Understanding Quality Metrics Under New CMS Reimbursement Models

Posted by Continuum on Apr 5, 2016 11:00:00 AM

As our healthcare system shifts from fee-for-service to value-based reimbursement, physicians face increasing requirements iStock_000014168761_Full_3_x_5.jpgto report on the quality of the care they provide.The Centers for Medicare and Medicaid Services (CMS) has established a complex system of financial rewards and penalties tied to quality and costs of care. And commercial payers are starting to follow suit. For these reasons, doctors need to understand the quality metrics against which their performance will be measured, and how to optimize the quality results they report.

Under the Group Practice Reporting Option (GPRO) Web Interface, CMS requires primary care physicians to report annually on several point-of-care measures – from how many patients received flu vaccines, to the number screened for colorectal cancer. 

Know the requirements

On the plus side, most doctors already provide high-quality, evidence-based medicine. Where they typically fall short is in understanding the requirements for meeting the quality standards -- including proper documentation.

Here are two examples of GPRO Quality Metrics, their requirements and common errors made by providers:

  • Screening for high blood pressure and follow-up. All Patients 18 and over must have a Blood Pressure (BP reading. If the patient's BP is 140/90 or above with a hypertension diagnosis, many physicians do not realize they’re required to initiate a care plan to address the diagnosis. The physician has a designated time period (for example, one year) to reduce and document the BP at below 140/90.
  • Body mass index (BMI) screening and follow-up. Physicians must document BMI for each patient, then provide counseling for those whose BMI is outside normal levels. Follow-up is critical: Even if BMI is too high or too low, the provider will still meet the metric if counseling is provided and documented.   


The right tools, best practices

In some cases, CMS requires doctors to use a particular tool to satisfy a metric. For instance, one mental-health metric requires use of the Patient Health Questionnaire depression screening (PHQ-9).

However, physicians can often use additional “best practices” to improve quality and reduce overall costs of care. A good example can be seen with the “screening for future fall risk” measure. This metric merely requires the physician to ask patients whether they’ve fallen within the past year. But to better predict fall risk, we advise doctors to conduct a fall assessment using the Timed Up and Go (TUG) test. A positive result enables the physician to implement preventive care such as physical therapy – potentially avoiding serious injury and accompanying high costs. 

To learn more about enhancing your value-based outcomes, download our Six Ways to Improve Quality checklist.

Help for physicians

Given the intricacies of capturing and reporting on quality, private-practice physicians may not have the time or inclination to master these challenges themselves. It’s often more efficient for doctors to work with a qualified enablement partner. Continuum, for instance, provides tools, training and workflows to make these processes manageable for office staff.

Ultimately, metrics will help doctors see their true results -- how well they’re doing for their patients, where they’re making an impact, and where they can improve. Even beyond the financial incentives, these will be the most meaningful rewards.

To learn more about enhancing your value-based outcomes, download our Six Ways to Improve Quality checklist.

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Topics: quality metrics, value-based reimbursement, medicare, CMS

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