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Value-Based Care News

Quality Metrics Pose Problems for Value-Based Care Reimbursement

Healthcare providers are facing challenges in meeting quality measures within value-based care reimbursement contracts.

By Vera Gruessner

The healthcare industry’s fast pace transition to value-based care reimbursement has led to some major challenges for both providers and payers. Adopting completely new payment contracts based on quality metrics is not a simple maneuver for health insurance companies. Providers also find switching from fee-for-service payment systems to reimbursement based on quality care improvements and quality reporting a complex process filled with controversies.

Healthcare Quality Measures

One of the biggest issues standing in the way of successfully transitioning to value-based care reimbursement is the potential pitfalls of meeting and reporting healthcare quality measures. Even the costs of reporting on healthcare quality metrics has risen to $15.4 billion, according to a report published by Health Affairs this past May.

The study found that cardiologists, internists, orthopedists, and primary care family physicians have all spent on average 785 hours per doctor reporting on quality measures. This leads to an average spending of average cost of $40,069 per doctor every year.

Along with the high costs of reporting on quality metrics, the repeal of the Sustainable Growth Rate Formula and adoption of MACRA legislation has also pushed providers to more quickly adapt to quality improvement efforts and reporting healthcare quality measures.

“Pretending it is now 2020, the way the legislation is set up, you are either a physician engaged in an alternative payment model like an ACO, or you’re participating in this merit based incentive program or MIPS,” Jeff Smith, Vice President of Public Policy at the College of Healthcare Information Management Executives (CHIME), told “Both of those buckets of activity are very dependent on value and quality and performance. Without question this legislation pushes value based payment in a really big way.”

READ MORE: Payers Benefit from Aligning with MIPS, Value-Based Care

Amy Nguyen Howell, M.D., Chief Medical Officer at CAPG, spoke with about the challenges that providers face when attempting to meet the requirements of MACRA’s quality payment program as well as the ways public and private payers could assist clinicians in reaching value-based care goals.

“One of the major challenges includes which quality measures to pick. There are hundreds of them out there across product lines: commercial, Medicare, and Medicaid. Which ones should they pick with MACRA and MIPS? Another challenge is how will they pay for all of this infrastructure to really report appropriately, adequately, and successfully. It includes their data, EMR, IT infrastructure, and their campaign management,” Howell noted.

Howell showed most concern for the costs and resources necessary to implement the infrastructure needed when switching from fee-for-service to value-based care reimbursement.

“The army that they’re going to have to really excel in population health payment because MIPS is the road to APMs. In order to really prepare for MIPS, you really need to put in the infrastructure and once you put in the infrastructure, then you will be ready to execute on APMs and that’s how groups and providers need to look at it,” Howell continued.

“Those who have been functioning in a fee-for-service world in practices including the doctor and one or two other people are not used to having a care team. They’re not used to reporting quality metrics. They’re used to churning out patients because of their payment reimbursement structure. Now everything is attached. Value and quality is attached to total cost of care. Now they’re going to figure out: How are they going to do it? What measures do they pick?” ” she asked. “How will they pay for the infrastructure? What does the IT infrastructure look like? What does the care team members look like? Those are the challenges.”

READ MORE: Why Value-Based Care Reimbursement, MACRA are Here to Stay

Next, Howell addressed how stakeholders and payers could assist providers struggling with the quality payment program by offering more educational resources and conferences meant to train providers in MACRA quality reporting.

“Some of the ways that stakeholders and partners like payers can help them is to provide them the education they need. We do a lot at CAPG in giving valuable resources like conferences, symposiums, hands on tools, and kits to really succeed in value-based care. We had a plethora of educational conferences this year,” Howell explained. “Each lecture such as risk adjustment can teach you: what are the things to look out for? How do you stratify your population? What are the codes you need to look at? What do you look for in stop loss contracting? When negotiating risk with a payer - what does that even look like and where do you start? We offer things like that.”

Howell also recommends payers to work with consulting companies and other healthcare organizations to ensure their provider network receives the education and conferences necessary to uphold value-based care reimbursement.

“Payers can collaborate with CAPG. We’re thinking of collaborating with national payers and holding conferences and symposiums to really teach and educate the providers because providers respond best to education. They’ll be motivated because the clinical outcome of their patients really matter to them. [Physicians will need to] understand the link between value, quality and cost,” she continued.

When it comes to creating a value-based care contract and operating an alternative payment model, payers will need “to know their network,” Howell explained. “Payers need to know where to stratify their network in the really high quality providers and be able to see whether these providers cover the broad majority of their network for the patients so that there’s limited leakage and access to healthcare.”

READ MORE: Communication Key for Transition to Alternative Payment Models

Having a greater knowledge on the quality and performance of their provider network will allow payers to position more certainty in value-based care contracts.

“The number one thing is to know your network and to stratify your network with high quality, high performing physician organizations and providers,” she concluded. “Using standards of excellence - a survey that providers take to understand and rank themselves in risk-based coordinated care. CAPG asks them a whole bunch of questions every year. We ask questions about their care team, post-discharge, access, provider adequacy, culture and language, social determinants of health, their risk contracting, and what kinds of risk share they’re in.”

Payers are advised to use these type of surveys and other public data to better analyze and create a stronger provider network in order to succeed in meeting value-based care reimbursement goals.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

How Medicare, Medicaid, and CHIP Guide the Health Payer Industry


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