In the big picture, CMS is doing the "right thing" with Clinical Quality Measures. The concept that providers can evaluate their Quality performance in near real time is a giant leap forward from the world of year-end reporting with Manual Abstracting built around Claims history. Beyond real-time, vendors are offering workflow tools and triggers that flag encounters for activity before and during patient visits. Implications soar beyond the days of "pay for submission" PQRS.
MIPS / MACRA present two levels of Quality Scoring that are new since 2017. Each provider receives a composite quality score, plus scores on specific quality measure each provider chooses to share with CMS. Even though these scores are based on 2017 activity, don't be tempted to relegate 2017 to the category of old news. 2017 is the data source for 2019 Medicare reimbursement, as well as for publicly reported Physician Compare content. In fact, 2019 is the first year in which the impact of new CMS policies is felt outside the cadre of people responsible for creating CQMs.
New Users of CQM content
Physician Compare - Want to get the attention of a dermatologist? Tell them that their 2017 MIPS Quality Scores will appear alongside their name in Google searches. Within the next couple months, CMS will release these data to software vendors and search engines in the form of a "downloadable database", containing every CQM reported by every provider in the country.
Those of us who are Quality Professionals know that the data are not all valid for comparing physician performance in all cases. The issue is not with the use of public CQMs by Quality Professionals - it is use by the grandparents of Quality Professionals.
MIPS Financial Adjustment - Want to get a CFO engaged in discussing Quality? Tell them that the variability in CQM scores equals variability in Medicare Reimbursement. As CMS phases out transitional rules that make MIPS reporting less impactful, MIPS adjustments grow. In 2017, best-case adjustments were around 2.2% of Medicare Payments. This was due to artificially low thresholds designed by CMS to minimize penalties. But the law passed by Congress only allowed these artificially low thresholds to be temporary. Once the transitional rules are gone, MIPS financial adjustments grow to a potential of 19%.
New scoring benchmarks - In 2017, a MIPS score of 90% generated almost as good a reimbursement as a score of 99%, because of the temporary performance thresholds and benchmarks. As the temporary rules are replaced with permanent ones, high scores become a matter of relativity. Every score below "average" gets penalized and contributes to a payment pool distributable to above average performers.
It gets worse with Quality Measures. Some of the most popular measures will become unattractive, when CMS tags them as topped out. Providers can still submit those measures, but won't be able to get full credit. Worse yet, since everyone in the pool has "high" scores on a topped out measure, there can be a lot of surprises with low comparative rankings.
New Methods for Creating CQM Content
Now, let's get back to the big topic of timeliness. In the 2019 MACRA Final Rule, CMS clarifies the long-term goal to move away from claims-based CQMs in exchange for the real-time capability of EHR-based CQMs. For many Quality Managers this runs counter to "common knowledge" that CQMs need after the fact manual processes that add data. While manual abstraction is truly a need for claims-based measures (since claims standard data layout don't have all the fields to create CQMs), EHR-based CQMs are inherently based on a richer clinical data set, which can be configured to populate all, or nearly all, required content. This direction drives EHR certification standards that may be new to many providers rolling out 2015 Edition CEHRT. Apart from ACOs (who are required to use the claims-based CMS Web Interface for CQMs), Medical Records staff and Quality staff engaged in manual abstraction will need to re-tool their skill sets as demand diminishes.
QRDA-I and QRDA-III are quality analytical and reporting standards explicitly required by 2015 CEHRT (and 2015 CEHRT is fully required in 2019 for the first time). CMS as yet cannot actually receive QRDA-III format as part of annual submission, but it is a reporting standard that should dramatically open up the numbers and quantity of reportable CQMs. Provider groups who cannot obtain real-time CQM data via this technology should seek redress from their EHR vendors through the CMS ONC Certification website.
New Programs for Optimizing CQM Content
With the capability to generate near-real-time CQM content comes the opportunity to optimize CQM scores throughout the year. With the twin demands for competitive scoring (MIPS Reimbursement, and Physician Compare Downloadable content), providers who wait until year-end to generate CQMs may well find Medicare Reimbursement and new patient referrals reduced.
The first tool in optimization should be a structured program of Monthly MACRA measurement, analysis and enhancement. Enhancement can be a matter of simple measurement and reporting. In the case of measures that don't improve quickly enough, we have found a LEAN Six Sigma program tailored to CQM enhancement to be efficient and effective. In some cases, EHR add-on tools that create workflow and face-to-face questionnaire tools provide another layer of cost-effective improvements.
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MACRA Monitor is an subscription-based product from C3 Partners that optimizes CQM and PI through a MACRA database with dedicated Concierge service for ACOs and other complex organizations.