Emphasizing Quality in the US Health Care System
Bayes Impact is committed to contributing to an equitable health care system that is affordable, accessible and delivers high quality care for everyone. That is why we are working with the Center for Medicare and Medicaid Services (CMS) to implement the Quality Payments Program (QPP). The QPP aims to incentivize Medicare providers (individual clinicians or group practices) based on quality of care metrics rather than on a transactional, fee-for-service basis. This quality-based care model will transform care for 55 million of the country’s citizens who use Medicare, many of whom are vulnerable and underserved. 18 million Medicare beneficiaries are living on incomes below 200 percent of the federal poverty level ($20,160 for a family of 2 adults and 1 child in 2016) and nine million live with complex care needs that hinder them from carrying out everyday tasks.
As a result of the landmark Medicare Access and CHIP Reauthorization Act (MACRA), a bipartisan bill passed in 2015, Medicare reimbursements will move towards being ‘value based’. Before MACRA, Medicare had a perverse incentive structure with a ‘fee-for-service’ reimbursement scheme, whereby clinicians and practices were paid for every service provided, regardless of whether or not it improved patient health outcomes. Clinicians participating in Medicare were incentivized to increase services, which increases their profits, sometimes at the expense of the patient.
Quality is the most heavily weighted of a number of ‘performance categories’ introduced by the Merit Based Incentive Payment System authorized in the MACRA Bill. It accounts for 50 percent of a physician’s overall score. Other performance categories include cost of care, advancing care information, and improvement activities. Bayes Impact is playing an important role in this big project, alongside multiple other players and many moving parts.
So what exactly is Bayes Impact doing within the QPP? Clinicians report their scores for up to 180 different quality measures through a variety of means, including a web interface, electronic health records, and claims. The Bayes Impact team is building automated claims processing data pipelines to calculate quality scores for 280,000 providers. The system processes over 3 billion claims per year and is one of the largest medical records databases in the US. Our overall goal for this project is to build a system that supports complex analyses of claims data, and eventually allows real-time analysis of Medicare health data.
The solution we are building is scalable and will allow for frequent feedback to providers regarding their quality measures. Starting this year, clinicians and practices will be able to view their current quality scores throughout the course of the year, with monthly updates being provided to the data. Even better, these quality scores will be available for the public to view as well.
2017 was the first performance period year for Medicare clinicians and practices to opt in to the program, with an incentive provided for early participation. Clinicians will receive reporting, feedback and payment based on their performance before January 2019.
The QPP represents a monumental shift in the way Medicare reimburses clinicians and practices for the health care services they provide. Historically, the Medicare program has served as a precedent for Medicaid and private insurance markets in terms of policy reform. We are excited by the potential of this project to catalyze values-based care across the US health care system.
Beyond this project, Bayes Impact has the unique opportunity to leverage learnings from the QPP as a foundation for integrating quality metrics into other areas. One area we are particularly excited about here is assessing health care network adequacy. Stay tuned for more!
Editor’s note: This project was executed in collaboration with Bayes Impact.
