Regulatory Measures


Darren O'Brien

2021 Changes to the Quality Payment Program: Must-Know Guidelines for ACOs

In 2021, CMS proposes the following four key changes to the Quality Payment Program (QPP) that will impact quality measurement for ACOs and ACO participants:

The discontinuation of the CMS Web Interface.
The introduction of the alternative payment model (APM) Performance Pathway (APP).
The discontinuation of the APM scoring card.
The addition of the APM entity as a submitter type for MIPS.

Each change will create new challenges for ACOs and ACO participants. Organizations can successfully navigate these shifts by partnering with a robust quality measures solution that creates a complete picture by combining comprehensive data and measures information in performance visualizations. An inclusive quality measures solution also creates a thorough workflow by combining the monitoring and improving processes, then submitting performance to payers.

Darren O'Brien

The Complete Guide to MIPS 2021: Scoring, Payment Adjustments, Measures, and Reporting Frameworks

This resource is a comprehensive guide to 2021 updates to Merit-based Incentive Payment System (MIPS) quality measures. This guide will help increase your understanding of MIPS quality measures so you can choose the best quality measures for your team. Learn about important updates to MIPS for 2021, including:

Four significant scoring changes for MIPS 2021.
How CMS weights MIPS categories differently for different MIPS reporting frameworks.
New MIPS scoring hierarchy.
And much more.

Darren O'Brien

Complete Guide to the APM Performance Pathway (APP) for MIPS APM Participants and ACOs

In the 2021 Final Rule, CMS introduced a new and streamlined QPP reporting framework for both MIPS APM participants and ACOs. (Note: a MIPS APM participant is a clinician that participates in an APM but does not qualify as an advanced-APM participant, meaning the clinician is not exempt from MIPS.) The new reporting framework is the APM Performance Pathway (APP). The APP is optional for all MIPS APM participants but required for ACOs participating in the Medicare Shared Savings Program (MSSP).

Rachel Katz

Medicare Advantage HEDIS and Risk Reporting: A Primer for Providers

Medicare Advantage (MA) has exploded over the last 10-15 years, with the number of beneficiaries increasing by almost 400 percent in that timeframe. Provider groups have an increasing percentage of revenue and patients in MA plans and providers
are increasingly compensated based on HEDIS quality measures and risk scores through a combination of claims data and supplemental data. Submitting supplemental data can be critical to ensure providers receive credit for the quality of care they deliver and the true complexity of their patient population. Some plans have well-defined reporting programs, while others have little-publicized channels for reporting supplemental HEDIS and risk data. There are also significant bonuses that MA plans offer to providers for reporting, since the plan benefits immensely from receiving the data.
In this article, you’ll learn:

Why is HEDIS and risk data so important to health plans?
What is supplemental data?
And how do you as a provider organization report this data efficiently to earn incentives?

Will Caldwell, MD, MBA

The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care

Medicare patients make up the majority of health systems’ revenue; yet, organizations earn only a one percent profit while caring for this population. Despite historically low profit margins, Medicare can be lucrative for health systems, and through the Medicare Shared Savings Program, healthcare organizations can increase revenue with four tools:

The ability to aggregate and analyze data.
The ability to align financial incentives between payers and providers.
The ability to engage patients in behavior or lifestyle modifications.
The ability to garner support from clinicians and encourage them to lead the shift to VBC.

As the shift from fee-for-service to value-based care continues, health systems can leverage MSSP to deliver the highest level of care while also increasing profit margins.

Rachel Katz
Darren O'Brien

A Complete Guide to MIPS Quality Measures

This comprehensive guide includes 12 frequently asked questions about Merit-based Incentive Payment System (MIPS) quality measures. This guide will help increase your understanding of MIPS quality measures so you can choose the best quality measures for your team. Find answers to your questions, including:

Where can I find a list of MIPS quality measures?
What are specialty measure sets and how do they categorize MIPS quality measures?
What are submission methods for MIPS quality measures?
How are benchmarks used to score your performance in MIPS quality measures?
What is the burden of different MIPS quality measures?

Tarah Neujahr Bryan

The Able Health Quality Measures Solution: Why a Comprehensive Approach Matters

Able Health combines all claims and clinical data from a health system’s data sources (inside and outside of the hospital) into one location, allowing healthcare leaders to focus more on improving care and less on data management. The combination of a measures engine that calculates performance, a performance dashboard that displays measure performance, and a submission engine that submits data to payers, all powered by the Health Catalyst® Data Operating System (DOS™), enables health systems to identify areas for improvement based on one complete picture of quality performance.

Health Catalyst Editors

Putting Patients Back at the Center of Healthcare: How CMS Measures Prioritize Patient-Centered Outcomes

Today’s healthcare encounters are too often marked by more clinician screen time than patient-clinician engagement. Increasing regulatory reporting burdens are diverting clinician attention from their true priority—the patient. To put patients back at the center of care, CMS introduced its Meaningful Measures framework in 2017. The initiative identifies the highest priorities for quality measurement and improvement, with the goal of aligning measures with CMS strategic goals, including the following:

Empowering patients and clinicians to make decisions about their healthcare.
Supporting innovative approaches to improve quality, safety, accessibility, and affordability.

Britney Rosenau

Evolving CMS Quality Measures Move Towards More Patient-Centered Care, Less Burden for Clinicians

With today’s comprehensive Meaningful Measures initiative, CMS has refocused healthcare quality measures on improving patient needs and experiences, reducing regulatory burden on clinicians, and removing barriers to value-based payment. The evolved quality measures center on patient, clinician, and health system needs and strategic goals to truly impact improving care and lowering costs.
Meaningful Measures, according to CMS, must meet seven criteria:

Are patient-centered and meaningful to patients, clinicians, and providers.
Address high-impact measure areas that safeguard public health.
Are outcome-based where possible.
Minimize the level of burden for providers.
Create significant opportunity for improvement.
Address measure needs for population-based payment through alternative payment models.
Align across programs.

Darren O'Brien

Complete Guide to MIPS Value Pathways (MVPs)

In the 2020 Final Rule, CMS confirmed MIPS Value Pathways (MVPs) as the “future state” of MIPS. MVPs would significantly change the way clinicians participate in MIPS starting in MIPS 2021. This guide explains that transformation.
This guide answers these questions:

What are MIPS Value Pathways?
Will CMS make MIPS Value Pathways mandatory or optional?
When will CMS implement MIPS Value Pathways?
Why is CMS moving to MIPS Value Pathways?
How would MIPS change with MIPS Value Pathways?

Stephen Grossbart, PhD

Engaging Health System Boards of Trustees in Quality and Safety: Six Must-Know Guidelines

The quality and patient safety movement of the early 21st century called for greater board of trustee involvement in improvement. However, too many health systems still don’t have the resources in place to effectively engage their boards around quality and safety measures.
Six guidelines describe how organizations can better leverage data to inform their boards:

Emphasize quality and patient safety goals.
Leverage National Quality Forum-endorsed measures.
Use benchmarking and risk adjustment to select targets.
Access data beyond the EHR.
Provide data and information for multiple organizational levels.
Develop a board-specific measurement and presentation strategy.

Daniel Orenstein, JD

Exceptions to Information Blocking Defined in Proposed Rule: Here’s What You Need to Know

Information blocking practices inhibit care coordination, interoperability, and healthcare’s forward progress.  The ONC’s proposed rule ushers in the next phase of the Cures Act by defining information blocking practices and allowed exceptions. To make the final rule as strong as possible, exceptions should be narrowly defined. In proposed form these include the following:

Preventing Harm.
Promoting the Privacy of EHI.
Promoting the Security of EHI.
Recovering Costs Reasonably Incurred.
Responding to Request that are Infeasible.
Licensing of Interoperability Elements on Reasonable and Non-discriminatory Terms.
Maintaining and Improving Health IT Performance.

This article covers each of these exceptions and discusses what to watch for in the final version of the rule.

Mike Dow
Levi Thatcher

How Healthcare Text Analytics and Machine Learning Work Together to Improve Patient Outcomes

Healthcare organizations that leverage both text analytics and machine learning are better positioned to improve patient outcomes.
Used in tandem, text analytics and machine learning can significantly improve the accuracy of risk scores, used widely in healthcare to help clinicians identify patients at high risk for certain conditions and, therefore, intervene.
Health systems can run machine learning models with input from text analytics to provide tailored risk predictions on both unstructured and structured data. The result? More accurate risk scores and the ability to identify every patient’s level of risk in time to inform decisions about their care.

Bobbi Brown, MBA

Value-Based Purchasing: Four Need-to-Know Domains for 2018

Health systems that meet the 2018 Hospital Value-Based Purchasing Program measures stand to benefit from CMS’s $1.9 billion incentive pool. Under the 2018 regulations, CMS continues to emphasize quality. To reduce the risk of penalty and vie for bonuses, it’s increasingly critical that organizations leverage data to build skills and processes that meet more demanding reimbursement measures.
To thrive under value-based payment, healthcare systems must understand CMS’s four quality domains, and their associated measures, for 2018:

Clinical Care
Patient- and Caregiver-Centered Experience of Care/Care Coordination
Efficiency and Cost Reduction

Bobbi Brown, MBA

The Best Solution for Declining Medicare Reimbursements

I am one of the brave souls who takes the time to read the report issued each spring by the Medicare Payment Advisory Commission (Medpac). The report shows the numbers of Medicare beneficiaries and claims are growing; healthcare organizations are increasingly losing money on Medicare; payment increases certainly will not keep pace with declining margins; and Medicare policies will continue to incentivize quality and push providers to assume more risk. But the report also reveals that some healthcare organizations—referred to as “relatively efficient”—are making money from Medicare with an average 2 percent margin. How do you become one of these organizations? And how do you target and counter Medicare trends that impact your business?

Bobbi Brown, MBA

The Top Three Healthcare Financial Trends in 2017: Payment Transitions, Disruption, and New Skills

Influential healthcare financial trends in 2017 emerged in three areas:

Transitions in payment.
Disruption from familiar players and newcomers.
Emerging data skillsets.

Uncertainty has been a common theme for 2017. Organizations continue waiting for clarity on the future of the Affordable Care Act (ACA), while working to implement value-based care. Changes from established healthcare organizations as well as the arrival of prominent newcomers (e.g., Amazon) add to the unsettled outlook, as do emerging data skillsets.
Amid the uncertainty, however, healthcare is clearly continuing on the path to patient-centered care. Organizations best positioned for 2018 will understand their performance in 2017’s top three healthcare financial trends as they evaluate their preparedness for the coming year.

Daniel Orenstein, JD

Healthcare Reform: Is Bipartisan Legislation Possible?

The effort to repeal and replace the ACA in 2017 failed, leaving the industry wondering if bipartisan healthcare reform is possible in today’s political climate. This article explains why it is possible, by taking a close look at why repeal and replace failed, and why the 21st Century Cures Act and MACRA have been successful.
To stand a chance of being successful, proposed bipartisan healthcare legislation will most likely have one (or more) of five features:

Driven by practical need rather than politics.
Focuses on cost control/cost reduction.
Targets areas that are expected to save money.
Doesn’t involve creating new programs.
Stabilizes the ACA.

There are many bipartisan healthcare legislation opportunities, from expanding the use of HSAs to innovation waivers; opportunities that won’t come to fruition unless the proposed legislation tackles practical problems.

Dorian DiNardo
Maggie O'Keefe

Tackle These 8 Challenges of MACRA Quality Measures

The Medicare Access and CHIP Reauthorization Act (MACRA) appears to be a reporting challenge for many healthcare provider systems with few resources for managing the menagerie of measures. Indeed, with more than 270 measures in play, many systems have yet to jump in, but the deadline is inevitable. A plan of action is possible by recognizing and acting on these eight challenge areas:
Challenge #1: High-level performance insight
Challenge #2: Defining measure specifications
Challenge #3: Data quality reporting requirements
Challenge #4: Benchmarking data
Challenge #5: Proactively increasing measures surveillance to enhance outcomes
Challenge #6: Strategically aligning measures on which to base risk
Challenge #7: Identifying measures with the largest financial impact
Challenge #8: Taking risk in multi-year, value-based contracts
Mid-to-large size provider groups need a strategy around MACRA quality measures and a tool to help them make sense of all the reporting requirements.

Britney Rosenau

Five Strategies for Easing the Burden of Clinical Quality Measures

Healthcare systems need to view regulatory measures in a different light. Rather than approaching them as required processes that burden the system, they should be viewed as quality improvement opportunities that lead to best practices. It helps to have a strategy to get there:

Prioritize measures that truly impact patient care
Have a line-of-sight to reimbursement
Understand measure alignment across programs
Involve the right people
Get involved in measure development upstream

The right tools also help, but a plan for success is advised for healthcare system administrators and clinicians who need to ease the reporting burden and take advantage of every measure in a positive way.

Daniel Orenstein, JD

Three Affordable Care Act Questions Everyone in Healthcare Is Asking

Trump/Republican rhetoric recently met reality when it comes to the Affordable Care Act (ACA). The latest version of the bill that passed in the House is far from a complete repeal and replacement of the ACA. However, the bill includes significant changes to healthcare policy and coverage, from severe Medicaid cuts to shifting financial accountability.
ACA uncertainty has healthcare leaders concerned about how to plot a path forward, with three questions on the top of their minds:

What will the final bill look like?
How do I plan for the changes?
What should happen next to fix the problems with the ACA?

Answers to these questions, although helpful, distract the industry from the ultimate goal: delivering on healthcare’s longstanding mission to provide quality, affordable healthcare. In short, health systems need to continue prioritizing patients until the ACA dust settles in Washington.

Stephen Grossbart, PhD

Preparing for Changes to Medicare Reimbursement—The Latest CMS Proposed Measures

Health systems that aren’t prepared for changes to Medicare reimbursement under a value-based system risk quality penalties and reduced reimbursement. They can protect themselves by following the Centers for Medicare and Medicaid Service’s (CMS) annual Measures Under Consideration List—and not waiting till it’s too late to address gaps in their system. The measures accepted from the list of proposals will help determine the areas of care delivery that Medicare will hold organizations accountable for.
It’s never too early for health systems to prepare. CMS selects measures that are already nationally recognized as priority areas for improvement, giving organizations proactive direction in their improvement strategy.

Daniel Orenstein, JD

Is Value-Based Healthcare Here to Stay? Looking for Answers in New Policies

Healthcare leaders are eager for a modicum of clarity when it comes to the industry’s shift to value-based healthcare given the uncertainties of Congress and the new Administration.
Fortunately, an analysis of three key pieces of information tells us value-based healthcare is likely here to stay:

The 21st Century Cures Act (Cures).
The Executive Order on reducing the “burden” of the Affordable Care Act (ACA).
Tom Price’s comments at his confirmation hearings.

It is a relatively safe bet that value-based healthcare delivery and payment programs will continue to be supported by federal law and regulation for several reasons:

Bipartisan support: The success of Cures indicates that bipartisan cooperation will continue on key healthcare issues.
Market-based innovation: The emerging evidence is that Congress and the Administration will support innovation in payment and delivery models.
Support for Existing ACA Innovation programs: Although highly uncertain, there are some indications that not all of the ACA will be scrapped.

Paul Horstmeier

Introducing Health Catalyst MACRA Measures & Insights—Addresses Top Physician Concern: Capturing Compliance Measures

A recent Health Catalyst®/Peer60 survey revealed that compiling quality metrics is the top concern for physicians—a regulatory burden expected to worsen in 2017 as physicians struggle to report quality metrics for the Medicare Access & CHIP Reauthorization Act (MACRA)—the federal law that changes the way Medicare pays doctors.
MACRA Measures & Insights™—Health Catalyst’s new MACRA solution—does so much more than alleviate this reporting burden:

Helps health systems track and monitor all MACRA measures across multiple departments.
Helps systems maximize Medicare reimbursement and monitor performance against measures year over year.
Enables healthcare organizations to tactically and strategically identify the optimal measures to include within multi-year, value-based care contracts with commercial payers.

Powered by the Health Catalyst Analytics Platform™, which can integrate virtually all of the granular data in a healthcare system, including claims and other external data, MACRA Measures & Insights gives health systems deep insight into performance measures at the degree of detail required for measurement and performance improvement.