial complex. We are in the age of the healthcare industrial complex. We must be aware of the many actors that are outside the government and demand for timely, accurate answers regarding these public programs.

A few key tips to keep in mind:

  • Email your inquires about 2016 quality reporting to This email address is being protected from spambots. You need JavaScript enabled to view it..
  • Keep electronic and paper copies of all correspondence in cases of audits for 5-7 years, based upon your document retention policies.
  • Where possible, help the QualityNet Help Desk route your question to the appropriate contractor by naming the contractor (or acronym) for your question.
  • If you haven’t already, double-check both your NPPES and PECOS files for accuracy, especially on the listed specialty/taxonomy for each of your clinicians. Each specialty/taxonomy listed first is the one that counts for these programs.
  • If you are reporting data to CMS via a vendor (registry, QCDR or EMR), call your vendor and find out more about what data is being submitted and the timeline. While data is required by March 31, the government does allow data to be overwritten if you find errors. Work with your vendor to get data in early, and double-check exactly what they send. We had a caller show us that for their specialty physicians, they submitted data on dental measures because their EMR system collected the data. They were considered poor performers because the measures were reported without their specific knowledge.
  • Stay on top of your deadlines. For inquiries and help, anticipate seven or more business days for response. Plan to get information into the appropriate vendor two weeks ahead of deadline.
  • Comments are due on MIPS by 5 p.m. on Dec. 19. Submit comments through Regulations.gov by searching CMS-5517-FC to find the correct regulation. 

About the Author

Jennifer Searfoss is the founder and chief solutions strategist at SCG Health, LLC, a boutique value improvement organization focused on creating value in healthcare through workflow optimization, revenue cycle management, and strategic planning in this post-health reform industry environment.

Contact the Author

This email address is being protected from spambots. You need JavaScript enabled to view it.

Comment on this Article

This email address is being protected from spambots. You need JavaScript enabled to view it.

If you listen to all the association, media, and blog buzz, “uncertainty” seems to be the theme for summer in healthcare. No one really knows what will happen Jan. 1, 2017, in the brave new world of the Medicare Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

But several things we know for sure: with the exception of meaningful use, the changes won’t grossly affect the current reporting year. The requirements will apply to you whether you’re a Medicare participating or non-participating provider. And by focusing your summer to-do list on meaningful use, quality data capture, and patient engagement, you’ll be better prepared for the MIPS/APM future when it finally arrives.

Step No. 1: Perform a quarterly electronic health record (EHR) meaningful use checkup..

One possible change affecting physicians and hospitals in 2016 wasn’t included in the proposed physician fee schedule. Instead, the change to a continuous 90-day reporting period for EHR meaningful use attestation was part of the proposed Medicare Hospital Outpatient Prospective Payment System.

Under current guidelines, physicians and hospitals must collect data and report performance over the entire 2016 calendar year. For many, this significantly increases the number of instances in which performance should be scrutinized, requiring a more consistent approach to meet and exceed attestation thresholds. Thus, the proposed change to a continuous 90-day reporting period is a welcome reprieve for the majority of Medicare providers.

But whether the reporting period is a calendar year or 90 continuous days, July is the perfect time to find out how each of your physicians and/or your overall hospital is doing on their respective objectives. Individual provider education, like that offered by SCG Health, can help you get your numbers up.

Through quarterly checkups, SCG Health has found that workflows can break down, system glitches can prevent the flow of data, and clinical staff can simply get lazy. Clients tend to experience two major sticking points. One is secure electronic prescribing of controlled substances. Some find it easier to just keep the prescription pad out for all drugs rather than switching back and forth between paper and the computer.

The other sticking point is computerized provider order entry. Different staff appear to enter orders in different ways, creating entirely separate workflows. This is especially true on orders for outside services like MRIs or CT scans, when a paper form may be used because the service provider isn’t set up to accept electronic orders in that system.

Step No. 2: Capture and report your quality data.

The big 2016 deadline for physician groups and health organizations to sign up to report Medicare quality data under a single TIN has passed. This is called the Group Practice Reporting Option (GPRO). Failure to report data in 2016 for the Physician Quality Reporting System (PQRS) means a 2-percent penalty in 2018. This same failure then adds on an additional 4-percent penalty from the value-based modifier. So now is the time to answer these questions:

  • Have you signed up your TIN for an accountable care organization (ACO) reporting mechanism for 2016?

This year, three SCG Health clients – who had no idea they were in an ACO – discovered that an individual physician had signed up their provider group for ACO participation. Always remember that ACO designation is listed by the parent TIN. Don’t know if you have an ACO designation? To confirm it, have an authorized person from your office call QualityNet, the Medicare PQRS support vendor, at 1-866-288-8912. Your registry and data partners can’t call on your behalf.

  • How will you report your data?

As noted above, it’s important to find out if you’re reporting individually as an NPI/TIN unique combo or as a TIN for all Medicare credentialed NPIs (GPRO). You’ll also need to determine which method to use to get your data to Medicare. For example, you may think you’ll use claims-based reporting. But if you haven’t started yet, it will be tough for you to meet the requirement to include data on 50 percent of your Medicare claims on the first submission. Other options, which require a per-clinician fee, include using the certified electronic health record system to submit electronic clinical quality measures, which is a much skinnier list than that used for PQRS, registry reporting, and Qualified Clinical Data Registry reporting. You’ll find a list of recognized entities on the CMS website at www.cms.gov/PQRS. Just keep in mind that registration fees are often cheaper the earlier you sign up.


 

  • What are you going to report?

It’s late in the game to start figuring out your nine reporting measures. If you haven’t determined them already, start with what you did last year and double-check that a) the measure wasn’t retired; and b) how you’ll report that measure to CMS. Remember, not all measures are available for claims-based reporting, and different measures are available for EHR and registry reporting.

  • How are you doing on performance?

While PQRS doesn’t evaluate performance of a measure, the value-based modifier does. Clinicians are expected to perform at or better than the national performance rate. The most recent performance data we have for benchmarking is from 2014. In many cases, the bar is set pretty high. For example, the 2014 mean performance rate is 83.64 percent for PQRS measure No. 130: Documentation of current medications in the medical record. Do you have structured data that can illustrate this performance? Do you have sufficient documentation that would support performance if you were audited? CMS has indicated its interest in proving the veracity of quality reporting data for 2016 reporters.

Step No. 3: Make patient engagement part of your value proposition.

The most critical new area for most SCG Health specialists is appropriate care coordination. These specialists are proactively asking each patient who their primary care provider (PCP) is, then confirming that the PCP has seen the patient this calendar year. If they haven’t, they’re asked to schedule an appointment with the patient. Specialists are also identifying ways to share relevant information with PCPs to improve health outcomes and reduce emergency department visits and re-hospitalizations.

To get started on your own patient engagement strategy:

  • Ask for and confirm PCP info. Train your front desk or registration staff to ask each patient who their PCP is and when they last had a checkup. Once you have this information, figure out how to confirm, whether by direct secure messaging, fax, or an old-fashioned phone call.
  • Have a plan for PCP referrals. If a patient is missing an important member of his or her care team, consider going the extra mile – make an appointment for them! It goes a long way in demonstrating good customer service.
  • Identify the best communication method. Interoperability can be forced, but it may not be as easy as using an ATM. First, ask your clinical staff to identify key data points they want to receive from, and share with, their patient’s care team. Then brainstorm a “dashboard” for sharing the information. Work with your IT staff to make your dream a reality.

Why does patient engagement matter? Remember that value-based modifier? It can mean a penalty of up to 4 percent of your 2018 receipts. The second part of the equation is evaluating how your cost compares to that of your peers when it comes to unmanaged diagnoses and acute and chronic diseases. So engaging PCPs on care coordination is just the tip of the iceberg. And when the MIPS and APMs are the new norm, these processes will be exactly what’s needed.

Checking off these items on your summer to-do list will not only help you successfully meet today’s reporting needs – it will help you face an uncertain MIPS/APM tomorrow, too.

About the Author

Jennifer Searfoss is the founder and chief solutions strategist at SCG Health, LLC, a boutique value improvement organization focused on creating value in healthcare through workflow optimization, revenue cycle management, and strategic planning in this post-health reform industry environment.

Contact the Author

This email address is being protected from spambots. You need JavaScript enabled to view it.

Comment on this Article

This email address is being protected from spambots. You need JavaScript enabled to view it.

Earlier this month, a joint health plan consortium released a set of quality measures intended to serve all payors. Covering primary care and certain high-expense specialties, the measures are intended to “reduce, refine, and relate” measures for a consistent and unified approach to promoting affordable quality healthcare. Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS) stated that “this agreement today will reduce unnecessary burden for physicians and accelerate the country's movement to better quality.”

The Core Quality Measures Collaborative includes health plan representatives for an estimated 70 percent of covered patients across the U.S. Payor representatives on the Collaborative include CMS, America’s Health Insurance Plans, Aetna, Anthem, the Blue Care Network, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield Association, Cambia Health Solutions, Cigna, Group Health Cooperative, Harvard Pilgrim Health Care, HealthPartners, Heath Care Service Corporation, Highmark, Humana, Kaiser Permanente, The AmeriHealth Caritas Family of Companies, and UnitedHealth Group.

The first release of the “Consensus Core Set” groups measures that have been publicly endorsed by the National Quality Foundation as quality measures and NCQA health plan HEDIS measures. For example, in the primary care core set, titled “ACO and PCMH/Primary Care Measures,” the Collaborative endorsed the forthcoming 2016 HEDIS measure for controlling high blood pressure rather than NQF 0018, noting that the NQF measure’s recommended systolic blood pressure target is not in line with the 2014 guidelines (140 mmHg). Instead, the NQF measure aligns to the outdated 2004 Joint National Committee hypertension guidelines. This divergence of measure recognition underscores the lag in the measure development and endorsement process and highlights a gap in the federal quality initiatives. Since NCQA is the measure steward for both the NQF and HEDIS measures, the hope is that the 2017 NQF measures reflect the 2014 guidelines.

For leaders curious about how they can capture reports that align to these measures with ease, the NQF measure is used for both the Medicare Physician Quality Reporting System and the certified electronic medical record technology meaningful use attestation. Thus, inconsistencies in evidence-based medicine and availability of updated guidelines continue to represent a gap in the national construct of quality measurement. It’s one thing to endorse what should be captured; it’s another to require vendors to incorporate the appropriate measures into technology available at the point of care. And without this mandate, it simply won’t happen.

The February 2016 Core Measure Set Release included:

  • ACO and PCMH/Primary Care Measures
  • Cardiovascular Measures
  • Gastroenterology Measures
  • HIV/Hepatitis C Core Measures
  • Medical Oncology Measures
  • OB/GYN Measures
  • Orthopedic Measures

The day after the release of the Core Measure Sets, CMS closed the extended comment period on their request for information on the certification frequency and requirements of clinical quality measures for the meaningful use program. The agency received 150 comments from a broad group of individuals and organizations representing physicians, hospitals, consultants, and vendors. However, few comments provided guidance on how to integrate measures when new evidence-based medicine conflicts with endorsed measures. However, numerous commenters requested over a year to implement changes in quality measures to allow vendors and on-the-ground providers to respond with adequate training and technology.

The Core Measure Sets include one important guidepost. At the end of each document, the Collaborative included “future areas for measure development.” Here, industry geeks can find exciting true quality measurement metrics with outcome focus and items of interest for employers. In the orthopedic measures, the Collaborative listed emergency department visits, which good orthopedic care and coordination with urgent care should divert away from the ED. Likewise, the “health-related quality of life” measures get to the patient-reported outcomes reflecting adequate primary care coordination.

Overall, this development is exciting. To share industry consensus regarding the measurement of quality will be a fascinating endeavor. The next step over the next three years will be integrating these measures into the payment methodology for public and private entities. This early menu is a starting point where some larger healthcare entities can begin to identify synergistic measures that have been shown to bend the cost curve. For smaller organizations, this publication should kick-start the budget review process for strong investment in technology to capture quality data and provide analytics to identify pockets of shared savings.

About the Author

Jennifer is the Founder and CEO of SCG Health.  Previously Jennifer was the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payer operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare.  Prior to this, Jennifer served as the External Relations Liaison for the Washington, DC-based Government Affairs Department of the Medical Group Management Association (MGMA). As the External Relations Liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the Government Affairs Representative for the Eastern & Southern Sections. She began her work with MGMA in August of 2001.  She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics In Context.

Contact the Author

This email address is being protected from spambots. You need JavaScript enabled to view it.

Comment on this Article

This email address is being protected from spambots. You need JavaScript enabled to view it.

We always seem to forget one key decision-maker when we talk about health insurance: the employer. Forty-three percent of America’s insured individuals remain covered through employer-sponsored plans despite the Patient Protection and Affordable Care Act reforms of health insurance benefit structures. I’ve even heard employers tell me that since they pay the Federal Insurance Contributions Act (FICA) tax, Medicare itself is an employer-sponsored plan. Employers think differently about healthcare and they are curious about alternative payment models involving quality providers to bring down costs.

I recently sat down with a specialty client to begin identifying meaningful quality metrics that would interest large employers in their service area. We started by looking at the information required by attesting physicians for meeting and exceeding the Medicare meaningful use requirements and then turned to the Medicare Physician Quality Reporting System measures.

Honestly, we found very little data that the employer would not already know. Employers should have access to information on whether their employees smoke (self-attested) and are filling their prescriptions. Employers have access through their partner health plans to more information than providers have. For example, did the patient fill the prescription (and refill), and was it for a generic unless the clinician indicated to dispense as prescribed? That’s something that’s not always clear to all parties. The rest of the data collected by the majority of specialists may not even be helpful. Primary care providers have more options, which are discussed in more depth below.

Data Areas to Focus on and Advocate for

Since so little of the data collection mandated through the Medicare program is useful to employers, what works? Currently, there are three major areas of focus to being able to streamline care to increase coordination and decrease overall costs. While health plans may be interested in decreasing costs for a one-year period, employers are more likely to look at cost savings over a longer period – the average tenure of an employee, for example. Areas to look for mutual interest are chronic disease control, point-in-time cost control, and cost aversion.

Thus far, the evaluation process has pointed to a number of areas without industry measures or peer-reviewed study. Over time, this process may result in proposals for new measures and published results of these activities. And since so few of these data points are recognized in the industry, only a few are captured in association registries and other data-collecting bodies.

Our process began by finding a concept, identifying the appropriate workflow to gather data, and then evaluating the data over a short-term period to see if it is meaningful and yielding a reasonable expectation of better outcomes and decreased cost. If the concept doesn’t glean the anticipated information, or if the workflow is too difficult and time-consuming, the next concept is evaluated. One of the biggest challenges has been capturing data that requires clinical involvement – physicians and other clinical staff are tired of clicking yet another button in their electronic medical records.

Chronic Disease Control

As noted above, Medicare does have key areas of focus for employers regarding adult chronic disease management. For pediatrics, there are some decent measures in the meaningful use data set. However, the main critique of all of these measures is that they are process-oriented and not outcome-focused. That means that these measures are the starting point and require additional data to be collected and evaluated to identify quality outcomes and cost savings. In the end, for the measures to become meaningful, they must be part of a measure set and all data points must be captured, in addition to the outcomes and cost information gathered by the entity.

Measure # Description Age demographic
NQF 0001 Asthma: Assessment of Asthma Control 5-64
NQF 0059 Diabetes: Hemoglobin A1c Poor Control 18-75
PQRS 301 Hypertension: Low Density Lipoprotein (LDL-C) Control 18-90

Additional data points that are required are numerous. Below are a few to consider:

Description Age demographic
Days post-visit (or intervention) to return to work/school 5 and older
Quality of ability to complete work with ailment; post-intervention 18 and older
Volume of previous 12-month visit(s) to an emergency department All
Volume of previous 12-month admission to the hospital for any reason All
Other clinicians seen for all medical, emotional and exercise support 5 and older

Note that the concepts above do not center on quality of life or activity. Those are metrics that interest academics and Medicare. This is strictly focused on working-age productivity.

Also, consider that some of this information may not be reliable if it is patient-reported. So, alternative sources must be considered, including partnering with area hospitals and connecting with health information exchanges. Most data may be captured via patient self-reported data through intake questionnaires for new patients and follow-up visits. Concerns are patient fatigue and answering the same questions over and over again – questions that are repeated at all medical offices – and the level of health literacy of the patient population. Any changes to patient questionnaires should be evaluated and piloted to ensure accuracy of the data collected and patient understanding of the need for correct information.

Point-in-time Cost Control

This has been a key area for public and private health plans, with some active participation by employers. Alternative payment models fit into this area for bundled payments, reference pricing, capitation, and other structures where reimbursement is predictable and some financial risk can be shifted to the provider. Therefore, it is an area of great experimentation, and new concepts are being met with excitement.Areas to evaluate are:

  • Predictable care episodes: Are there treatment regimens that are episodic and standardized in your patient population? Could you establish a universal budget for each patient that has little risk adjustment? Areas with some success in this realm are knee and total hip replacements and colonoscopies.

  • Prescriptions: Are you prescribing generic drugs when possible? Are you managing patients with multiple prescriptions to reduce the overall quantity and costs while producing the same outcomes? This may be a controversial topic for many clinicians that don’t see their role as involving the management of polypharmacy. As biologics expand and new genetic therapies emerge, however, this area will become a point of emphasis. Groups that move past cultural barriers and take on this role can and should use this area for shared savings discussions with both health plans and employers.

  • Productive workforce: Employers invest in healthcare coverage so they can have a productive workforce to accomplish their business objectives. But for the last several decades, employers have been stuck with a lackluster investment that leaves their workforce less than optimized due to health issues and missed days in the office. Data shows that interventions and therapies with superior return-to-work time periods and heightened activity (more time able to stand, walk, carry items, etc.) are exactly what employers are looking for, and most will be very willing to partner with groups able to deliver results.

Cost Aversion

The most longstanding measure that falls into this category is the aversion of readmission to a hospital during a specified global period. It’s a big-ticket item and a hard nut to crack across all diagnoses. Other areas that ambulatory facilities can evaluate include:

  • Alternative treatment settings: Several pilot programs have evaluated readmission and emergency department visits following initial patient encounters in an alternative treatment setting such as an urgent care center or chronic care education clinic (an asthma center, for example) or post-care visits in the home. Here the cost aversion is somewhat speculative, but it’s a significant win if a hospitalization is avoided. However, ambulatory care runs into an inherent problem that the inpatient and outpatient sides of the Medicare dollar do not flow back and forth. Instead, these are programs to evaluate for the working aged until the Part A and Part B buckets are aligned in forthcoming reforms.

  • Protocol adherence: Offices with standardize protocols for diagnosis and treatment regimens are at an advantage. For example, offices that don’t require a CT or MRI for a pneumonia diagnosis, and instead encourage the order of a flat X-ray, will be a step ahead in the game of cost aversion. Where clinicians can agree on protocols, workflows can be modified as required by medical necessity – but consider the overall cost of modification, should it be pursued and adopted. These protocols help demonstrate clinical integration for care coordination models, group practices, and other health provider models scrutinized for abuse of market power. And these protocols can be used to reduce overall treatment costs.

  • Prevention: This is an exercise of population health data analysis. For example, primary care offices that give flu immunizations can evaluate the incidence of complication and hospitalization in their populations and extrapolate using relevant data. This can be applied to numerous other existing measures for preventive services such as breast examinations, screening colonoscopies, etc.

As this new era of reform in the healthcare industry takes hold, data holds a key to success. It also provides an opportunity to meet bedfellows that were not as transparently at the table before. Direct engagement with employers must be a part of the medical provider’s strategy for success; otherwise, important initiatives and mutual areas of benefit will be lost.

About the Author

Jennifer is the founder and CEO of SCG Health. Previously Jennifer was the vice president of external provider relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare, and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payor operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare. Prior to this, Jennifer served as the external relations liaison for the Washington, D.C.-based Government Affairs Department of the Medical Group Management Association (MGMA). As the external relations liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the government affairs representative for the Eastern and Southern sections. She began her work with MGMA in August of 2001. She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics in Context.

Contact the Author

This email address is being protected from spambots. You need JavaScript enabled to view it.

Comment on This Article

This email address is being protected from spambots. You need JavaScript enabled to view it.