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CMS’ Value-Modifier 2018: Where is the transparency?

by Alexis Isabelle, Senior Manager, Clinical Quality Management

We made it through the holidays and came out on the other end ready to kick off an exciting 2017, but providers participating in the Physician Quality Reporting System (PQRS) and Value-Based Payment Modifier (VM) 2016 programs can’t move on quite yet.  With the end of the reporting period comes the all-important data submission period which extends through the end of February or March, depending on how the provider elects to report.  Using data submitted through PQRS, CMS’ VM program will adjust Medicare Part B payments by paying providers based on how well they treat their patients, not just how much they treat their patients. To accomplish this, CMS leverages national benchmarks generated from PQRS 2015 data to set the tone for what constitutes a provider’s low, average, or high quality performance. In theory, this is a great thing—using the more recent quality data to generate healthy competition among providers and physicians groups with the opportunity to receive an incentive payment for delivering high quality. When done in a timely fashion, giving providers and physician groups insight into their current performance allows them to define quality improvement goals and set attainable improvement.

But with the reporting period over, it is too late for providers to strive for improvements in quality performance in 2016. It is, however, time for providers to get their data submitted to CMS and focus on improving quality under the latest CMS program, QPP.  But how can we ask providers to move on when they can’t feel confident that the data they are submitting puts them in the best position to protect their financial interests while demonstrating a high quality of care?

We’ve called for this before, but we won’t stop pointing this out until it is fixed: CMS cannot continue its policy of releasing performance benchmarks after performance periods have ended. Imagine being asked to run a race but only knowing if you crossed the finish line after you are done running! CMS did release benchmarks for the Quality Performance Program on December 29, and while that is still too late for clinicians to make any meaningful course corrections on their performance, it does make it even more ridiculous that the benchmarks for the VM program—which are based on the same core PQRS 2015 data set—remain a secret.

At athenahealth, we’re addressing both of these issues. First, we’ve already helped our providers pick quality measures that we know they have a greater chance of meeting based on their patient population, actual performance data, and the PQRS 2014 benchmarks as reference. When the real benchmarks are released we will re-evaluate our providers against all available PQRS measures we support (over 150) and then identify the optimal reporting method (EHR, Qualified Registry, Registry Measures Group) and the optimal set of clinically relevant measures which will result in each provider contributing the highest quality score for each of their TINs.  Second, we’re getting them off on the right foot for QPP. Learning from our experience with Meaningful Use and PQRS we will, in the words of my colleague, “ensure that we are optimizing athenahealth practices for success so they can met the minimum requirements and perform at a pace that enable them to gain the positive adjustments they deserve.”

We continue to encourage CMS to recognize that providers cannot improve their quality of care when they don’t know what they need to improve upon. Until then, we encourage providers to lean on their health IT partners to help them gain the insight and real-time data they need.

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