Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Practice Management News

GAO: Quality Measure Misalignment Impedes Provider Improvement

GAO found that providers cannot develop appropriate quality improvements for value-based care because of healthcare quality measure misalignment across payers.

By Jacqueline LaPointe

- Healthcare quality measures are integral to determining value-based reimbursement, but misalignment of quality measures across public and private payers has made it more difficult for providers to develop quality improvements for value-based care models, the Government Accountability Office (GAO) stated in a recent report.

Providers cannot implement quality improvements for value-based care because of quality measure misalignment, GAO states

“While the full extent of quality measure misalignment has not been quantified, evidence indicates that misalignment creates administrative burdens for healthcare providers and often results in quality information from different payers that is not comparable,” the report stated. “This, in turn, diminishes providers’ ability to identify high-impact quality improvements or prioritize the resources dedicated to them.”

GAO investigators found that quality measure misalignment occurred across public and private payers as well as across state and regional healthcare programs. For example, only about five percent of quality measures used by commercial health plans were included in more than half of the plans, according to a cited 2013 Health Affairs study. The study also showed that 17 out of 301 Physician Quality Reporting System measures and five Medicare Shared Savings Program measures were the same as measures commonly used by commercial plans.

Another 2013 report also found that 48 state and regional healthcare programs, including state Medicaid programs, commercial health plans, and regional collaboratives used a total of 509 quality measures, but only 20 percent were used by more than one program.

In addition to different measures, GAO also found that providers oftentimes had to report on the same measures, but each payer had different specifications.

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As a result, GAO stated that providers, especially those in smaller practices, experienced administrative burden. Reporting on different measures with different specifications led to clinical workflow disruptions and additional provider workloads. Providers also needed to acquire technological infrastructure and administrative support to gather, report, and analyze quality measures, the study stated.

Quality measure misalignment resulted in providers receiving performance assessments from payers that was not comparable, GAO contended.

“The expert stated that with misalignment, a provider may receive feedback from one payer indicating that the provider performs adequately, while receiving feedback from another payer indicating poor performance,” the report stated. “Some of the experts indicated that this conflicting feedback in turn diminishes providers’ ability to identify high-impact quality improvements or prioritize the resources dedicated to them.”

GAO investigators revealed that quality measure misalignment was driven by decision-making gaps among payers and providers, data collection and quality reporting system variations, and a lack of meaningful healthcare quality measures.

Decision-making on quality measure development is dispersed among payers and providers, the report stated. Healthcare stakeholders typically develop and implement quality measures based on their specific needs. For example, payers may prioritize some measures because of the patient populations they serve or providers may encourage payers to use certain measures based on specific conditions that they treat in their practices.

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GAO also noted that states and regions develop their own quality measures regardless of multiple payers using a core set of measures at the national level.

In addition, providers use a variety of data collection and quality reporting systems, which can make it more challenging to standardize quality measures. Since providers use varying EHR systems, paper records, and clinical data registries, payers must accommodate each method by selecting different measures, modifying existing measures, and allowing providers to decide on measure specifications.

“While these accommodations by payers may allow providers to report on measures using the data each has available, they can also contribute to misalignment and necessitate that providers contracting with several payers produce multiple reports with different measure requirements,” GAO wrote.

The report also stated that a lack of common measures or measure specifications makes it more difficult for EHR vendors to design systems that standardize data collection and reporting.

Quality measure misalignment was also driven by a lack of meaningful quality measures that providers can use to improve quality of care. GAO found that some providers hesitated to align with certain payers because their quality measures could not be meaningfully used for quality improvement.

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Stakeholders, however, faced many challenges with developing meaningful quality measures, including a lack of reliable data and resources needed to develop, test, and validate new measures.

To better align quality measures, GAO called on the Department of Health and Human Services (HHS) to prioritize the development of electronic quality measures for core measures. In 2014, HHS established the Core Quality Measures Collaborative (CQMC) to provide a space for CMS and private payers to negotiate core quality measure sets on which they would agree to use as part of provider performance assessments. By 2016, the CQMC released its first seven core measure sets, which target primary care and specialty care conditions.

GAO noted, however, that HHS has not taken significant steps towards developing electronic quality measures and standardizing data elements for the seven sets. The federal watchdog stated that electronic quality measure sets would reduce administrative burden because providers could use EHRs to report quality. Standardized data would also encourage health IT vendors to create systems that support streamlined quality reporting.

CMS should also create a timeline for how it plans to develop new and more meaningful quality measures, especially measures that will contribute to the core measure sets from the CQMC, GAO advised. Under the federal agency’s Quality Measure Development Plan, released in 2016, CMS detailed several quality measure development objectives, such as creating clinically relevant measures for specialties, developing more outcome-based measures, evaluating team-based care, and integrated physical and behavioral health.

However, GAO found that the plan has “no clear indication of how CMS’s ongoing measure development efforts will help CMS to achieve its goal of reducing measure misalignment, such as through the development of new quality measures that are most likely to help promote quality measure alignment among federal and private payers.”

In response, HHS agreed with GAO recommendations. The federal department affirmed that it intends to prioritize the development of electronic quality measures and refine planning documents to include more comprehensive timelines.

Aligning quality measures across public and private payers may also help providers reduce healthcare costs. According to a May report in Health Affairs, general internists, family physicians, cardiologists, and orthopedists spend more than $15.4 billion annually on quality reporting for payers.

The medical professionals in the study also reported spending an average of 785 hours per physician to report quality measures, totaling an average cost of $40,069 per physician per year.

“The cost to physician practices of dealing with quality measures is high and rising,” researchers stated. “There is much to gain from quality measurement, but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures.”

Dig Deeper:

Preparing the Healthcare Revenue Cycle for Value-Based Care

What Clinical Quality Measures Mean to Healthcare Providers


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