One of the priorities of the Obama Administration, through HHS and CMS, is assuring quality health care in the United States. CMS has been implementing a number of quality initiatives across participating providers and suppliers with the goal of increasing effective, safe, efficient, patient-centered, equitable, and timely care. Quality reporting for Medicare providers began with voluntary programs and demonstration projects; it then expanded to become a condition of reimbursement. The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) contained provisions linking Medicare payments to quality outcomes by creating value-based purchasing (VBP) programs for hospitals, skilled nursing facilities, home health agencies, ambulatory surgical centers, and physicians; making improvements to the physician quality reporting system (PQRS); and creating new quality reporting requirements. Regulations have designated quality measures related to health care processes, outcomes, patient perceptions, and organizational structures and systems and provided monetary incentives for high performance, as well as penalties for poor results. Quality reporting initiatives have been implemented for physicians, end-stage renal disease, nursing homes, hospitals, and home health agencies; CMS is now working to standardize performance measurement across all providers to allow individuals to compare care options.
There are many potential pitfalls for providers related to quality reporting. CMS often adds or changes quality measures, and providers must stay informed about what the current requirements are and what documentation is needed. Up-to-date policies and procedures can minimize errors, as can regular comprehensive training, but there are many complicated requirements that providers have to follow. To better understand the impact of quality of care reporting on providers, Wolters Kluwer interviewed Michaela D. Poizner, a member of the Health Law Group in Baker Donelson’s Nashville office.
Wolters Kluwer: Explain the emphasis CMS is placing on quality of care reporting and how that will affect providers.
Poizner: I think there are three interrelated drivers behind CMS’ emphasis on quality of care reporting, and those are cost, outcomes, and patient engagement. These three drivers really form a triangle, with each impacting the other. If patients are more involved in their own health care decisionmaking (and bear some of the expense) that involvement can bend the cost curve. Similarly, patient engagement leads to better outcomes because patients feel empowered to address their health issues and are more inclined to adhere to their treatment programs. If CMS emphasizes outcomes, hospital readmissions and excessive or repetitive tests are likely to decline, which saves costs.
Quality reporting and these three drivers impact providers because patients are more committed to their own care. I am not a clinician, but I can imagine it must be very frustrating to care for someone who, for a variety of reasons, is not invested in his or her own health and wellbeing. Getting patients involved in the process helps providers to do what they really want to do, which is make a meaningful difference in patients’ lives. And, of course, quality reporting often comes along with financial benefits, so providers are appropriately incentivized to provide the best care possible, even as the nation’s health care spend declines. It really is a win-win-win among patients, providers, and taxpayers, who pay for government health care programs.
Wolters Kluwer: What are the main goals of quality of care reporting?
Poizner: I believe that one of the primary goals of quality of care reporting is right in the phrase: quality; but wrapped into that are several other important concepts. Our country right now is at a crucial time from a health care budget standpoint. I think everyone agrees that the incredible amounts of money that we’re throwing at health care are not achieving the desired result. By and large, we are still far less healthy as a nation than some countries that spend much less. We have to be smarter about the way we deploy our resources, meaning our spending should be more efficient. We need dollars to translate to results, and I think that is the heart of quality of care reporting.
Another significant goal of quality of care reporting is transparency. When quality metrics are published in a user-friendly way, two things happen. Patients start to believe that they have the ability to make decisions about their own care—they start taking ownership of their personal wellness, and they take an active role in choosing their health care providers. They vote with their feet. This leads right into the second result of transparency: providers are highly accountable for their results. They’re not only accountable to CMS, but they’re accountable directly to patients. This kind of direct accountability can’t help but drive providers toward excellence.
Wolters Kluwer: As designed right now, are the reporting measures an effective way to achieve those goals?
Poizner: As for the effectiveness of quality reporting measures, I think that is not a simple question. First, this initiative has taken many different forms, some of which are more successful than others. I think overall the concept of quality reporting is an effective way to improve patient care, reduce costs, and increase transparency. But this is absolutely a work in progress. CMS does not have this completely figured out, and there will always be room for improvement. But I think our health care system is moving in the right direction.
One key as this process unfolds is the need for constant communication with the provider community. I know one thing that frustrates providers is when CMS rolls out an initiative, providers invest money, time, and human capital in implementing the initiative, and then CMS changes direction abruptly. This is bit far afield from quality reporting, but we have seen this story play out in the electronic health records incentive program. I think providers understand that trying to improve quality and efficiency is an evolutionary process, but no one wants to be blindsided, especially after a significant investment. Hospitals, especially, do not turn on a dime, and I hope that CMS will be sensitive to that as it continues to mature its quality reporting initiatives.
Wolters Kluwer: Do you think quality of care can be measured?
Poizner: Measuring quality on the micro level can be difficult, because checking a box on a web interface does not tell the full story of a patient. For example, one patient being readmitted to a hospital three times in a month may represent a failure of the hospital to effectively treat the patient on his or her first visit. But in another case, a patient may be readmitted to a hospital three times in a month because he or she truly needed intensive care each time. Despite these individual variations, I think the numbers in the aggregate can tell a compelling story. Understanding that there are outliers, seeing how a provider generally performs on certain metrics, both year-over-year and against other providers, can be very informative.
One important factor is that providers—whether individuals or sprawling health systems—should be compared against similarly situated providers, [rather than] not all providers in the same category. I’m not sure the current quality of care measurement system does a good enough job of taking into account the differences in patient populations, for example. An inner-city safety net hospital on a shoestring budget should be compared against other safety net hospitals in the region, not against the profitable private hospital across town. If quality metrics are going to have an impact on providers’ reimbursement rates, there should be some adjustment for socioeconomic reality. Otherwise, steep reimbursement cuts will eat into a struggling hospital’s already strained budget and further jeopardize quality of care available to patients with the fewest options.
Wolters Kluwer: How should providers approach their preparation for quality reporting? What should they be conscientious of in developing their policies and procedures? Do you recommend any best practices?
Poizner: When providers are preparing to implement a quality reporting initiative, documentation is crucial. This important pillar of all reimbursement and incentive programs cannot be overstated. Policies and procedures should emphasize the creation and retention of documents that substantiate a provider’s quality report. This concept impacts every step of the care process, from adequately documenting care in a patient’s medical record to generating and saving relevant reports from an electronic health records system.
One thing is sure: where there are government payments, there will be audits. Having the records to back up assertions about quality is crucial. Without documentation, the most impressive quality of care report is meaningless.
The other pillar of quality reporting preparation is employee training[, including t]raining providers to create robust medical records, training the records professionals to appropriately retain those records, even training staff how to properly use the quality reporting interface. Every aspect of the process should be fully spelled out in the provider’s policies and procedures, and all staff should be thoroughly and regularly trained to execute the procedures correctly.
Wolters Kluwer: How can providers maximize reimbursement and protect themselves against penalties based on quality reporting?
Poizner: Documentation and training, documentation and training. Breakdowns in these cornerstones have been the source of angst for many a provider. These quality programs are often complicated. The requirements can be dense. And they change. Throw in sloppy recordkeeping and uninformed staff members, and you have a real mess on your hands, a real, expensive mess.
In short, know the rules, be able to prove that you followed the rules, and trust people in your organization to implement the program who understand that the stakes are high and can effectively communicate that to everyone who will be involved. Not only will this maximize your reimbursement and avoid penalties on the front end, but you’ll also be in a much better position to handle the dreaded audit letter when it arrives. Because when the auditor says, “Show me your policy related to fill-in-the-blank quality program,” and you say, “What policy?” that does not bode well for the results of your audit.
Attorneys: Michaela D. Poizner (Baker, Donelson, Bearman, Caldwell & Berkowitz, PC).
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