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Quality out, cost in: MIPS expert says pay attention to spend per beneficiary

One of the sources in our new MIPS tips story -- about how to use the data CMS is now releasing about your MIPS performance in 2017 to boost your performance and possibility of positive payment adjustment in 2018 and beyond – is Theresa Hush, CEO and co-founder of Roji Health Intelligence in Chicago. Hush has some thoughts about the program in general that didn’t quite fit our issue, but which we think are worth sharing with readers here.

Hush thinks the quality measures that are the backbone of MIPS will eventually fade from prominence as the cost measure – originally delayed until 2019, but unexpectedly making its debut with this year’s program – becomes paramount.

Given the slack CMS has been giving providers in years one and two, "It looks to us like the quality component will get easier until it eventually disappears,” she says. Also, despite the emphasis in the original MACRA law on outcome measures – which tell how the patient is responding to care – over process measures – which basically tell how well the provider is reporting measures – CMS has been slow to make them prominent in the actual program.

CMS’s Meaningful Measures  program also suggests to Hush that quality reporting as such will be scaled back.

“Meaningful Measures is one of the strategies CMS is using to ‘streamline’ – that is, reduce -- quality measures,” says Hush. She sees the Meaningful Measures comparable to the “core set” of measures applied to ACOs, which for one thing excludes a lot of specialty care – “such as surgical complications and actual functional status change” – and which also lean more on process than outcomes. 

“Reducing quality measures definitely reduces the burden for providers,” Hush says, “but it renders the performance measurement results somewhat meaningless and very difficult for consumers to use in comparing doctors.”

At the same time, says Hush, CMS is pushing people toward risk-based models such as the Direct Provider Contracting model for which the agency recently released an RFI, and advanced alternative payment models (APMs), which are the current alternative to MIPS. And “they’re adamant about making APMs take on risk faster,” she adds. These models are about “capping costs,” says Hush, “and as it goes that way I’m not sure that the quality component, which has been the main feature of all these Medicare programs in the past, will be the main feature anymore — it will instead be cost.”

This move toward cost as the key factor in assessing provider importance will probably bring more reliance on episode-based reimbursement bundles. While CMS has scaled back or cancelled some of these recently, they’ve added others, such as the Bundled Payments for Care Improvement (BPCI) Advanced program.

“Episode-based reimbursement accomplishes a couple of important things,” says Hush. “First, bundling the procedures and care within a timeframe -- including multiple physician, lab services, etc. – makes it easier to compare costs and therefore to apply financial risk; second, quality measures could also be applied to the episodes, including more unique quality measures such as complications, redos, blood clots, readmissions, etc.”

MACRA suggested even primary care would move toward an episode-based model, but “it’s more likely to be a single-risk payment in the future than episodic,” says Hush.

To prep for the move to cost, practices should “look beyond the artificial structures in the quality measures,” says Hush. “In the quality area, they get points and that leads them to approach it like a cookbook. But eventually, the way the cost piece works is spending-per-beneficiary. To bring it down, they have to actually look at the spending reports, and the big culprits like outpatient service, post-acute, ER.”

That battle begins in primary care – “a high number of admissions on ambulatory conditions speaks to the lack of primary care intervention” – and, as she does in our story, Hush counsels to get patients more involved and invested in their own care to move the needle in the right direction.

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