Published 2/1/2016
Jackie Ryan, MPA

Healthcare Performance Measures Increase in Importance

Performance measures symposium will help answer growing list of questions
Some say the performance measurement train has left the station. There is no doubt that there is widespread concern from physicians about the financial consequences and regulatory complexity of the Physician Quality Reporting System (PQRS), Meaningful Use, Electronic Health Records (EHR) Incentive Program, and Value Based Modifier. In 2015, the Sustainable Growth Rate Reform, also known as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), called for the consolidation of all of these programs into a new system called the Merit-Based Incentive Payment System (MIPS), which will begin in 2019. Yet in order to avoid negative payment adjustments, providers are still required to successfully participate in the current Medicare quality reporting programs. As a result, there is a wave of questions and concerns about the measurement of cost of care without accompanying quality of care measures in the current quality reporting programs.

The major players
These days it seems everyone inside and outside of medicine demands improvement in patient outcomes by way of explicit measurement and reporting by individual providers, as well as care delivery systems. The major players include the U.S. Centers for Medicare & Medicaid, private payers, the U.S. Agency for Healthcare Research & Quality, The Joint Commission, the National Quality Forum (NQF), America's Health Insurance Plans, and the public. Yet there is a lack of information, and a prevalence of misinformation about the requirements and how to participate in the quality reporting programs.

The role for physicians
As the quality reports system continues to evolve, orthopaedic surgeons and AAOS need to play a central role by acting together and:

  • developing evidence-based clinical practice guidelines (CPGs) for important orthopaedic conditions
  • developing clinical quality performance measures for important orthopaedic conditions, useful to orthopaedic surgeons and based on evidence-based CPGs
  • working toward standardization of performance measures
  • sharing information about performance measurement and the use of measures in reporting programs

Key terms
It is important that any discussion of performance measurement include a basic understanding of important terms:

Quality—Quality is how good something is. For health care, it is often expressed in a range. When a person receives high-quality health care, he or she has received the right services, at the right time, and in the right way to achieve the best possible health.

Performance Measure—Healthcare performance measure is a way to calculate whether and how often the healthcare system does what it should. Measures are based on scientific evidence about processes, outcomes, perceptions, or systems that relate to high-quality care. NQF-endorsed measures are tools that show whether the standards for prevention, screening, and managing health conditions are being met. Patient experience measures are performance measures, and the concepts that the patient-experience survey evaluate are based on evidence.

eMeasure—eMeasures are performance measures that have been developed for use in an EHR or other electronic system. eMeasures pull the information needed to evaluate performance directly from the electronic record. They can be far more efficient than traditional approaches of extracting data from paper charts or claims databases

Cross-cutting area—Cross-cutting areas refer to broad topics that people are interested in measuring and improving across the healthcare system. Sometimes we think about high-quality health care in the context of a disease, such as cancer, and making the right choices for treatment. Other times we think about factors that affect everyone receiving health care regardless of disease, like how well physicians and nurses communicate with patients.

Health Information Technology (HIT)—HIT is of increasing importance for health care. Using HIT means that computer hardware and software do the work of storing, retrieving, sharing, and analyzing healthcare data. HIT helps healthcare providers to communicate securely, coordinate care, and better manage services for their patients. HIT can include the use of EHRs as well as personal health records.

Measure specifications—Measure specifications are the technical instructions for how to build and calculate a measure. They describe a measure's building blocks: numerator, denominator, exclusions, target population, how results might be split to show differences across groups (stratification scheme), risk adjustment methodology, how results are calculated (calculation algorithm), sampling methodology, data source, level of analysis, how data are attributed to providers and/or hospitals (attribution model), and care setting.

The future
Health care has been moving, albeit slowly, toward quality reporting programs. Even though the PQRS program has been in place since 2007, there are very few relevant orthopaedic performance measures available for surgeons to use. With the passage of MACRA and the new system in MIPS, quality measure reporting is center stage. It is critical that orthopaedic surgeons work together to develop relevant performance measures, and for them to understand their quality measure reporting options.

To learn more about how Medicare quality standards guide both government and commercial reimbursement, and examine the business case for PQRS participation, register to attend the Performance Measures—Clinical Quality—Medicare PQRS Pathways for Payment Symposium at the 2016 AAOS Annual Meeting in Orlando, Fla., on Tuesday, March 1, from 1:30 pm to 3:30 pm, in Valencia Room B of the Orange County Convention Center.

Jackie Ryan, MPA, is manager, performance measures at AAOS. She can be reached at ryan@aaos.org

The NQF Phrasebook. Available at http://public.qualityforum.org/NQFDocuments/Phrasebook.pdf. Accessed January 14, 2016.