Regulatory Measures


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.

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.

Bobbi Brown, MBA
Dorian DiNardo

Are Health Systems Ready for MACRA? Survey Reveals the Number One MACRA Concern and Varying Degrees of Readiness

The Medicare Access and Chip Reauthorization Act (MACRA) replaces a number of value-based reimbursement programs and will use 2017 as its first reporting year. But, despite being right around the corner, a survey of healthcare professionals around the country reveals only one-third are ready.
But while only 35 percent of respondents have a strategy and believe they’re prepared for MACRA, most will participate in the new program. A majority of surveyed hospitals believe MACRA will benefit their physicians (or that they’ll at least break even).
MACRA is new, complicated, and rife with uncertainties given the new administration. According to the survey, the top concern for health systems is compiling MACRA quality measures. But despite the industry’s slow movement towards MACRA, the bottom line is that it’s right around the corner, so hospitals must start preparing for MACRA today.

Daniel Orenstein, JD

Why the 21st Century Cures Act Is Great News for Healthcare

The 21st Century Cures Act, approved by the U.S. Senate on December 7, 2016, is perhaps the most significant federal legislation as it relates to health information technology (HIT) in years. What the Cures Act means for HIT companies and providers is two key things:

Health information interoperability will be strongly promoted (involves the development of a “trusted exchange framework” which is expected to facilitate the exchange of health information nationally and locally).
Information blocking practices will be strongly prohibited (e.g., Implementing HIT in nonstandard ways likely to increase the complexity or burden of accessing, exchanging, or using electronic health information—with fines as much as $1,000,000).

The Act’s impact on the healthcare industry is monumental, with significantly improved provider access to clinical, financial, and operational data to improve outcomes. The Act’s provisions to promote the free exchange of health information will improve care coordination industrywide.

Bobbi Brown, MBA
Bryan Oshiro, MD
Dorian DiNardo

Preparing for MACRA: A Comprehensive FAQ for Physicians

The Medicare Access and CHIP Reauthorization Act (MACRA) overhauls the payment system for Medicare providers. It’s a complex program that requires careful study so physicians can make the best choice for how they want to report. This choice ultimately impacts reimbursement and the potential bonuses or penalties associated with each reporting option.
This FAQ covers both tracks of the new rule, the Merit-based Incentive Payment System (MIPS), and the Advanced Alternative Payment Model (APM), with a background review and a comprehensive list of questions and answers.
It’s a practical guide complete with next steps for strategic and tactical planning.

Josh Ferguson APRN, ACNP, ANP-BC

The Who, What, and How of Health Outcome Measures

Even though thousands of health outcome measures have the potential to impact the work we do every day, how well do we really understand them? In this article, we take a close look at the definitions, origins, and characteristics of health outcome measures. We break down the financial relevance of certain measures, the relationship between outcome measures and ACOs, and which measures impede, rather than enhance, a typical healthcare system. We review the role of an enterprise data warehouse and analytics, and we touch on the future of health outcome measures, all in an effort to provide deeper insight into some of the mechanics behind outcomes improvement.

Bryan Oshiro, MD

How Physicians Can Prepare for the Financial Impact of MACRA

If all goes according to plan, the first performance period for the new Medicare Access and Chip Reauthorization Act (MACRA) is just around the calendar corner. It’s a complicated reimbursement structure with multiple tracks that are guaranteed to reward with bonuses or inflict pain through penalties in CMS’s new zero sum game. To the physicians and practices that adopt this new program early and position themselves for the best fiscal outcomes, go the spoils. But for many smaller practices and those that consistently underperform, the outlook may be glum regardless. Here are some highlights of the new program and the financial impact it will have on clinicians and practices.

Bobbi Brown, MBA

The 7 Best Ways to Prepare for MACRA Today

The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law in 2015, with major impacts starting in 2019. MACRA attempts to prioritize quality over quantity by letting providers choose between two value-based payment tracks: MIPs and APMs. Providers won’t have to choose until 2019; until then, they will receive a .5 percent annual increase.
The industry is conflicted about MACRA. On the one hand, many believe it is part of the overall shift to value-based healthcare. On the other hand, many say the administrative burden will overwhelm providers. Another area of MACRA controversy has to do with meaningful use which, contrary to what the CMS Acting Administrator said in 2016, isn’t going away with the introduction of MACRA.
Although it seems a ways away, MACRA’s base year will likely be 2017. Armed with the seven best ways to start preparing for MACRA today, and an EDW that provides clinicians with the self-service tools to monitor their performance, health systems can be ready to tackle MACRA when it finally goes into effect.

Jared Crapo

Why We Need to Shift Healthcare Quality Measures from Volume to Value

Healthcare quality reporting is integral to achieving the Triple Aim and improving outcomes. But the sheer volume of quality measures has become as much a part of healthcare as healing and prevention. Recently, CMS and AHIP took the unprecedented step of aligning and consolidating measures in seven care categories. This will go a long way toward reducing the amount of time physicians and staff spend every week on quality reporting, but it’s only a beginning. Healthcare’s focus needs to shift from volume to value of quality measures, such as those that concentrate on quality of life and patient-reported outcomes. The International Consortium for Health Outcomes Measurement is setting the right example for quality measures designed to actually improve outcomes rather than just processes.