In this week’s episode, Dr. Dan Mingle examines the impact of the Quality Payment Program and offers advice for provider assignment in a large ACO.

Click play below to listen to this episode now:

Question One: MSSP vs. MVPs vs. MIPS

Nicole asks: “Our organization runs multiple ACOs and has a couple of provider groups that are still Medicare Fee For Service and liable for MIPS. We want to know whether it is better to fold them into the existing ACOs, keep them in traditional MIPS, or utilize the new MVPs. Do you have any advice for us?”

If you’re considering rolling these groups into one of your ACOs, consider the reporting cost and the impact the provider additions might have on ACO performance.

Incorporating these providers into one or more of your existing ACOs is easy and won’t significantly affect the reporting cost. Most vendors are charging by the Medicare patient or the unique provider represented by TIN-NPI. Discounts on the reporting cost tend to increase as the number of providers or covered lives increases.

But a significant consideration for this choice is what it will do to the performance of the ACO.

How will the addition of these providers affect the performance of the ACO? There are four ways they will influence the existing ACOs:

• Patient count: More patients with the same quality and cost performance will translate to higher shared savings. However, the same dynamic occurs with losses. If you expect your ACO to be liable for a shared loss, adding these providers will exacerbate those losses.
• Cost performance: If these providers manage to a lower overall cost, they will improve your shared savings and losses. And, of course, the reverse is true.
• Quality performance: If their data is inaccessible, it could threaten your ACO compliance with data completeness criteria and invalidate the quality submission. Pulling the overall quality performance score upward or downward can decrease or increase your ACO’s ability to collect on earned savings.
• Cost of care: If you manage your patient population well, your ACO performs well. Building equivalent infrastructure for the added providers could be a significant added cost. This infrastructure cost will be a bigger factor if they are in a different community.

If you keep these providers fee-for-service (not in an ACO), MIPS vs. MVPs is an easier decision.

You should do both options. Build a traditional MIPS submission for these providers, and choose one MVP to build your familiarity with the process.

And once you’ve built both, you can submit both. Your group will be assigned the best of the two composite scores.

Question Two: Quality Payment Program Compliance

Georgina asks: “It still doesn’t seem to me like we’re making a difference in the value of care. Should we continue to comply with the QPP requirements?”

With the Physician Quality Reporting Initiative (PQRI) in 2007, Medicare introduced quality reporting and incentives based on reporting.

CMS later changed the name of this program to the Physician Quality Reporting System (PQRS) and changed it from a pay-for-reporting system to a penalty-for-not-reporting system.

CMS rolled cost of care analysis in with the Value-Based-Modifier program and with evolving models of Medicare ACOs that ultimately moved into the Medicare Shared Savings Program (MSSP) and introduced rewards for high-value care and penalties for low-value care.

With the introduction of the Quality Payment Program (QPP) in 2017, the Medicare Shared Savings Program (MSSP) became one facet of the First Pathway of the QPP, one of many Alternative Payment Models now available. The Physician Quality Reporting System became the Merit-Based Incentive Payment System (MIPS), the second pathway of the QPP.

So far, I have not seen definitive data nor anecdotal evidence of significant progress to higher value.

I still see high costs and problems with distribution. Inaccessibility, inequity, delays, healthcare costs, and health insurance costs are all growing faster than overall inflation. US healthcare costs are still the highest per capita in the world.

Medicare annually assesses the performance of the healthcare system and has generated enough evidence of constrained growth of cost to remain committed to the Quality Payment Program and Alternative Payment Models.

With those commitments intact, we can expect the Merit-Based incentive System to remain even if it’s simply because Medicare is using it to train providers in value measurement and payment and move them to Alternative Payment Models, particularly the MSSP.

Many of you saw or heard about the article in JAMA in December 2022, by lead author Amelia Bond, Ph.D., finding that “MIPS scores were inconsistently related to performance on process and outcome measures.”

Overall, we have yet to make a great deal of difference.

But we are on the right track. The data is going to be behind reality. On Bond’s article in JAMA:

• If we follow the flow from healthcare work in real-time through:
  1. Collection and submission of data to Medicare
  2. And publication and availability of data through Medicare’s Physician Compare files
  3. To Bond’s team analysis of the data before writing and publishing this paper
  4. And finally, to our reading and making sense of it, there is at least a five-year gap between the performance year and our examining and concluding the resultant data.

That’s five years in a program that is changing dramatically, evolving every year. And it’s also measuring a system that took three years off during the COVID Public Health Emergency.

It’s simply too early to tell if it’s making a difference.

I also observe: This program teaches us the difference between process and outcome measures in healthcare.

With that lesson in mind, it’s apparent to me, looking at the composite MIPS scores or the calculated savings and quality of the MSSP, cost is one of the primary outcomes we are trying to impact.

But quality is a process measure. It measures our ability to capture and report data more than it measures important qualities of care.

Question Three: Quality Payment Program End

Georgina asks: “If it seems like these programs have yet to make an impact, should we lobby hard for their end?”

The only choice worse than continuing to participate is to end the program.

We can do better than we are.

The Quality Payment Program is pushing in the right direction, but by itself, it will not give us the high-value health system we desire.

We have to measure cost, make sense of it, and take action to lower it.

We can only lower costs by monitoring quality. Otherwise, we save money by denying care to our most expensive patients.

Measuring cost and quality is necessary but insufficient to improve our healthcare system. Beginning and ending our attention to cost and quality on the limits of the Quality Payment Program will never be enough.

If all we do is react to the changing rules of the QPP, we will more likely add costs and, perhaps, gain quality in some domains at the expense of quality reductions in others.

The Quality Payment Program and related programs provide tools for committed healthcare practitioners to improve value if they are interested.

Combine commitment with measurement, and we might get somewhere.

There are three parts to the task that is right in front of us. The fundamental challenges of our professional lives are:

• Add quality to care
• Remove cost
• and relating to both, we can’t change what we don’t measure

We can’t change what we don’t measure. I believe that. And that puts my support behind the Quality Payment Program.

If you say:

“But the Quality Payment Program is faulty and hasn’t achieved those goals.”

I agree. But it does not reduce my resolve. I can still use the tools that the QPP provides to do a better job. And I must contribute to a steady evolution of the QPP and related programmatic rules to drive the desired change.

I am envious. The tools I wished for decades were available to my practice are now available to you youngsters. Everything is coming into place that we can use to build a high-value healthcare system.

Here are some of the crucial tools now available to us:

• EHRs to take cost out of care: primarily by reducing the cost of documentation.
• EHRs to add evidence-based quality to care: we need a measurement system that accommodates not just four or six measures, but monitors 35,000 known evidence-based rules for healthcare.
• Emerging models of prospective payment: to pull us out of the rut of face-to-face office-based care and permit innovations to care delivery to be truly patient-centric.

I think that there are only three things that you should be doing.

I think that there are only three things that I should talk to you about

1. Taking cost out of healthcare.
2. Adding value to healthcare.
3. Using measurement to improve value.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.