Value Management as way to increase alignment on Outcome-oriented measures
In October of 2016, the U.S. Government Accountability Office (GAO) provided results of a study to the U.S. Department of Health and Human Services (HHS) with recommendations that the department prioritize its development of electronic quality measures for the core measures used by private payers, and comprehensively plan, including setting timelines for developing more meaningful quality measures. HHS agreed with the GAO recommendations.
Both the federal government and private payer organizations, such as health insurance plans, have various programs that use quality measures to incentivize providers, such as physicians and hospitals, to improve the quality of healthcare delivery. However, there is concern that if measures are misaligned across these programs, the misalignment could create an administrative burden for healthcare providers.
In addition to ongoing programs at HHS that use quality measures to assess provider performance, the department has proposed to begin implementing the CMS Quality Payment Program in January of 2017. The CMS Quality Payment Program is a new incentive payment program for physicians and other eligible providers, in accordance with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This program will adjust physician and other provider payments through bonuses or penalties based in part on their performance on a set of quality measures. At the same time, multiple private payers have expanded their use of different quality measures to assess physician and other provider quality and adjust their payments accordingly. The combination of these public and private efforts has led to physicians and other providers facing increased financial incentives to demonstrate high or improving performance across a growing list of diverse quality measures.
Areas for resolution
The Medicare Access and CHIP Reauthorization Act of 2015 includes a provision for GAO to examine the use of quality measures across HHS programs and private payers, with a focus on reducing administrative and financial burden. In the GAO report, three specific areas were examined, 1. what is known about the extent and effects, if any, of quality measure misalignment; 2. key factors that can contribute to misalignment; and 3. HHS’s efforts to address any misalignment.
HHS has acknowledged the need to substantially improve quality measurement for physicians and other healthcare providers, and has a stated goal of improving alignment between federal and private payers.
To increase the near-term likelihood that HHS will achieve its goals to reduce quality measure misalignment and associated provider burden, the GAO report recommended that HHS take two primary actions:
- Direct the Centers for Medicare and Medicaid (CMS) and the Office of the National Coordinator (ONC) to prioritize their development of electronic quality measures and associated standardized data elements on the specific quality measures needed for the core measure sets that CMS and private payers have agreed to use.
- Direct CMS to comprehensively plan, including setting timelines, for how to target its development of new, more meaningful quality measures on those that will promote greater alignment, especially measures to strengthen the core measure sets that CMS and private payers have agreed to use.
However, the GAO Report asserts that current plans from CMS do not indicate how its efforts will target new measures that will lead to greater alignment. Achieving greater alignment will make it more likely that the efforts of CMS and private payers to hold healthcare providers accountable for the quality of their care, including CMS’s Quality Payment Program, will reduce administrative burden and provide more meaningful information that healthcare providers can use to identify high-impact improvements.
Value Management Application to HHS and CMS
To address the misalignment cited by the HHS GAO report, implementing a collaborative framework through Value Management methodology can provide a holistic approach to examining the use of outcome-oriented measures among payers, providers, and patients.
Establishing a Value Management capability and related methodology can serve as a potential solution to optimize the alignment of outcome-oriented measures among all involved stakeholders, facilitating the creation of measures that matter most to patients, payers, and providers. This enables healthcare payers and providers to evaluate business process changes and enterprise initiatives, and establishes critical value-based care models. A collaborative Value Management capability also will enable related organizations to determine standards that can predict desired outcomes using a standards-based value realization framework to shift from reactive business operations to proactive service provision of value-based healthcare.
Implementing Value Management processes will also enable CMS to evaluate projected and realized outcomes from major business process changes and enterprise initiatives, such as those resulting from MACRA implementation.
The shared vision is for healthcare provider organizations to apply Value Management as a way of doing business to ensure efficient deployment of capital, improve clinical outcomes, and achieve strategic, operational, and financial objectives.
Value Management process improvements and the Value Realization Framework can present HHS with tools to begin developing outcome-oriented measures that will allow for improved alignment between healthcare public and private payers and providers.