The Economic Case for Clinical Quality Measures - White Paper Extract

Despite the uncertainty in today’s healthcare market, one thing remains clear: the move to value-based care and reimbursement is well under way.

While emphasis has consistently been focused on the Affordable Care Act (ACA) and its replacement, other important legislation is already in place that contains a great deal of policy relating to the transition to value-based reimbursement. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—which provides financial incentives for providers to participate in risk-bearing, coordinated-care models and to move away from traditional fee-for-service reimbursement—was passed with overwhelming bipartisan support in both Houses. This suggests that the transition to value is likely to continue. According to a recent Deloitte report1, however, half of surveyed physicians have never heard of MACRA, which is on track to fundamentally change how they are reimbursed under the Medicare Physician Fee Schedule (PFS). And although the first year for payment adjustments under MACRA is 2019, performance in 2017 will determine those payments for many providers.

The Centers for Medicare and Medicaid Services (CMS) has installed a Quality Measure Development Plan framework to build and improve quality measures that providers can use to meet MACRA requirements. These quality measures support the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs), which make up the two tracks of Medicare’s Quality Payment Program. Commercial insurers are also beginning to follow Medicare’s lead2. Aetna expects 75% of its spend to be in the form of value-based contracts by 2020 and Blue Shield of California reported $325 million in cost savings over a five-year period as a direct bi-product of its investment in accountable care.

The Deloitte survey revealed another key issue: physicians recognize that they will need new capabilities—especially as it relates to reporting—in order to address their increased financial risk. In the survey,

It is clear that the new payment reforms that are intended to deliver better care at lower cost share a common requirement: providers, payers, and other healthcare stakeholders must make fundamental changes in their day-to-day operations to improve quality and reduce the cost of care. 

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J. Siemienczuk, MD