Quality Review and Accountability 1 PDF

# SECTION 2 - Quality Review and Accountability ## Section Contents **Introduction:** - Increased focus on transparency and accountability for healthcare quality, outcomes, cost, and value. - The healthcare quality professional must guide their leadership team toward improved clinical and financia...

# SECTION 2 - Quality Review and Accountability ## Section Contents **Introduction:** - Increased focus on transparency and accountability for healthcare quality, outcomes, cost, and value. - The healthcare quality professional must guide their leadership team toward improved clinical and financial outcomes. - Strategies and tactics for data reliability, effective utilization of reporting and analytics tools, compliance with external reporting requirements. - Discussion of methods to drive multidisciplinary stakeholder collaboration. **The Accountability Imperative:** - System complexity is inherent in healthcare. It is a dynamic network of interactions across diverse stakeholders. - Patients seek illness prevention, maintenance of health, or recovery from illness; providers desire to use the best possible science; and payers and regulators strive to balance economic responsibility while adapting to social, scientific, and environmental changes. - The principles of value-based care have prompted the industry to take greater accountability for those multistakeholder costs and outcomes. - Healthcare spending in the United States reached $3.8 trillion in 2019. - Quality review and accountability combines the science of data acquisition, data integrity, analysis, modeling, and benchmarking with the art of communication, collaboration, partnership, and behavior change. **Making the Business Case for Quality** - Healthcare has roots in a cottage industry where the craft of medicine was practiced at the local level. - Quality review starts with a grassroots effort to drive the adoption of value-based care initiatives within the organization, identify productivity and efficiency gains that lead to cost reduction. - The growth of value-based reimbursement necessitates a more collaborative relationship between providers and payers of healthcare. - Healthcare quality professionals need to be prepared to demonstrate the unique value of the organization and its capacity for improvement using data to focus on centers of excellence and recent performance improvement successes. - Healthcare organizations measure financial performance using markers such as operating margin. - The debate over the relationship between cost and quality is a driving force behind healthcare reform. **Quality and Payment Models:** **Value-Based Care Agreements:** - Providers are incented to deliver an evidence-based care model that focuses on health and wellness. - Payment is based on performance derived from a combination of measures of efficiency and effectiveness. - Performance-based payment models have reshaped the healthcare landscape from 2012–2022. - More than a third of U.S. healthcare payments were the result of a form of value-based payment. - This relationship of cost and reimbursement to quality has redefined the role of healthcare quality measurement and management. **Quality as Policy:** - The COVID-19 pandemic exposed many problems in the U.S. healthcare system. - Current fee-for-service payment models pay only for specific clinical services. - An emphasis on SDOH helps mitigate barriers to accessing preventive care in marginalized populations. - Policy makers are becoming increasingly aware of the need to care for the whole patient. - The increased focus on strategies to address social needs led 24 states to require that Medicaid managed care organizations screen beneficiaries for unmet social needs. **Quality as a Profession:** - Prior to 1983, hospitals were paid for each unit of service. - Under the Inpatient Prospective Payment System, patients were grouped into DRGs. - This first wave of payment reform elevated the medical record itself to a source of revenue. - The quality profession evolved from its roots in quality assurance (i.e., monitoring and reporting of measures) to a profession that is now driving quality, safety, value, and innovation in healthcare. **Quality as a Center of Excellence:** - Quality is not a program or a project; it is not the sole responsibility of a single individual or the quality department. - The healthcare quality professional should be a guide and trusted advisor. - Organizations have been plagued by information silos. - Value-based payment models forced the dissolution of those silos across the healthcare system. - Bringing multiple disciplines together with different skills, knowledge, attitudes, and responsibility around a common mission creates transparency. **Quality as an Operational Mandate:** - As the population ages and chronic conditions increase, so does healthcare spending. - The need to provide value requires the clinical and financial accountability of providers and payers alike. - The introduction of APMs requires provider-sponsored health plans to take responsibility for a specific subset of Medicare patients. - When providers and payers share financial risk, patients benefit from a coordinated approach. **Quality as an Organizing Structure:** - As healthcare delivery has historically been fragmented, making it difficult to control costs and accountability, the evolution of payment models may necessitate a redesign of many organizational processes. - A key goal of value-based healthcare models is to improve coordination of care. - Organizational structures influence cost and quality performance. **Multihospital Systems:** - Multihospital systems can create economies of scale and expand their delivery network. - Clinically integrated networks share a high degree of risk and rely on interdependence among network physicians to ensure cost management and quality. **Clinically Integrated Network:** - Providers are either integrated via ownership or contractual relationships. **Physician Hospital Organization(s):** - Physicians maintain independent ownership and management of practices. **Integrated Delivery System:** - Providers join systems through ownership or formalized contractual agreements. **Payment Taxonomy Framework** - This framework is instrumental in developing the payment structure. - Depending on the type of model, the contribution of the quality measures to the reimbursement model will vary. **Current and Emerging Payment Models:** - **Fee-for-service:** Payments are based on volume of services. - **Traditional Capitation:** Paid to cover all service within a specific period of time. - **Pay-for-performance:** Paid for achievement of (or improvement in) a quality measure. - **Bundled Payments:** Paid for all services rendered for a given episode of care. - **Shared Savings:** Paid based on spending below a predetermined benchmark over a period of time (contingent on meeting certain quality targets). - **Blended FFS and Capitation:** Combination of FFS and capitation based models. - **Comprehensive (Primary Care) Payments:** Paid a risk-adjusted amount to cover all primary care services. **Government Payers:** - CMS has led the way in launching new models such as the Hospital Value-Based Purchasing (VBP) Program. - State Medicaid programs have increasingly included payment reforms in their waivers and managed care contracts. - CMS has continued to test various models, including quality bonuses in a traditional fee-for-service model, to full capitation in the form of patient-centered medical homes, and integrated accountable care organizations. **Commercial Markets:** - Programs evolve and improve as market demands change, and commercial markets tend to leverage innovation. - Increaseing premiums and OOP costs have triggered an increased interest in consumerism and tranparency. **Alternative Payment Models:** - Risk sharing is an agreement between providers and payers to share financial responsibility for the cost of patient care. - The greater the risk, the greater the incentive to provide efficient, cost-effective care. - **Upside Risk:** Providers share savings with the payer if the cost of care is below the benchmark. - **Downside Risk:** Providers who exceed the financial benchmark must refund the payer for all or a portion of the expense. - **Two-Sided Risk:** Providers may have both upside and downside risk. **Transition to New Payment Models:** - The transition from traditional fee-for-service payment is fueled primarily by CMS. - Healthcare systems across the country are redesigning their delivery models to embrace value-based care. **Forums on Healthcare Payment Reform** - Healthcare policy can change rapidly so it is necessary for the healthcare quality professional to be aware of current and pending changes to health payment reform. - Healthcare quality professionals should participate in external forums and meetings. **Transparency and Quality Improvement** - Patient access to their own medical records is important. - The impact of transparency on quality is evolving as consumers have increased access to their own health records, understand the price of services, and compare hospital and physician outcomes and performance. **Performance Measurement:** - When quality measurement reflects the care delivered, any variation from the expected measure result represents an opportunity to improve. - Improvement opportunities should be identified using appropriate analytics practices, addressed through the organization’s performance improvement policies and procedures. - **Trends and patterns:** Healthcare is dynamic and subject to external influences of economic, social, and political change. - **Benchmarks:** A key benefit of most value-based reimbursement programs is the availability of standardized data. - **Multidimensional Analysis:** Variations in care found in quality measures impact financial outcomes, and vice versa. - **Physician decisions:** Waste in healthcare is defined as failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. - **Patient Contribution:** Research shows that cost increases as severity rises. - **Process variability:** Patient flow and throughput not only contribute to hospital cost but can have an impact on patient quality. ## Hospital Performance: - The transparency of hospital and physician quality was established with the launch of the CMS Hospital Compare initiative. - As part of the quality review process, practitioners must demonstrate compliance with accreditation standards, contractual obligations, and federal regulatory requirements. - Peer review is conducted to determine areas of risk. - The Hospital VBP Program is designed to incentivize providers for delivering high-quality care while reducing costs in the inpatient setting. ## Medical Peer Review: - Peer review is a process in which the quality of the review by those under review is critical to ensuring the integrity of the process. - The first step is to identify an appropriate peer. - The medical review process is responsible for maintaining confidentiality throughout the process. - **Physician Champions:** Physician champions talk directly with medical staff about their data. - **Physician Profiles:** Practitioner profiles are extremely important to maintain and are used to evaluate performance and maintain privileges. - **Ongoing Practitioner Performance Evaluation:** Practitioners who are granted clinical privileges are required to undergo ongoing practitioner performance evaluation (OPPE). ## Public Reporting: - Public reporting of quality information may be considered as one of the key external drivers for transparency and accountability. - In the early 1990s, New York State began releasing mortality data on patients who underwent open-heart surgery by hospital and ranked hospitals according to how much they deviated from case-mix-adjusted values. - The broad implementation of mandatory public reporting was intended to guide hospitals and physicians. ## Customer Demands: - From the perspective of its customers, a review of the healthcare market segments as well as an assessment of the specific needs, requirements, and expectations will help determine what the organization should do. - The organization determines appropriate mechanisms for obtaining information from its customers. ## Value-Based Service Delivery: - As healthcare delivery system transforms from fee-for-service to value-based service, organizations plan, evaluate, and refine their strategy in response to the ever-changing healthcare market. - Healthcare quality professionals need to understand and demonstrate key competencies related to population-health management and care transitions. ## Quality Measurement Programs: - The landscape of quality measurement programs associated with value-based care is extensive. - Maintaining a current understanding of the programs and how those impact the organization is important. - The healthcare quality professional brings unique skills to advise leadership on the costs and benefits of participating in both mandatory and voluntary measure reporting programs. ## CMS Quality Measures: - CMS uses quality measures in its various quality initiatives that include quality improvement, pay for reporting and public reporting. - **Safe:** The culture of patient safety should be systemic. - **Effective:** Patient receive treatment to effectively manage their condition based on best available evidence. - **Efficient:** Waste in healthcare delivery such as overuse of services, poor supply management, and patient flow bottlenecks result in unnecessary costs. - **Patient-centered:** Care should be individualized for each patient considering social determinants of care and other factors. - **Equitable:** Appropriate care should be delivered to all regardless of race, ethnicity, language, sexual orientation, and gender identity. - **Timely:** Reduce barriers that delay timely treatment, diagnosis, or preventative care. ## Hospital Readmissions Reduction Program: - The hospital readmissions program aims to encourage hospitals to improve patient care by reducing payment for excess readmissions in the following six 30-day, procedure specific, risk-adjusted categories: - Acute myocardial infarction. - Chronic obstructive pulmonary disease. - Heart failure. - Pneumonia - Coronary artery bypass graft surgery - Elective primary total hip arthroplasty and/or total knee arthroplasty. ## Quality Payment Program: - MACRA incorporates quality measurement into payments with the goal of creating an equitable payment system for physicians. - The Quality Payment Program includes two participation tracks: - The Merit-Based Incentive Payment System (MIPS) is linked to performance, including following defined, evidence-based clinical quality measures or - Advanced alternative payment models provide financial incentives to clinicians to provide high-quality and cost-efficient care. - MACRA replaced legacy programs for physicians. - The program is known as the Meaningful Use or MU. ## Accountable Care Organizations: - ACOs are groups of doctors, hospitals, and other healthcare providers who come together voluntarily. - They give coordinated high-quality care to the Medicare patients they serve. ## MIPS Quality Measure Examples: - **Effective Clinical Care:** - Diabetes: Hemoglobin A₁ poor control (>9%) - **Communication and Care Coordination:** - Diabetic retinopathy: Communication with the physician managing ongoing diabetes care. - **Patient Safety:** - Rate of carotid endarterectomy (CEA) for asymptomatic patients, without major complications (discharged to home by postoperative day no. 2) - **Person and Caregiver-centered Experience and Outcomes:** - Cataracts: Improvement in patient’s visual function within 90 days following cataract surgery. - **Community/Population Health:** - Preventive care and screening: Unhealthy alcohol use screening and brief counseling ## Data Management and Reporting: - Data management is a broad concept that encompasses multiple aspects of data access, storage, security, distribution, quality. - Data governance is a discipline adopted and managed by the organization’s IT department in partnership with other functional areas within the organization. - Activities include authorities, roles, responsibilities, organizational structures, policies, processes, standards, and resources for the definition, stewardship, production, security, and use of data. **Data Modeling and Design:** - Healthcare generates massive amounts of data. - Data must be optimized for reporting. **Data Quality:** - Ensuring data accuracy is important. **Documents and Content:** - The organization should regularly review and revise data content policies to determine what data are required and available for quality reporting. **Internal Reporting Activities:** - Data quality management should be embedded in the routine reporting schedule. **External Reporting Activities:** - Claims data are submitted, measures are calculated by the payer, strategies are negotiated with the payer. ## Administrative Data: - Also known as patient billing data. Created as a by-product of the patient care process. - This data is often used as a foundation for public reporting. ## Claims Data: - Claims data differ from administrative data in that it typically describes what the payer reimbursed the provider for care. - It is the source of data that insurers rely on for HEDIS reporting. ## Electronic Health Record: - The Health Information Technology for Economic and Clinical Health Act of 2009 helped advance the adoption and meaningful use of EHRs. ## Patient Surveys: - Surveys provide direct access to the patient to assess experience and satisfaction with the healthcare provider. - Organizations use a certified third party to survey clients directly or use a third party to capture the information by mail, telephone, or website. ## Patient-Reported Outcomes: - Patient-reported outcomes are a mechanism for patients to self-report on health condition, functional status, symptoms, and health behaviors. - The Patient-Reported Outcomes Measurement Information System tool is one example of an instrument to administer the survey and collect the data. ## Meaningful Measures: - Government, commercial, and internal programs have been burdensome to clinicians. - The Meaningful Measures objective was to reduce the number of Medicare quality measures, ease the burden on users, and prioritize patients over paperwork. - Meaningful Measures 2.0 moves from measure reduction to measure modernization by: - Focusing on key quality domains and measures - Aligning measures across programs and partners - Prioritizing outcomes and patient-reported measures - Transforming measures to fully electronic - Developing and implementing measures that reflect social and economic determinants. ## Quality and Accountability: - The Joint Commission announced four initial core measurement areas for hospitals, which included acute myocardial infarction and heart failure. - Commercial quality management solutions evolved into a range of robust tools that may combine quality management, risk management, case management, and patient safety management with comparative data and advanced analytics. ## Organizational Structure: - The size and scope of the buying organization will drive the capabilities required in a quality management solution. - Quality management solutions range in functionality from regulatory reporting-only solutions to fully integrated quality, risk, safety, and case management solutions. ## Interoperability: - Organizations may lean toward a single vendor strategy, centered around the EHR, to limit the number of suppliers, improve interoperability, and lower IT costs. - The EHR clinical decision support capabilities are essential to quality management. - The EHR may not contain a fully integrated suite of products. ## Analytics Capabilities: - Any quality management system will have standard reports for viewing results. - Healthcare quality professionals should determine the level of analytics available; for example, multiple layers of segmentation. ## Vendor Support: - Quality management vendors must stay up to date on regulatory reporting requirements and are accountable for providing the most current measure definitions to their customers on a timely basis. - Vendors may also be asked to provide documentation of their security and privacy infrastructure. - The service philosophy of a vendor is important to understand as it may impact the skill sets needed. ## Decision Making: - Conduct due diligence on any potential product purchase and solicit the collaboration of strategic, financial, and technical stakeholders. ## Continuous Learning: - It is the role of the healthcare quality professional to adopt a practice of staying informed. - This includes attending webinars, reading newsletters, or reviewing the Federal Register. ## Business Intelligence: - Tools that provide dashboards, interactive visualization, and self-serve data analysis create transparency for key stakeholders across the organization. ## Clinical Informatics: - Domain expertise in clinical documentation is a key success factor in the secondary utilization of EHR data for quality measure reporting. - Clinical informatics focuses on how data are acquired, structured, stored, processed, retrieved, analyzed, presented, and communicated. ## EHR Vendor: - The EHR vendor plays a strategic role in the ability to structure data so healthcare providers can easily retrieve and exchange patient information. ## Marketing: - Healthcare is a competitive business with organizations competing for: - patients - payers - staff - market share - mind share ## Data Management and Reporting: - Data management is a broad concept that encompasses multiple aspects of data access, storage, security, distribution, quality. - Data governance takes place through a framework or structure for ensuring that data assets are transparent, accessible, and of sufficient quality. ## Sharing Performance Results: - Healthcare leaders are faced with unprecedented amounts of information and dozens of decisions to make every day. - The processing capacity of the conscious mind has been estimated at 120 bits per second. - **Know the Audience:** The two hemispheres of the human brain specialize in distinct mental functions. The healthcare organization functions similarly where multiple disciplines need to connect to make strategic decisions. - Financial leaders may view outcomes through an organizational lens of cost, revenue, and margin. - Clinical leaders hold a patient perspective. - **Building a Common Vocabulary:** Healthcare leaders may find that a different vocabulary used across clinical and financial disciplines. - **Reframe Positive Outcomes:** Research suggests that the human brain has a bias toward remembering negative events. - **Storytelling:** Storytelling is a powerful means of communication. It existed long before written human history as a means of entertaining, providing safety, sharing traditions, and passing down knowledge and morals. - **Analysis:** Analysis is the foundation. - **Relevance:** Reports must be supported by relevant, real-life situations. - **Trust:** Trust is the third component. - **Visualizing Data:** Reports are simply a record of the findings of the data aggregation from which the analysis can be formed. - **Presenting Best Practices:** The goal of storytelling is to take complex ideas and make them relatable to the audience. ## Key Points: **Quality and Accountability:** - The growth of value-based reimbursement necessitates a more collaborative relationship between providers and payers of healthcare. - Strong collaboration between the quality, managed care, and financial leaders yields the most successful contract negotiation and management for the organization. - Healthcare policy can change rapidly, so it is necessary for the healthcare professional to be aware of current and pending changes to health payment reform. - The healthcare quality professional is uniquely positioned to evaluate quality management solutions, ensure improved performance on quality metrics, and support both internal and external reporting needs. **Performance Measurement:** - Multiple data sources are required for measure development, including claims, clinical, and survey data. - Best practices for staying informed of quality measure changes include participation in webinars and events sponsored by CMS, payers, EHR vendors, and thought leadership organizations. - Reporting activities for various payment programs should be identified and managed to ensure critical timelines are met. **Data Management:** - Data governance is a core competency, and components should involve technical, education, business intelligence, and reporting capabilities. - Collaboration across stakeholders is necessary to ensure a successful transition to eCQMs. - The CMS Measure Inventory Tool is a key resource for identifying the status of measures, measure definitions, and calculations. - Meaningful Measures 2.0 is reducing the number of measures by focusing on key domains, outcome priorities, and measure alignment across multiple programs, with the goal to transform measures to fully digital by 2025. **Sharing Performance Results:** - The healthcare quality professional must engage in effective communication to prevent information overload. - Building a common vocabulary across clinical and financial disciplines can minimize misunderstandings. - Use storytelling to motivate multiple stakeholder. - Transparency of quality enables patients to be a partner in decisions. - Effective presentation skills and use of presentation tools are a must. **Organization Structure:** - The size and scope of the buying organization will drive the capabilities required in a quality management solution. - Integrated solutions (quality, risk, care management) offer the promise of streamlined data acquisition. This strategy can be especially impactful across large integrated networks. **Interoperability:** - The EHR may not contain a fully integrated suite of products for quality measurement. **Analytics Capabilities:** - Healthcare quality professionals should determine the level of analytics available. - Usability is a key feature that will increase utilization and ensure adoption of the measures results. **Vendor Support:** - Quality management vendors must stay up to date on regulatory reporting requirements and are accountable for providing the most current measure definitions to their customers on a timely basis. - The service philosophy of a vendor is important to understand as it may impact the skill sets needed. **Decision Making:** - Conduct due diligence on any potential product purchase and solicit the collaboration of strategic, financial, and technical stakeholders. **Continuous Learning:** - The healthcare quality professional’s role is to stay informed. - This includes attending webinars, reading newsletters, or reviewing the Federal Register. **Business Intelligence:** - Tools that provide dashboards, interactive visualization, and self-serve data analysis create transparency for key stakeholders. **Clinical Informatics:** - Domain expertise in clinical documentation is a key success factor in the secondary utilization of EHR data for quality measure reporting. **Marketng:** - Healthcare is a competitive business with organizations competing for: - patients - payers - staff - market share - mind share **Data Management and Reporting:** - Data governance is a discipline adopted and managed by the organization’s IT department in partnership with other functional areas. - Data governance helps maintain and improve the quality and transparency of data. **Sharing Performance Results:** - Storytelling is a powerful means of communication. - Analysis, relevance, and trust are important components. **Online Resources:** - Agency for Healthcare Research and Quality - AHRQ QI Software - CareDash - Centers for Medicare & Medicaid Services - Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) - Measures Inventory Tool - Medicare Provider Data - Youtube Channels - DocSpot - Healthgrades - Kaiser Family Foundation - Look Up Your Hospital: Is It Being Penalized by Medicare - International Classification of Diseases (ICD) - Regions Hospital - University of North Carolina Cecil G. Sheps Center for Health Services Research - Rural Hospital Closures - The Joint Commission - Quality Measurement Webinars and Videos - WebMD - ZocDoc