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How Regulatory Compliance Supports Optimal Patient Care and Higher Earnings

Article Summary


Hospitals spend over $7.5 million every year on regulatory compliance. Payers, such as CMS, rely on these quality measures to evaluate health system and provider performance and determine reimbursement rates for services rendered. As a result, regulatory performance is critical to the care process and revenue stream. However, many health systems fail to meet these care standards and maximize reimbursement rates because they lack analytic insight into regulatory performance. With a data engine that tracks and submits quality measures data, leaders understand their compliance performance, gaining insight into opportunities to improve patient-centric care and value-based performance. This data-informed approach allows organizations to increase profits through peak regulatory performance and avoid financial penalties associated with underperformance.

healthcare regulatory measures

The American Hospital Association reports the average community hospital spends over $7.5 million every year on regulatory compliance. As organizations spend increasing amounts of money to meet stringent regulatory measures, they need a data-driven approach to measure the value of the care they deliver and avoid financial penalties.

Healthcare providers and administrators often view quality and regulatory measures as ever-changing and difficult to meet. Additionally, many healthcare organizations feel a heavy reporting burden because they lack the infrastructure to automatically calculate, track, and submit performance data.

Although regulatory measures can be hard to understand and feel daunting to providers, they play an important role in keeping patients safe, holding health systems accountable, and promoting quality care. With comprehensive data and supporting infrastructure, organizations can deliver patient-centered care and increase profit margins while meeting these rigorous standards of care.

Healthcare Regulatory Measures Infrastructure Supports Optimal Compliance Performance

Organizations should invest in regulatory measures infrastructure to more easily meet healthcare regulatory measure requirements. One common reason for regulatory measure underperformance—or falling short of these high standards of care—is that organizations don’t know their actual performance or how it compares to other providers or local and national benchmarks. Organizations that manually collect and report regulatory measures performance data often miss relevant information and base conclusions on incomplete data sets.

A comprehensive healthcare regulatory measures solution (e.g., Able Health™ by Health Catalyst) automatically aggregates claims and clinical data from multiple sources and provides a comprehensive view of regulatory performance. This allows health systems to easily identify areas in which they don’t reach compliance targets and track improvements. Real-time analytic insight into performance leads to optimal reimbursements and higher profits.

Patient-Centered Care Aligns Organizations with CMS Quality Measures

As healthcare continues to shift toward value-based care (VBC), quality measures keep patients at the center. For example, the Meaningful Measures Initiative, a CMS quality improvement framework, identifies areas in which providers can better prioritize and involve patients and their families throughout the care process.

One way the framework emphasizes patient-centered care is by eliminating duplicate regulatory measures across programs to reduce the reporting burden on providers. Less time in the EHR allows clinicians to spend more one-on-one time with patients. The Initiative further prioritizes patients by gathering and using patient and provider feedback throughout the care process. This feedback can guide regulatory organizations and health systems as they create and comply with performance measures that focus on areas with the biggest impact on patients’ health and lowering costs (e.g., preventive care).

Healthcare Regulatory Measures Data Plays the Lead Role in Value-Based Care

Health systems have historically lost money when caring for Medicare populations due to lower reimbursement rates. And, as CMS estimates that Medicare spending will keep rising, these lower reimbursement rates mean health systems aren’t maximizing profits while caring for this growing 65-and-older population.

To survive in this new value-based world and increase earnings in VBC programs such as the Medicare Shared Savings Program, organizations need accurate data to ensure they are delivering value rather than volume. Regulatory measures, and the data that provides a high-level view of a system’s measures performance, act as a safeguard for health systems on the road to VBC by identifying areas in which systems fall short of quality performance and expectations.

To meet healthcare regulatory measures and increase profits, health systems must accomplish the following:

  • Aggregate and analyze data from multiple sources to reveal continual opportunities to improve care and prevent poor health outcomes.
  • Align financial incentives between payers and providers to allow providers to receive financial rewards for the quality—and not volume—of care.
  • Increase patient engagement in behavior or lifestyle modifications to increase the likelihood of an intervention’s success.
  • Garner support from clinicians and encourage them to lead the shift to VBC to set the example for other clinicians and team members.

Regulatory Compliance Can Boost Profit Margins and Patient Health

Meeting regulatory measures is an integral part of the healthcare process because payers, such as CMS, use them to evaluate health system and provider performance, measure value, and then determine reimbursement rates. Therefore, health systems should proactively prepare to meet these rigorous standards rather than reacting to them, risking financial consequences. A robust measures engine, a renewed focus on putting patients first, and a more strategic approach to VBC allows organizations to more easily meet these healthcare regulatory measures, improve patient outcomes, and increase profit margins.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

  1. The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care
  2. 2021 Changes to the Quality Payment Program: Must-Know Guidelines for ACOs
  3. The Complete Guide to MIPS 2021: Scoring, Payment Adjustments, Measures, and Reporting Frameworks
  4. Complete Guide to the APM Performance Pathway (APP) for MIPS APM Participants and ACOs
  5. Complete Guide to CMS-HCC Risk Scores—RAF Scores and Medicare Risk Adjustment
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