Growing Pains in Quality Reporting Measures Affect Your Reimbursement Rates

Meg Barbor, MPH

June 2017, Vol 7, No 6 - Reimbursement


Orlando, FL—“Are we really measuring quality, or are we measuring our ability to report?” asked Brian R. Bourbeau, MBA, Director, Practice Operations, Oncology Hematology Care, the US Oncology Network, Cincinnati, OH. “So far it’s been the latter,” he said.

At the American Society of Clinical Oncology’s first Oncology Practice Conference in March 2017, Mr Bourbeau offered insights into setting realistic metrics that support value-based care in oncology.

The evolution of the Centers for Medicare & Medicaid Services (CMS) quality payment programs began with the Physician Quality Reporting System (PQRS), which later evolved into the Physician Value-Based Modifier (PVBM) program. Recently, CMS released the Merit-Based Incentive Payment System (MIPS), a reimbursement model in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

A natural jumping-off point for the reimbursement discussion around quality metrics is with MIPS, said Mr Bourbeau. MIPS metrics under MACRA can be applied to other value-based programs with private payers, and can be used to measure overall quality care in an oncology practice, he explained.

The Problem with the Old Reimbursement Method

Mr Bourbeau argued that quality measures in the PQRS and PVBM programs have not been sufficient in measuring quality differences between groups. The 2016 PQRS measures that are relevant to oncology and hematology put forward “odd numbers,” as the mean score across all Medicare providers for myelodysplastic syndrome or acute myeloid or lymphocytic leukemia baseline cytogenetic testing was 97%, but the standard deviation was 10.4. He attributed this to consistent and efficient reporting on the measure from certain providers, whereas others struggled with reporting and threw off the numbers.

“It’s impossible under the old methodology to be considered high quality,” said Mr Bourbeau. “If you’re 1 standard deviation below the mean, you’re considered low quality.”

Practices that struggled with reporting received financial penalties, and practices that were high quality were overlooked because of skewed data. Among thousands of practices that were rated by Medicare in 2014, none was deemed high quality or low cost. Approximately 5400 groups received penalties from PQRS and PVBM, putting them in the low-quality or high-cost category.

“We have to be part of the discussion around how to improve these programs, differentiate among provider groups, and educate groups on how to avoid penalties due to failures to report. And MIPS is trying to improve upon this,” said Mr Bourbeau.

MIPS has introduced more challenging measures, and rather than characterizing all providers as high or low quality, the introduction of a decile-based program will provide a clearer picture of where providers stand.

Alternative Payment Framework

In 2016, the Health Care Payment Learning & Action Network published a white paper titled “Alternative Payment Model Framework,” which divides value-based care into 4 categories. Mr Bourbeau encourages using this framework as a guideline, because there is currently no standardized definition of value-based care.

Fee-for-service payment models with no link to quality or value fall under category 1.

The category 2 payment model is linked to quality and value, but with minimal risk, including foundation payments for infrastructure and operations, pay for reporting, and rewards and penalties for performance.

Category 3 includes Advanced Payment Models built on fee-for-service architecture, but with risk and shared-savings opportunities.

Category 4 includes comprehensive and/or condition-specific population-based payment.

The majority of practices fall under category 1, but when this framework was first developed, there was pressure from government and payer representatives to push practices into category 4, which would shift all risk onto provider groups. However, pushback from providers landed most practices in categories 2 and 3, said Mr Bourbeau.

Shared-Savings and Risk-Based Payments

Mr Bourbeau reported that 94% of his oncology practice in Cincinnati used the fee-for-service payment model in 2012. In 2016, he set a goal of 63%, and reached 64% of payments linked to impactful measures for the practice. By 2020, he aims for 90% of payments to fall under the value and quality payment model, and to shift more toward shared-savings and risk-based payment programs.

Mr Bourbeau encourages the introduction of provider-based pathways into fee-for-service payment models. “If you want to talk about pay-for-performance to a local payer, pathway adherence is an option for you,” he said. “But don’t wait around for payers to develop their own; offer to measure and share what you’re doing and establish that as a pay-for-performance measure,” he added.

In shared-savings and risk-based models, focus on key cost areas, such as hospital and emergency department admissions, advised Mr Bourbeau. “If you lower those rates, you can design shared-savings models around that,” he said.

Regarding episode- and population-based payment, providers must ask for more data, Mr Bourbeau emphasized. “This can’t just be data on overall trends. Know unit cost, look at utilization rates, develop strategies, and get into high-end data analytics,” he added.

“Not everyone is at the same place in their value-based journey, so they won’t be in the same place for measurement,” said Mr Bourbeau.