How Today's Healthcare Regulatory Alphabet Soup is Driving the Need for Optimization

Understanding today’s physician practice regulatory requirements and alphabet soup of acronyms is a daunting task. The sheer volume of information makes it increasingly difficult for practices to understand what it all means, where to start, and how it will impact reimbursement. One recent example is the Centers for Medicaid and Medicare Services’ (CMS) shift in payment models under a new act called the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. While some initial background and technical details, along with an acronym map, are helpful in understanding the purpose, goals, and meaning of MACRA, adoption of its principles does not need to be overwhelming. This white paper presents an approach that simplifies adoption through the application of four common quality program processes. When applied, these optimization activities help ease MACRA adoption, improve current performance of metrics, and position practices for future quality initiatives and updates. As to the alphabet soup, it is a lot to take in—even for those who have a solid understanding of the healthcare industry and its complicated regulatory and compliance environment. To help make better sense of at least the acronyms presented here, we have provided short glossary of terms at the end of this paper.

MACRA: An Overview

In October 2015, CMS published section 101 of MACRA which repealed the former methodology for updating the physician fee schedule (PFS) and replaced it with a methodology called the Merit-based Incentive Payment System, or MIPS. MIPS consolidates components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program. MIPS also includes an additional category for Clinical Practice Improvement Activities (CPIAs). The final rule was released on October 14, 2016, and it is clear that these changes will require significant adjustments for participating providers. While the full impact of the final rule is still being reviewed, the effective date for data collection and reimbursement changes are scheduled to occur as early as January 1, 2017, leaving providers with little time to prepare. With potential reimbursement gains as high as 12 percent and negative impacts of up to nine percent, it is imperative that practices prepare quickly for these changes. Rather than address specific measures and regulations, this white paper suggests that this radical change in approach by CMS affords an opportunity to optimize current quality initiative approaches in order to remain responsive to current regulatory requirements and proactively prepare for future requirements. 

Optimizing a Practice’s Quality Program Approach

In recognition of the ever-increasing regulatory requirement burdens placed on providers and in an attempt to decrease the total number of measures, CMS has consolidated program measures, eliminated redundancies, and retired measures that are no longer necessary. They have also softened many of the former “all or nothing” requirements. These changes allow practices to customize their response by leveraging those measures for which they have strength and allow time for improvement in areas of weakness in order to meet the overall regulatory requirements. By optimizing, or formally developing, these four common quality program steps, practices can simplify and solidify the process for achieving successful regulatory compliance:

  • Create (or refine) a Practice-wide Quality Program structure
  • Build, test, and validate reports • Identify, prioritize, and select metrics
  • Establish ongoing monitoring and solicitation of feedback

Creating a Practice-wide Quality Program Structure

In the past, quality initiatives were often distributed among different people or even different departments (i.e., quality, compliance, performance improvement, financial, etc.). For smaller practices, many times they became the responsibility of one person who may or may not represent the overall practice goals and mission, or assigned to an already overworked provider. There was insufficient focus and a segmented approach where decisions might not reflect the long-term practice strategy, or worse, result in redundant or conflicting work efforts. This inefficient approach often resulted in the inability to respond in a timely manner to requirements and updates. In a Practice-wide Quality Program structure, practices develop short and long-term goals and establish a governance and decision process that ensures alignment of work efforts and resources and results in the rapid selection of metrics to be addressed. The first step is identifying ownership of quality initiatives and defining an overall approach to quality metrics. This includes identifying goals and guidelines for deciding which quality programs the practice will choose to participate in and how specific metrics will be selected. This facilitates the coordination of metrics across quality programs and creates efficiencies in development and metric implementation by eliminating duplicate or competing work efforts. It also allows practices to efficiently respond to new developments and requirements.

Building, Testing, and Validating Quality Reports

Reporting is undoubtedly one of the largest challenges facing most practices today. With a reported average of $40,069 per physician, per practice spent on quality reporting each year, having accurate information readily available is critical to success. Reporting requires an understanding and application of data governance, effective data capture, and the ability to reproduce timely reports that accurately reflect the clinical activities representing individual provider’s metrics. Quality reports must be built, tested, and validated before they can be interpreted. Interpretation is essential for focused selection and prioritization of metrics that will help drive the organization’s short and long-term decisions for their quality program.

Identifying, Prioritizing, and Selecting Metrics

With a solid Practice-wide Quality Program structure in place, the next step is to identify, prioritize, and select metrics. Practices must be able to accurately report on their current state during this process and should factor in the following considerations:

  • Measure alignment across different providers and quality programs is necessary for efficient EHR builds and support, so consideration should be given to those measures found consistently across practices.
  • Limited resources necessitate selecting measures that can be met with existing technology and workflows, while prioritizing others for build, testing, and training.

Monitoring and Soliciting Feedback

Finally, after completing the first three steps, the last area of optimization is the current approach to monitor and solicit ongoing feedback. Too many practices have entered into quality initiatives that, despite great forethought, decisions, and implementations, were ultimately unsuccessful due to the absence of a formalized process for monitoring and soliciting timely feedback.

In order to change the daily activities of providers to successfully achieve compliance with each measure, providers must first understand the baseline for each measure and why providers are being asked to perform in a particular manner. While the frequency of monitoring and feedback will vary depending on the particular metric, the ownership, accountability, and escalation processes should be established at the onset and remain consistent throughout the life of the metric. Even with the most efficient and timely reporting, without monitoring, timely feedback, and accountability, experience shows most practices will remain unsuccessful.

Optimization – The Time is Now

With the release of CMS’ 2,398-page Quality Payment Program final rule covering MACRA, organizations have immediately begun a detailed review to determine the impact on provider practices and reimbursement. Once these details are fully understood, practices can began to develop and refine their approach. Regardless of the details, it is clear CMS is dramatically changing the approach to provider payment, solidifying their move from a fee-for-service (FFS) to a pay-for-performance (PFP) system.

With January 1, 2017, just months away, all Medicare providers should be making plans to prepare, if not already preparing, for compliance with the new MACRA requirements, yet a recent study found that half of all physicians have never even heard of MACRA. While understanding the final rule is certainly important, there has never been a better time to optimize your practice’s overall approach to quality programs in preparation for what is certain to be a continued evolution of performance reporting requirements. 

Glossary of Terms/Acronyms

Why CTG?

CTG is a recognized leader in the planning, design, implementation, and optimization of today’s leading healthcare information technology solutions and business processes.

CTG has provided support for various quality programs, including helping practices successfully establish individualized Practice-wide Quality Program structures. Our experience with the quality initiatives under MACRA allows us to provide knowledgeable assistance with the foundational building blocks of a formal quality initiative approach, including recommending participants and team members, committee governance and decision process, the development of long and short-term goals, and intervention and risk mitigation strategies.

Using best practices and industry experience, CTG helps guide practices on metric identification, prioritization, and selection, while imparting the skills necessary to provide regulatory education and understanding to practice staff. CTG’s combined technical and clinical resources can also assist with the complete life of a metric, beginning with the build, testing, and validation through education and training.

CTG’s industry experience with the various quality initiatives in MACRA gives us the ability to make best practice recommendations on the type of monitoring, frequency, and feedback for various metrics and practices. With deep experience in metric monitoring, CTG can help practices establish a minimally invasive monitoring program that will provide timely and relevant feedback on performance and result in successful metric submissions.

CTG’s Advisory and Implementation Services combine experienced clinical and technical consultants, deep knowledge of the healthcare industry, and a wide breadth of technical knowledge, including hands-on experience with more than 200 healthcare systems. By tightly integrating strategy, technology, vendor knowledge, and industry best practice, CTG’s offerings help our client’s achieve the foundational governance necessary to support technical and clinical transformation. 

For More Information:

Hamish Stewart-Smith

Managing Director, North American Sales, Health Solutions

+1 610 246 7778