Measuring value in the health care value based performance based delivery model?

CMS on January 26th announced its intention to speed up the transition away from a strict Fee-for-Service reimbursement model to one that incorporates increasing measures of value and quality. The Health and Human Services agency announced the setting of a goal tying 30 percent of traditional, or Fee-for-Service Medicare payments to quality or value through alternate payment models, such as Accountable Care Organizations or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmission Reduction Program

Several statements by HHS Secretary Sylvia M. Burwell and others are worth noting as part of the announcement:

  • “Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.  Today’s announcement is about improving the quality of care we receive when we are sick, while at the same time spending our health care dollars more wisely,” Secretary Burwell said. “We believe these goals can drive transformative change, help us manage and track progress, and create accountability for measurable improvement.”
  • “We’re all partners in this effort focused on a shared goal. Ultimately, this is about improving the health of each person by making the best use of our resources for patient good. We’re on board, and we’re committed to changing how we pay for and deliver care to achieve better health,” Douglas E. Henley, M.D., executive vice president and chief executive officer of the American Academy of Family Physicians said.

With Congress wrestling with devising a workable replacement for the ill devised Sustainable Growth Rate Formula payment update for physicians that is politically palatable, the MEDPAC Commission recommending movement away from volume based Fee-for Service payment models, this announcement from CMS and other third party payer performance alternative payment models such as Blue Cross Blue Shield Massachusetts Alternative Quality Contract, it is clear that at some point not too far in the distant future, physician’s practice of medicine will be dependent upon the ability to report value and quality.

A fundamental challenge in this movement to performance, value and quality based provider payment models is objectively defining and measuring value and quality. There are currently many quality initiatives in existence where measures have been objectively reviewed and endorsed by the National Quality Forum. The National Quality Forum, is a “not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare.” The NQF “endorses consensus standards for performance measurement; ensures that consistent, high-quality performance information is publicly available; and seeks real-time feedback to ensure measures are meaningful and accurate.” [Quotes excerpted from NQF website]. The real challenge is objectively defining and measuring value, what may be considered as value on one physician’s viewpoint may not be considered value from another physician’s point of view.

The article titled “Physicians need to be ready for the end of fee-for-service” that appeared in February 2th’s publication. caught my attention for several reasons; however a few key points resonates in my mind after reading the article twice.  I quote the following from the article

  • Physician, not the government, bring value to healthcare
  • Physician, not the government, who know best what should be measured, and how, and what should not.
  • The real test of HHS’s new goal of replacing FFS with value-based payments is not just whether 50, or 60, or 90 percent of payments are based on value and quality in the next few years, but whether the changes required really help sustain the most important component of the value equation, which is the value that caring physicians provide to their patients each and every day.

Unequivocally, physicians have control and command of the value they offer in the patient-doctor relationship through the quality and effectiveness of the medical record documentation recorded that is associated with this long standing relationship. Studies over time have demonstrated a direct correlation between the quality of documentation and the quality of care achieved. Complete, accurate and effective clinical documentation does not necessarily equate to more documentation, just more effective documentation, recognizing the primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. in addition, the clinical record is a document that shares the patient’s story in as much detail as is required to retell the story (Annals of Internal Medicine – Position Paper, Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians)

In summary, the current Fee-for-Service payment model is not extinct like a dinosaur. However, as Fee-for-Service evolves and metamorphoses into a hybrid model incorporating elements of both Fee-for-Service and Value/Quality/Performance, physician’s best preparation and anticipation strategies must include attention to embracing and adhering to best practice standards of clinical documentation that accurately and effectively report and account for the patient-doctor relationship and its inherent value. My next blog will outline that constitutes best practice standards of clinical documentation