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Are Claims-Based Quality Measures Dead?

February 7, 2018

According to the Centers of Medicare and Medicaid Services (CMS), in the 2018 Quality Payment Program Final Rule, 70% of claims-based quality measures are topped out.[1] The newly established topped out timeline will retire a quality measure after 3 consecutive years as a topped out measure during rulemaking in the 4th year.[2] Topped out measures have a large majority of clinicians performing at the top of the distribution which leaves minimal area for improvement. Therefore, by calendar year 2021, 52 of the current 74 claims-based quality measures will be proposed for retirement. 

 

This is a big deal because 278,039 clinicians in 2018 are expected to submit quality measure performance using claims-based quality measures which is the largest number of clinicians across all other reporting mechanisms.[3] While the retired measures will not immediately affect Accredited Care Organizations (ACO) or groups using the CMS Web Interface, the writing is on the wall. In addition to retiring topped out measures in 4 years, beginning in 2020, MIPS payment year (2018 performance year) measures identified as topped out will be capped at 7 out of 10 in achievement points.[4] The ability to improve on a topped out measure will be limited and therefore limit the improvement scoring opportunity. This action will also limit the quality category score, CEHRT bonus and reduce the overall composite performance score and associated incentive payment. CMS stated "We noted, however, that we proposed a timeline for removing topped out measures in future years (82 FR 30046). We believe this provides MIPS eligible clinicians the ability to anticipate and plan for the removal of specific topped out measures while providing measure developers time to develop new measures."[5] On the other hand, only 45% of registry/QCDR and 10% of EHR measures are topped out. CMS foreshadowed this action in the 2017 Quality Payment Program Final Rule stating that, “We agree with utilizing EHR whenever possible and encourage the use of EHR to collect data whenever possible. We intend to reduce the number of claims-based measures in future years…"[6]

 

Transitioning away from claims-based measures by using patient-generated data to maximize EHR clinical decision support and close real-time care gaps, that lag using claims-based information, will improve quality outcomes. Often claims-based measures require modifiers creating clunky workflow for clinicians that are ideally captured and satisfied as a by-product of documenting the assessment and plan of care in the EHR. Transitioning to using electronic clinical quality measures (eCQM) requires an organization to align the EHR build, clinical decision support and workflow, as well as, maintain a robust change management and validation process for all organizational initiatives. The patient-generated data offers a wealth of information for risk stratification and population health management when used in parallel with eCQMs.

 

Summary: 7 reasons to transition away from claims-based quality measures

  1. 70% of the measures are topped out

  2. Topped out clinician distribution in claim measure performance will reduce clinician incentive payments

  3. Topped out measures have minimal improvement scoring capability

  4. 2020 payment year the topped out capped scoring goes into effect

  5. CEHRT bonus is not available

  6. Not easily actionable at the point of care

  7. Improved workflow

 

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Footnotes:

[1] Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year, Published Date: 11/16/2017, 82 FR 535568, https://www.federalregister.gov/d/2017-24067/p-1810

 

[2] Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year, Published Date: 11/16/2017, 82 FR 535568, https://www.federalregister.gov/d/2017-24067/p-876

 

[3] Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year, Published Date: 11/16/2017, 82 FR 535568, https://www.federalregister.gov/d/2017-24067/p-4001

 

[4] Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year, Published Date: 11/16/2017, 82 FR 535568, https://www.federalregister.gov/d/2017-24067/p-4422

 

[5] Medicare Program; CY 2018 Updates to the Quality Payment Program; and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year, Published Date: 11/16/2017, 82 FR 535568, https://www.federalregister.gov/d/2017-24067/p-1818

 

[6] Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, Published Date: 11/04/2016, 81 FR 77008, https://www.federalregister.gov/d/2016-25240/p-1042

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