Authors: Karen B. Domino, M.D., M.P.H. et al
ASA Monitor 06 2017, Vol.81, 8-10.
Karen B. Domino, M.D., M.P.H., is Professor and Vice Chair for Clinical Research, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle.
Michael B. Simon, M.D., M.B.A., is Chairman, Department of Anesthesiology, Osceola Regional Medical Center, Kissimmee, Florida and Transitional Medical Director for Sheridan Healthcare, Inc.
DeLaine Schmitz, MSHL, is ASA Quality and Reporting Executive.
In 2014, the 53rd Annual Emery A. Rovenstine Memorial Lecture titled “Health Care at the Crossroads: The Imperative for Change”warned anesthesiologists about soon-to-come innovations in reimbursement by health care payers. In 2017, the “time is now” as these innovations will be affecting nearly every anesthesiologist in the U.S.!
Why should your group focus on measuring and reporting quality metrics?
2017 will be a year of transformational change for physician reimbursement, as the new provisions of MACRA (Medicare Access and CHIP Reauthorization Act) begin to take effect: positive and negative Medicare payment updates based upon performance on quality metrics, cost and value in the Merit-Based Incentive Payment System (MIPS) that will apply to most anesthesiology groups. In addition to the federal government, purchasers of health care (business and insurance plans) are increasingly requiring demonstration of metrics of quality and value in the assessment of whether to include your group and hospital in their plans.
While many large and mega-group practices are successfully navigating these waters, small and medium-sized groups, including those in academia, are being left behind. This is not something to ignore, as the consequences of failure to participate may have existential ramifications, including loss of contracts, reduced salary and potential job loss! While not all communities in the U.S. have yet to be affected by this sea of change, the provisions of MACRA will affect us all within the next several years. Even if your proportion of governmental reimbursement is low, many funders of health care will incorporate the governmental payment policies with emphasis on value into their choice of networks and providers. Hence, if your group is not already considering what this means to your practice, you will need to focus now on how you can make the change to measure and report quality metrics. Fortunately, ASA and the Anesthesia Quality Institute (AQI) have outstanding resources to help you navigate your way!
What type of anesthesia groups are at greatest risk?
The best data we have concerning which anesthesia groups are at greatest risk come from the AQI participants in the National Anesthesia Clinical Outcomes Registry (NACOR), a Qualified Clinical Data Registry (QCDR) and Qualified Registry (QR). In 2016, AQI had contracts with 431 anesthesia practices, with 242 practices (56 percent) participating in the QCDR (which is needed for involvement in MACRA) and 189 practices (44 percent) participating in the QR. Of the 242 enrolled practices in the QCDR, a quarter did not meet quality reporting requirements, including 6 percent that did not provide any quality data to NACOR. Eight percent of practices participating in the QR also were not able to provide any quality data.
Does group size impact the overall group’s success? Data from the Anesthesia Quality Institute’s Qualified Clinical Data Registry (QCDR) in 2016.
What impacted reporting success? Timing, practice size, IT/software vendor support, and physician/practice administrator engagement were important factors that determined success. Practice size is of particular concern, as anesthesiologists in large groups (>250 providers) achieved the greatest success (85 percent), whereas anesthesiologists in groups of 21-50 had the lowest success (60 percent). Groups with less than 50 providers had the highest proportion of submission of incomplete or no data, whereas none of the large groups and mega groups were unsuccessful due to submission problems. This factor is particularly important as positive updates and financial rewards for exceptional performance will go disproportionately to large and mega groups that possess quality and IT infrastructure. Additionally, vendors are not uniformly responsive to groups and vary tremendously in their performance to successfully deliver quality data to the QCDR. Physician/practice administrator engagement is also critically important for successful reporting of quality data.
What physician leadership characteristics are essential for successful implementation of quality reporting?
Leadership requires passion and interpersonal skills to motivate and engage other stakeholders to achieve a common goal. In many medium-sized practices, the burden to achieve high rates of compliance fall to a few. A motivating story that conveys the joint purpose of improving quality and urgency of quality measurement with stakeholders (e.g., practice and hospital administrators, risk managers, surgeons and patients) is important. The AQI analysis of success and failures emphasizes the importance of a physician leader to articulate the importance of registry reporting for patient safety, inclusion in payer networks for reimbursement of services, and enforcement of reporting compliance among physician peers. Partnership with practice administrators and project managers is vital to understand the quality measures and reporting requirements, monitor reporting progress/data validity, meet deadlines and hold vendors accountable. While leadership skills are often poorly taught in medical school and residency, they can be effectively learned through experiential educational programs such as the Institute for Healthcare Improvement (www.ihi.org), based in Boston, which offers online courses in quality improvement and leadership, such as “Leadership and Organizing for Change.”
I work in a small or medium-sized anesthesia group. What assistance is available from ASA and AQI to help our group successfully report quality metrics?
There are two quality reporting options available through NACOR. The first option is designed for successful practices that do not require additional IT support to format or merge files (50-60 percent of practices). For this option, participants will need to sign up for quality reporting through NACOR, which is available as an ASA member benefit without additional fees. For practices struggling to submit properly formatted and merged files, AQI staff will reach out to the practice to discuss options to improve success, including making file corrections on their own, outsourcing corrections to a vendor of their choice or using Quality ConciergeTM to provide the corrective file formatting or merging services (fee-based service).
For practices in need of a more robust solution, AQI recently collaborated with ePreop (Seal Beach, California) to offer Quality Concierge, aimed at mid- to smaller-sized practices lacking the resources necessary to successfully submit data to NACOR. Quality Concierge is ideal for practices that lack the internal infrastructure to support quality measure collection or submission, including assistance with measure selection, assistance with reporting options (individual versus group), extraction and merging of data from multiple sources, including AIMS and other electronic health record systems, quality capture applications, claims data and paper records. This vitally important service will be available at a $500/provider annual fee. Details are available on the ASA website at www.asahq.org/quality-and-practice-management/quality-reporting-nacor/vendors.
In summary, fee-for-service payments are being transformed to reward value in health care. While large groups are well positioned for success in this new landscape, medium-sized and smaller groups face many challenges. Physician leadership, practice administrator engagement and Quality Concierge services from the AQI will help groups achieve success!