Integrating New Payment Infrastructure
with Public Reporting Requirements
Emily Richmond,
Practice Fusion
Erik Pupo,
Deloitte
What is a public reporting requirement?
• The common belief vs. the reality:
• A provision of the Patient
Protection and Affordable Care Act
(Affordable Care Act) requires
health plans to submit reports
each year demonstrating how they
reward health care quality through
market-based incentives in benefit
design and provider
reimbursement structures.
Why is this critical to providers?
• Most providers have little to no experience with reporting requirements
associated with federal grant funding and other incentives
• The added burden of new payment models create new requirements for
reporting
• General rule is:
• The more variables in your payment model, the more reporting is
required
•
•
•
There may be no all-payer payment support
The reporting of data may generate new consent/privacy issues if the
reports are generated from data that is integrating behavioral health
services/records
Payment models need to have a feedback mechanism within the
infrastructure that alerts organizational leadership to gaps on one or more
reporting metrics.
Changing Role of Healthcare Stakeholders
Employers
Hospitals/
• Alignment of incentives
• Rewarding better
lifestyle choices
• Financial assistance
Physicians
• Screening and intervention
• Timely intervention
• Patient relationship and
engagement
• Evidence-based treatment
Leadership &
Governance
Care Delivery &
Management
Strategy
Health Plans
• Data aggregator
• Cost/risk insights
• Quality and health
outcomes insights
• Incenting high performing
networks
Government
Accountable
Care Capabilities
Incentive
Alignment
Information &
• Public health and wellness
Technology
initiatives
Services
• Policies to foster and support
competition
• Funding and subsidies for innovation
• Protection for Intellectual Property
Rights
Pharmaceuticals/
Devices/PBM
Business
Operations
Suppliers
• Launching clinically superior
products (R&D)
• Traditional efficacy to clinical
effectiveness
• Outcome-based
reimbursement
• Drug knowledge sharing
• Enhanced, coordinated experience
• Improved outcomes
• Better access
Problems with IT and public reporting
1.
Legacy data systems that use different
vocabularies or standards and require
workarounds to make data reportable
2.
Inefficient methods to gather clinical data,
such as manual chart abstraction and
interpretation of claims codes;
3.
Mistrust among stakeholders, especially
when they do not perceive any benefit to
sharing or reporting data;
4.
Intermediaries who may need to receive
reports as well
5.
Real and perceived restrictions on the
ways data can be identified and used
What kind of payment infrastructure
is needed?
Organizations seeking to become ACOs are required to have “an infrastructure that
enables ACOs to collect and evaluate data, and provide feedback to ACO
providers/suppliers across the entire organization including providing information
to influence care at the point of care.”
•
Systems that support providers in capturing, calculating, and reporting quality
measures
•
Technology that can accept, transform, and aggregate data into local, state, and
national systems (ex. databases, registries);
•
Tools to analyze data and produce actionable and consumable feedback for various
stakeholders including providers and consumers; and
•
Security systems that meet federal and state requirements to maintain patient privacy
and protect identifiable patient information
Is my organization ready for
a new payment model?
A typical CAH reports measures to 15 different entities including CMS, the Centers
for Disease Control, state hospital associations, health departments, quality
improvement organizations and private payors.
Do we as a healthcare system have the
infrastructure needed?
Breaking down a public reporting
requirement
• Sections 6055 and 6056 of the Affordable Care Act impose information
reporting requirements intended to facilitate IRS enforcement of the
“employee mandate” and the “employer mandate”
•
•
•
•
Section 6055 supports the individual mandate by requiring health insurers
and self-insured employer health plans to report individuals’ health
coverage
Section 6056 supports the employer mandate by requiring “applicable
large employers” to report whether they offered coverage to their full-time
employees
Due date is January 31 immediately following the year being reported,
beginning with January 31, 2015
Applies to health insurers, self-insured employers or other sponsors of selfinsured health plans, and governments that provide minimum essential
coverage
Details of what that means
Applicable Large Employers
Requires applicable large employers (generally employers with 50 or more full-time
employees) to report to the IRS information about the coverage that they offer to their
full-time employees and requires them to furnish related statements to employees,
including:
•
The name, date, and employer’s employer identification number (EIN)
•
A certification as to whether the employer offers to its full-time employees (and
their dependents) the opportunity to enroll in minimum essential coverage under
an eligible employer-sponsored plan (as defined in section 5000A(f)(2))
•
The number of full-time employees for each month during the calendar year
•
The name, address, and taxpayer identification number of each full-time employee
during the calendar year and the months, if any, during which that employee (and
any dependents) were covered under any such health benefits plans.
Basic Payment Infrastructure
Provider EHR
Data
Aggregation
and Hosting
Dashboard /
Scorecard
Aggregates care
delivery information
Ability to aggregate,
analyze, abstract, and
report reliable
utilization, cost, and
outcomes data in
timeframe required
Accounting
Systems
Integrates
reimbursement data
Other Systems
IT solution must enable exchange of clinical &
financial data among facilities
Primary Care Portal
Specialty Care Portal
Portal 2
Health System
Warehouse for
Clinical and
Financial Data
Acute Care Portal
Primary Care Portal
Portal 1
Behavioral Care Portal
Enables patient-centered care
through system-wide abstraction,
aggregation, analysis and
reporting
Member stratification
New member data entry
Medical record compilation
Care team assignment
Episode bundling
Referrals, prescriptions,
and authorizations
Adverse event triggers
Patient accounting
Reporting and analytics
State and
Regional
Health
Information
Exchanges
(HIEs)
Challenges we have learned
1.
Quality Measurement variability
2.
Pre-Reporting Surveillance
3.
Subjective Reporting Requirements
4.
Different Types of Public Reports
5.
Sources of Information
Quality Measurement Variability
CMS has established different reporting requirements for individual physician and non-physician
providers, as well as group practices for participating in the 2014 PQRS program. In 2014, if an
Eligible Professional (EP) or group practice does not satisfactorily report or satisfactorily
participate while submitting data on PQRS quality measures, a 2% payment adjustment will
apply in 2016
Methods of reporting :
– Registry Reporting
– EHR Incentive Program Reporting
– Group Practice Reporting Option
– Qualified Clinical Data Registry (QCDR)
Across all payment models,
•
Can I collect and analyze for a specific reporting option?
•
Can I support reporting options (E-Measure variability)
•
Variability in terminologies identified (infrastructure vs. measure)
Pre-reporting surveillance
Example - Analyzing the number of postoperative
infections by post-operative care setting (e.g.
home, SNF or home health) and by facility
•
Is my infrastructure designed for public
reporting or designed to analyze?
Example – Track beneficiaries in payment
population that are at high risk for Coronary
Artery Disease, but not yet on a drug therapy for
lowering LDL cholesterol.
•
Affects related performance measure
(measure 32, NQF#74)
•
Is my infrastructure able to support
incorporating checks and balances in care
giving processes and settings to ensure
beneficiaries who have that profile are
recommended for the drug therapy
Subjective reporting requirements
Lesson from ACO CAHPS survey – reporting to demonstrate how an ACO uses
the survey results to improve care.
• This type of data reported is beneficiary driven and contains subjectivity
• Public reporting requirements require level of comfort with subjectivity
Lesson from Pioneer ACO – reporting can be perfect but shared savings may not
be
• Public reporting requirements can drive goals to be set in a payment model
• Subjective reporting of the real picture distorts savings
Other types of public reports
Provide customized notifications
for patients via letters,
telephone/text messages, emails,
electronic reminders)
Generate automatic alerts for
providers and care teams about
patients who meet criteria for
preventive care or disease
management at the point of care
and between encounters
Produce real-time reports on how
practices, providers, and care
teams, are meeting quality,
financial and utilization goals
New Types of Information
Lessons Learned
•
Summary care measures work better
•
Targeted public reports work better
•
Strong culture of primary care supported by access to specialty, ancillary and hospital
care so that public reports are coordinated
•
Administrative, management and analytic acumen to support reliable performance
measurement;
•
A clear organizational mission and commitment to effectively report quality and cost
efficiencies
• Its not just infrastructure physically, but culturally
•
Robust health information technology to enable aggregation, analysis and reporting
• Support for any and all types of data
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