Published 3/1/2015
Elizabeth Fassbender

Quality Strategy Enters New Phase

CMS sets goals for shift from volume to value

Established as part of the Affordable Care Act (ACA), the National Quality Strategy was first published in 2011. It is administered by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Health and Human Services (HHS) and serves as a framework for aligning stakeholders on quality improvement efforts and a single approach to measuring quality.

More than 300 groups, organizations, and individuals provided comments to develop the strategy, which resulted in the following three broad aims used to guide and assess local, state, and national efforts to improve health and the quality of health care:

  • To improve overall quality by making health care more patient-centered, reliable, accessible, and safe
  • To improve the health of the U.S. population by supporting proven interventions to address behavior, social, and environmental determinants of health
  • To reduce the cost of quality health care for individuals, families, employers, and government

Within these broad aims are six priority domains (Table 1). Several organizations, including the California Department of Health Care Services and multiple federal agencies such as the Centers for Medicare & Medicaid Services (CMS), used the National Quality Strategy aims and priorities as a foundation to develop their own quality improvement strategies. Under the Physician Quality Reporting System (PQRS), for example, all clinical quality measures align with the National Quality Strategy.

In 2015, physicians are required to report on at least nine measures covering at least three domains of the National Quality Strategy to avoid a 2.0 percent negative payment adjustment in 2017. Selecting measures from only one domain will not result in optimal participation with PQRS. (See “Nonparticipation Has a Price,”)

“Although many in the physician community vehemently opposed this program, the government is continuing to expand its scope,” said Douglas W. Lundy, MD, MBA, FACS, a member of the AAOS Council on Advocacy. “Therefore it is critical that physicians and physician practices report the appropriate quality metrics to CMS to avoid future Medicare payment adjustments.”

Value-based payment goals
The administration’s commitment to quality was made even more apparent in its recent announcement to shift the basis for Medicare reimbursements from volume to value. Specifically, HHS has set a goal of tying 30 percent of traditional fee-for-service Medicare payments to quality or value through alternative payment models—such as accountable care organizations (ACOs) or bundled payment arrangements—by the end of 2016. By 2018, HHS aims to tie 50 percent of payments to these models.

“In alternative payment models, providers are accountable for the quality and cost of care for the people and populations they serve, moving away from the old way of doing things, which amounted to ‘the more you do, the more you get paid,’” said HHS Secretary Sylvia Burwell.

The shift doesn’t only apply to physicians; hospitals will be affected as well. The goal is to tie 85 percent of all traditional Medicare payments to hospitals to quality or value by 2016 and 90 percent by 2018. Programs such as Hospital Value-based Purchasing, under which hospital reimbursements for inpatient acute care services is tied to quality of care, and the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to hospitals with excess readmissions, will be used to meet those goals.

Many alternative payment models have already been implemented in healthcare systems around the country, and Medicare has been experimenting with various payment models for more than a decade. The Obama administration is hoping that the specific goals conveyed in this announcement will accelerate efforts to improve quality of care and control healthcare spending.

HHS also announced the creation of the “Health Care Payment Learning and Action Network,” which will first meet in March and help spread its reimbursement ideas beyond Medicare. The goal is to have private payers, employers, consumers, providers, and states, among others, expand alternative payment models and support their adoption.

Private payer efforts
A number of health systems and insurers have announced a joint effort to shift 75 percent of their business to contracts that focus on incentives for quality and accountability for costs. Initial efforts will focus on ACOs, bundled payment arrangements, and management of the cost and quality of care for high-cost patients, including those with multiple chronic conditions or near the end of their lives.

With ACOs, for example, physicians, hospitals, and other healthcare providers work together to provide complete, coordinated patient care with the goal of improving quality and health outcomes. According to a press release, task force members will seek to enter contracts that “successfully incentivize and hold providers accountable for the total cost, patient experience, and quality of care for a population of patients, either across an entire population over the course of a year or during a defined episode that spans multiple sites of care.”

The AAOS response
The American Association of Orthopaedic Surgeons (AAOS) recognizes that better coordination and integration of healthcare services will likely improve quality of care and patient satisfaction. However, it also notes that one of the biggest challenges in establishing an ACO is “ensuring that solo practitioners, small groups, and small hospitals have the option to participate.”

Other alternative payment models include primary care medical homes and new models of bundling payments for episodes of care. A primary challenge with all alternative payment models, however, is how to measure value and quality.

“In this changing reimbursement environment, innovative payment and delivery models offer many opportunities to reward high-quality care,” stated Thomas C. Barber, MD, who chairs the AAOS Council on Advocacy. “However, it is important that these efforts continue to be physician-led and patient-centric, while ensuring access to care is not compromised. AAOS has taken proactive steps like developing clinical practice guidelines, appropriate use criteria, and performance measures to define appropriate methodologies to accurately measure quality. It is crucial that orthopaedic surgeons retain a leadership position in defining the quality of orthopaedic care.”

Elizabeth Fassbender is the communications specialist in the AAOS office of government relations. She can be reached at fassbender@aaos.org

Learn More…
During the 2015 AAOS Annual Meeting, March 24–28, in Las Vegas, attendees will have several opportunities to learn more about quality programs and their impact on reimbursements, including the following:

  • Symposium B: Why Can’t We All Get Along: Solving a Growing Gap in EMR Satisfaction Between Clinicians and IT Professionals—Tuesday, March 24, 10:30 a.m.
  • Symposium K: Evidence, Quality, Costs, and Reimbursement: Connecting the Dots—Wednesday, March 25, 10:30 a.m.
  • ICL404—Practical Implementation of Quality Improvement in Orthopaedic Practice, Friday, March 27, 8:00 a.m.
  • ICL408—Payment Reform: Update on a Moving Target, Friday, March 27, 8:00 a.m.

Additional Information
AAOS quality efforts:

PQRS: www.cms.gov/PQRS or www.aaos.org/PQRS