Five Strategies for Easing the Burden of Clinical Quality Measures

Five Strategies for Easing the Burden
of Clinical Quality Measures
̶ Britney Rosenau

© 2016 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
The Current Healthcare Quality Landscape
To receive top reimbursement from payers,
Healthcare organizations must collect and
submit data on an increasing number of
clinical quality measures across programs
and across the care continuum.
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.

The Current Healthcare Quality Landscape
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 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.

Five Ways to 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.
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
2. Have a line-of-sight to reimbursement
3. Understand measure alignment across programs
4. Involve the right people
5. Get involved in measure development upstream

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 re-
admission 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.
Most importantly it could worsen a patient’s
satisfaction and health outcomes. Performing
poorly on patient safety measures means not
doing well by patients and leaving
reimbursement dollars on the table.

Continue to include 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.
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.

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. 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 measure-
ment 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.

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).
It is 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 govern-
ment 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
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.

5: Get involved in measure development upstream
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
which should ensure that measures dovetail
into clinical priority areas.

Tools that Help Prioritize Measures
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 required measures,
but also those with the greatest financial ROI,
optimize productivity, and ultimately do right by
patients through improving safety and outcomes.

Plan for Success with Regulatory Measures
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.

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

More about this topic
Link to original article for a more in-depth discussion.
Five Strategies for Easing the Burden of Clinical Quality Measures
The Unintended Consequences of Electronic Clinical Quality Measures
Laura Dietzel
The Who, What, and How of Health Outcome Measures
Josh Ferguson, Clinical Advanced Application Content and Deployment Director
Why We Need to Shift Healthcare Quality Measures from Volume to Value
Jarod Crapo - VP
MACRA Solutions
Health Catalyst
Introducing Health Catalyst MACRA Measures & Insights—Addresses Top Physician
Concern: Capturing Compliance Measures – Paul Horstmeier, Senior VP

Britney joined Health Catalyst in January 2015 as a Program Manager for Regulatory
Reporting and Operations through the Allina Health partnership. Prior to Allina Health she
worked for the CDC’s Prevention Research Center, in Minneapolis, conducting a program
evaluation on adolescent health. Britney has a Master of Public Health degree from the
University of Minnesota.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Britney Rosenau

Five Strategies for Easing the Burden of Clinical Quality Measures

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