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Value-Based Care in Uncertain Times: Navigating the Quality Payment Program
December 12, 2016

Value-Based Care in Uncertain Times: Navigating the Quality Payment Program

Though there are many unknowns regarding how the Trump administration will affect policy, there is bipartisan support for lowering costs and increasing quality. The Medicare Access & CHIP Reauthorization Act of 2015 is a separate law that was passed with 92% bi-partisan support in 2015. Read on for tips on creating a strategy that will set you up for success under advanced alternate payment models.
Ramping Up to Advanced APMs
MIPS engagement will be used as a baseline for future APM activity, but is the organization ready to assume financial risk? Are policies, processes, and analytics in place to measure if actual costs will exceed projected expenditures? These are critical questions that must be answered to determine whether the transition to Advanced APMs can happen.
After developing a MIPS-based strategy in 2016-2017, an organization can make better-informed decisions on if and how to participate as an APM or Advanced APM entity. Intermediary models such as Track 1 MSSP ACO or CPC+ may provide a means for many to test the waters of performance-based payment arrangements. Using experience in these and other programs, strategies can be aligned with inherent strengths based on historical performance in clinical quality measurement and utilization.
For example, a MIPS organization can transition to a MIPS APM by participating in an MSSP Track 1 ACO in 2018. By comparing quality measures that crosswalk between those available via Direct CEHRT reporting and GRPO Web Interface, a focus on quality improvement can begin now with this future objective in sight. Likewise, improving efforts to close the referral loop by electronically sending and receiving patient records will guarantee higher performance within the ACO or medical home by way of improved care coordination.
Additionally, public reporting of quality ratings on CMS’s Physician Compare website will be a factor in how practices compete in the marketplace, and non-participation will delay any favorable reviews. Before dismissing the accuracy or contextual validity of these reviews, organizations would be well-advised to consider the potential future uses. The consumer-generated ratings that CMS makes available on the Physician Compare website will be the same dataset that innovative tech start-ups will have available to them. Consumers shopping for healthcare providers may not be going straight to the Physician Compare website for reviews, but they may be using an app that does.
Learning by Doing
CMS doesn’t expect organizations to make the leap to Advanced APMs overnight. The QPP is designed to reward increased measurement, improvement, and risk assumption over time. Take a learning-based approach and begin planning a transformation from existing quality initiative efforts now. Leverage the analytics and workflow redesign capacity of the electronic health record to develop a clinically appropriate and cost-saving strategy to value-based care. Lastly, take a cue from CMS and solicit input from customers, in this case patients and caregivers.
Healthcare Reform Under a New Administration
What remains to be seen is how the mechanisms for controlling spending will change—will Congress continue with downside risk models (eg, MSSP ACOs) or focus its reform efforts on reimbursement cuts? Since there is little evidence to show that they have reduced costs for CMS, the future of ACOs may be in doubt if a full repeal or thorough dismantling of the ACA is achieved. Emphasis may instead be placed on bundled payments for episodes of care.
An important entity common to the ACA and MACRA is The Center for Medicare & Medicaid Innovation (CMMI). The CMMI is authorized by the ACA to test and scale new models in fee-for-service Medicare, including the Advanced APMs designated in MACRA. With a remaining budget of $3 billion through 2019, CMMI programs are not subject to congressional approval. There is uncertainty about whether Congress will choose to assume greater authority over these pilot payment reform programs or act to eliminate the CMMI along with the ACA. Early indicators of the HHS transition team appointees suggest that fundamental elements of market competition, data transparency, and patient access will remain central to any future legislation.

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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