Resources

FAQ

• How and why are we measuring the quality of healthcare?

  Measuring the quality of healthcare gives us insight into how the health system is performing as a whole and on the individual organizational level. This drives strategies to improve care across the continuum and prevents overuse, underuse and misuse of healthcare services to ensure patient safety and satisfaction. Quality measures help hold payers and provider organizations accountable for providing high-quality care. Finally, they measure and address disparities in how care is delivered.

  Quality is measured by leveraging data to evaluate the performance of provider organizations against standardized quality metrics. Quality measures typically fall into four broad categories:

  1. Structure: Evaluates the characteristics of a care setting. For example, does an intensive care unit always have a critical care specialist on staff?
  2. Process: Assesses if the services provided to patients are consistent with routine clinical care. For example, are primary care physicians ensuring their patients receive recommended cancer screenings?
  3. Outcomes: Determines the efficacy of care delivered based on patient health over time. For example, how many patients had to be readmitted following surgery?
  4. Patient Experience: Analyzes feedback from patients based on their experience of care. For example, are providers explaining treatment options to patients in ways they can comprehend?

  Many differing metrics can be used by payers to measure the quality of care delivered, the rates of readmissions and disease management programs.

  Quality metrics are reporting systems that measure and quantify healthcare processes, outcomes, patient perceptions and organizational structure and/or systems. Understanding and meeting quality benchmarks is critical to reach the goals of the Triple Aim — improving the patient experience of care, improving the health of populations and reducing the per capita cost of healthcare. These metrics also serve as the starting point for program management initiatives and quality improvement efforts.

• How does Medicare policy affect the day-to-day operations of provider organizations?

  Medicare policy affects every aspect of provider operations and care delivery. Medicare policy is currently designed, at a high level, to motivate and incentivize providers to meet the goals of the Triple Aim — improve the quality of care, enhance the patient experience and reduce costs. They are doing this by changing the way providers are paid for delivering care, monitoring patient health over time and organizing their operations. Typically, private payers follow Medicare policy over time, so provider organizations that follow, understand and adapt to Medicare policy changes can stay ahead of the curve when it comes to their overall success.

• What are Alternative Payment Models?

  Alternative Payment Models are a type of payment reform that incorporates quality and total cost of care into reimbursement, rather than a traditional fee-for-service structure. Some APMs include Accountable Care Organizations, Bundled Payments and Patient-centered Medical Homes. APMs offer new ways to pay providers for the care they give Medicare beneficiaries.

  APMs allow flexibility in the types of services delivered and the types of providers who can deliver those services. Success is measured based on outcomes, not on adherence to one-size-fits-all standards for structure or processes. In addition, performance benchmarks must reflect differences in the costs and outcomes.

• What are bundled payments?

  Bundled payments link payments for multiple services beneficiaries receive during an episode of care, including financial and performance accountability. These models drive higher quality and more coordinated care at a lower cost to Medicare. Bundled payments can be an organization’s first step into APMs; they provide clear focus, engage specialists and do not upend a hospital’s fee-for-service business model.

  Bundled payments are an alternative to traditional FFS payments for patient healthcare. Reimbursements based on the utilization of each specific service associated with an episode can have a large amount of variance for payers and providers. By bundling these payments, providers receive a single amount for an entire episode, regardless of the cost. These models account for frequency and variance of the episode cost and aim to reduce overall healthcare costs while still covering costs incurred by providers.

• What is healthcare analytics?

  Healthcare analytics refers to understanding and gaining insight from massive datasets. Modern electronic health datasets are so large and complex that they can be difficult to manage with traditional software or hardware. They can’t be easily managed with traditional or common data management tools and methods either. Big data analytics applications in healthcare take advantage of the explosion in data to extract insight for making better-informed decisions.

• What is value-based care?

  Under value-based care agreements, you are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease and live healthier lives.

  Value-based care differs from a fee-for-service approach in which providers are paid based on the amount of healthcare services they deliver. The “value” in value-based healthcare is derived by measuring health outcomes against the cost of delivering the outcomes.

  An example of a value-based care initiative is the Medicare Access and CHIP Reauthorization Act. MACRA replaced the previous Medicare reimbursement schedule with a pay-for-performance program that’s focused on quality, value and accountability.

• What are the benefits of value-based care?

  • achieving the quadruple aim of improved patient outcomes, patient satisfaction, provider satisfaction and reduced costs;
  • optimizing use of electronic health records;
  • improving care coordination and care management for patients; and
  • collaborating across the medical neighborhood.

• Why should I be concerned about value-based care now?

  Value-based payment models impact physician reimbursement. Without proper preparation and implementation, practices may face significant reimbursement penalties.

  Government and commercial payer policies have been shifting toward rewarding the value of care provided over volume. This shift is important for improving patient outcomes and utilizing healthcare resources wisely.