Quality is the New Revenue – So Measure and Act

August 23, 2016 David Fletcher

By David Fletcher, MPH
Vice President of Innovations, Streamline Health, Inc.

In my travels, I’m fascinated to find that clinical quality still is not a day-to-day concern for many revenue cycle managers. CMS has set a goal to have 50% of Medicare payments based on value— instead of volume —by 2018 and the programs are already starting to kick in. However, when I ask revenue cycle managers “How does clinical quality impact your work?”, I hear answers like “not much” or “there’s a different department for quality improvement”.  The story is only a little different for HIM departments and CDI programs. In those areas of the medical center, there’s a growing awareness around the importance of accurate clinical information to support both reimbursements and longitudinal patient care. But that hasn’t translated into substantive changes in departmental workflows and tools designed to help the organization make the changes necessary to remain profitable in the coming years.

What many may fail to realize about this change is that CMS intends to make this a budget neutral change. That means that incentive payments for providers who meet the requirements will come from the reduced reimbursements to those who failed. Given the magnitude of the changes needed to support this transition, it’s clear that mindsets within provider organizations are not shifting quickly enough.

CMS is motivating the shift from volume to value with a patchwork of voluntary reimbursement programs for providers. For any programs that are successfully executed, CMS can then expand and subsequently make participation mandatory. The learning materials on www.cms.gov are excellent; here are a few examples of these programs:

  • Pay for Performance
    • Hospital Value-Based Purchasing Program
    • Hospital Readmission Reduction Program
    • Hospital Acquired Conditions (HAC) Reduction Program
    • Merit-based Incentive Payment System (MIPS)
  • Bundled Payments
    • Care Improvement Initiative
    • Comprehensive Care for Joint Replacement
    • Oncology Care Model
  • Total Cost of Care Models
    • Medicare Shared Savings Program
    • Pioneer Accountable Care Organizations
    • Next Generation ACOs

Timely measurement and workflow agility are the keys to improving patient care and thereby succeeding under the growing scope of value-based reimbursement rules. Because of the ACA and its Meaningful Use program, we have more and more patient data to help us measure. Measurement means understanding your program’s performance and progress, and how you measure against the desired standards. It means knowing which patients need closer attention and where they are. Through analytics and flexible cohort builders, we can learn a lot about patient populations, their outcomes and the efficacy of interventions.

Speaking of measurement: your analysis is only as good as the data upon which it’s based. Clinical documentation is hugely influential to successfully transitioning to value-based care, which means your Clinical Documentation Improvement (CDI) and Health Information Management (HIM) programs are more crucial than ever for both accurate billing and clinical quality measurement. Documenting prior comorbidities, for example, could mean more accurate risk adjustment and an increase in reimbursement. But it could also trigger different workflows within the medical center or care team. Getting the documentation right—and doing so in a timely manner—helps not only to minimize billing cycles but also to get patients any follow-up care that will help improve their outcomes.

Reacting to timely measurement with agile workflow is the second key to success. For example, CDI programs are all about reviewing of documentation while patients are still in the hospital (concurrent review). A working diagnosis is established, with working DRG and ICD codes, and inquiries are sent to physicians to verify documentation. In the new world of value-based reimbursements, CDI programs are pivoting to also measure quality and patient safety indicators for each individual and recommending action (orders, referrals, etc.) to make sure each patient has the best chance to achieve the respective clinical quality targets.

Every time I visit one of our Clinical Analytics clients in the South Bronx, he never ceases to impress me. Despite caring for a large low-income patient population, they achieve amazing quality scores. They accomplish this by doing the simple things to stay ahead of the metrics. For example, they identify which patients are scheduled to come in the next day and they look for any missing steps in care plans. Diabetic patients coming in tomorrow with no recent foot exam or any patients over 50 years of age coming in and missing a colonoscopy. This capability to identify patient populations, measure quality and take action, is precisely what helped them achieve Patient-Centered Medical Home certification which, in turn, increased their reimbursements.

To some stakeholders, especially those without a lot of experience with quality programs, this may seem like too many programs, too much measurement and too many rules. However, at a basic level, we as a nation are aligning payment with quality of care and that is commendable. Quality is indeed the new revenue. And for healthcare organizations as a whole, expanding their understanding of care quality as a metric that directly influences their revenue cycle is fundamental to surviving and thriving in today’s market.

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