Five Strategies for Easing the Burden of Clinical Quality Measures

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While out for dinner the other night at a nice restaurant, I was disappointed when my food was served lukewarm. I made a mental note to deduct from my normal 20 percent tip. However, the food was still good and I didn’t get food poisoning, so I decided to tip 19 percent. Then, at the end of my dinner, the server brought out an oversized piece of cheesecake, which exceeded desserts from other restaurants in the country. At the end of my visit, I tipped more than I usually do and completed a full survey about my whole experience.

This is an exaggerated hypothetical that analogizes the complexities in the world of pay-for-performance programs and quality measurement. A world we love to hate, but that requires us to be strategic players.

The Current Healthcare Quality Landscape

Healthcare organizations expecting to receive top reimbursement are required by government and commercial payers to collect and submit data on an increasing number of clinical quality measures across programs and across the care continuum, not to mention the measures required by accrediting bodies, professional societies, state quality programs, and the external ranking agencies. These requirements are compounded by also having to perform at a certain level to get the highest reimbursement and gain recognition in external ranking programs, like the Truven Top 100 Hospitals study. This burden carries an understandable negative connotation and the quality improvement intentions can be overshadowed for frontline caregivers with phrases like, “Oh, we need you to do this to meet this measure.” But what if we can do a better job connecting the required measures into our quality initiatives, rather than seeing them as another box to check?

As the Director of Improvement Services, I take part in the regulatory strategy of a sizeable U.S. health system. My perspective is that we should not think of measures as regulatory, but as quality measures that happen to be required by regulatory bodies. Perhaps it’s a nuanced difference, but the primary message is that regulatory measures don’t have to be solely check-the-box requirements. Rather, we can think of them—and message them—as standards for best practice in clinical areas that CMS and other organizations deem so important, they need to be publicly reported and are worthy of additional reimbursement dollars. The challenge is aligning the regulatory measures with existing quality initiatives, given there are often differences in the details of the numerator and denominator for the measure population, so that our providers and caregiving staff can focus on patient care.

Five Ways to Effectively Manage Clinical Quality Measures

A hospital system can easily top 1,000 measures on which it must report regularly, and many factors go into prioritizing those that are most important. Performing poorly on some can lead to reduced reimbursement, while ignoring others can put a hospital at risk of shutting its doors. At the same time, regulatory measures don’t always align perfectly with a health system’s overall mission.

It helps to have a strategy around which ones to give the lion’s share of attention. Understanding this strategy has value across the organizational spectrum, from frontline clinicians to C-Suite executives. It’s easy to think that required means required and there’s no room for strategy, but here are five ways of looking at regulatory measures that would indicate otherwise.

1. Prioritize measures that truly impact patient care

We all work to keep patients safe and improve their outcomes. Thankfully, we see trends in required measures shifting from process to outcome measures to align with this focus. Outcome measures, like mortality and readmission rates, are important. Additionally, patient safety measures, such as surgical site infection (SSI), Catheter Associated Urinary Tract Infection (CAUTI), and Central Line Associated Blood Stream Infection (CLABSI) are part of multiple pay-for-performance programs with considerable visibility. When complications arise, a surgery or procedure can end up with a different DRG depending on coding, and contribute to decreased reimbursement through both the CMS Value-Based Purchasing and Hospital-Acquired Condition (HAC) Reduction programs, and most importantly, worsen a patient’s satisfaction and health outcomes. Performing poorly on patient safety measures means not doing well by patients and leaving dollars on the table. So continue including patient safety and patient harm measures on your organizational scorecards, but be aware of how your internal goals align with benchmarks and thresholds identified in the pay-for-performance programs.

2. Have a line-of-sight to reimbursement

Financial considerations need to be monitored in addition to those related to quality and safety. We learn this from the adage “no margin, no mission.” It’s important to look at the alignment of measures across programs, understand the reimbursement tied to each one, and then make informed decisions about which ones to support the most.

To further illustrate the importance of certain measures from the financial perspective, consider the HAC Reduction program that says CMS will reduce payments by one percent for hospitals performing in the worst quartile with respect to certain infection and patient safety measures. Additionally, these same hospitals are involved in the Value-Based Purchasing Program, a CMS program funded by a two percent reduction in participating hospitals’ DRG payments and redistributed based on quality performance. For sizeable health systems, this can add up to millions of dollars when adding up measures across inpatient programs like HAC, value-based purchasing, and readmissions.

Having tools available to show not only clinical performance on quality measures, but also the projected payment impact of that performance, allows an organization’s clinical and finance teams to work together to make informed decisions on prioritization of improvement efforts.

Figure 1: A performance tracking tool showing status of multiple measures and the financial impact of that performance.

Sometimes great clinical improvement work isn’t tied to any reported measures, but it still deserves financial recognition. For example, reducing spine complications is obviously good for patients, but when viewed from the value perspective, the improvement program may have a net-negative financial impact. Having this awareness and connection between quality reporting and reimbursement can help to then tie spine complication measures to a commercial pay-for-performance program and do the right work for our patients.

3. Understand measure alignment across programs

Health systems are on the hook for too many measures to count, but there are themes among these measures and it is critical to understand their similarities to optimize improvement efforts and gain efficiencies in data collection and reporting. There may be differences in measure numerators and denominators between programs, but the bottom line is to find the common ground that improves care in order to do well across program requirements, then integrate and align them so clinicians aren’t saddled with additional work while improving outcomes.

While many measures are fixed by program, others allow selecting a subset from a larger list (e.g., Electronic Clinical Quality Measures in the Inpatient Quality Reporting Program (IQR) or the Quality Payment Program in the Medicare Access and CHIP Reauthorization Act (MACRA). In the cases where there is choice in measurement it is helpful to keep an inventory of all organization-wide measures reported both internally and externally to see which ones fulfill reporting requirements across multiple programs, and then prioritize those.

A quality measures inventory can also filter measures by clinical program or regulatory agency. Then, for example, measures tied to the cardiovascular clinical program can be crosswalked to those associated with the orthopedics service line. Choosing measures that cover multiple service lines drives efficiency and productivity.

There may be a lot of a nuanced technicalities to all the rating systems, but ultimately, hospital systems want healthcare consumers to associate them with lists that rank for quality. Although it may seem like the tail wagging the dog, studies show that performance ratings reported to the public improve hospital quality and reputation. Focus on measures that are included in the various national rating systems, like Truven, Leapfrog, Healthgrades, and U.S. News & World Report.

In larger organizations, certain physicians need to report on specific measures for their professional societies (e.g., Society of Thoracic Surgeons and American Academy of Pediatrics). This gets challenging because the organization must support those efforts while satisfying the quality reporting demands of the broader enterprise. This makes it more important than ever, when devising a strategy around regulatory measures, to consider how they fit into the existing quality landscape and prevent them from being an extra burden for clinicians.

4. Involve the right people

For starters, include financial and clinical leadership—the former so they can budget based on performance in these programs, and the latter to track and monitor performance, and deliver the outcomes improvement work. This includes the department within an organization that is responsible for payer contracting. A strong connection with this team is critical to set measure goals with commercial payers that align with the efforts required of government programs.

Additionally, involve frontline nursing staff. I had an interesting conversation with a clinical nurse specialist who had attended classes for frontline nurses to explain the rationale behind certain measures and why they were being asked to document in a certain way. Until I met with her, I underestimated how much frontline staff value understanding this rationale.

Work with physicians to define and align internal measures with publicly reported measures. This has multiple benefits: optimized patient care, and improved forecasting and monitoring of performance in programs like the IQR.

5. Get involved in measure development upstream

It’s easy to feel helpless with the growing torrent of required measures rushing down the pipeline every year. It seems the only choice is to find a way to work on all of them. However, healthcare systems can impact the rules that guide the approval of measures and payments by CMS (e.g., the Inpatient Payment Prospective System or the Physician Fee Schedule Rule). Before measure requirements are embedded into rules and assigned reimbursement amounts, they go through the Measures Under Consideration process and most measures are endorsed by the National Quality Forum.

The Measures Under Consideration process exposes all proposed measures for a 12-month period. This is the first opportunity for public comment and a way to impact rules far upstream. Then rules are released as proposed, which presents another period for public comment. These are two opportunities to work with your regulatory affairs team or government and public policy team to draft letters, including clinician feedback, to CMS. Feedback may not be incorporated 100 percent of the time, but change is affected by following this strategy and it is a process that gives a voice to healthcare organizations.

Develop a feedback loop for selecting measures and rules. Everyone feels greater ownership when they are allowed input into the process. Create opportunities in the measure development cycle and how rules are adopted for people to provide feedback on measures. This ensures that measures dovetail into clinical priority areas.

Tools that Help Prioritize Measures

Several applications highlight the quality measures with the most impact on patient care and the bottom line.

Inventory Tools

A quality measure inventory helps select measures and rules. Many programs have fixed measures, such as value-based purchasing, while others allow for some choice, such as the Merit-based Incentive Payment System (MIPS) within MACRA.  This depends on the regulating body. An inventory tool can find measures that fulfill a reporting requirement across multiple programs, which eases the reporting burden and creates efficiencies.

Scorecards

A pay-for-performance scorecard can take measures, by program, and include both performance monitoring as well as projected payment impact. This provides all the pieces of the puzzle for executive leadership to make decisions on those measures that deliver the highest impact to patient care and the bottom line.

Measure Management Tools

Some tools help with managing measures, estimating payment impact, and can integrate hundreds of measures across financial, regulatory, and quality departments. An ideal measure management tool supports accountable care organizations (ACOs) that participate in the Medicare Shared Savings Program (MSSP), which need to monitor and manage actual performance against CMS required measures.

Figure 2: An ideal measure management tool can display a dashboard to support health systems involved in an ACO.

Plan for Success with Regulatory Measures

Regulatory measures can add value across the organizational spectrum. Hospitals and physicians can be more strategic about which ones to implement to improve care quality, increase patient satisfaction, and reduce costs. When making decisions about quality priorities for the organization, consider not only what measures are required, but also those that have the greatest financial ROI, optimize productivity, and ultimately do right by patients through improving safety and outcomes. And now MACRA presents a unique set of organizational challenges as it impacts the quality performance of hospital-based physicians. As the regulatory landscape continues to shift and reshape, a strategy for managing measures becomes more and more valuable.

Additional Reading

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

  1. The Unintended Consequences of Electronic Clinical Quality Measures
  2. The Who, What, and How of Health Outcome Measures
  3. Why We Need to Shift Healthcare Quality Measures from Volume to Value
  4. MACRA Solutions
  5. Introducing Health Catalyst MACRA Measures & Insights—Addresses Top Physician Concern: Capturing Compliance Measures

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