Quality, a Healthcare Triple Threat

Aug 06, 2018

On Thursday July 12, The Centers for Medicare & Medicaid Services (CMS) unveiled proposed rules involving the Medicare Physician Fee Schedule and the Quality Payment Program (QPP). One of the important proposals would make changes to the QPP quality reporting requirements to focus on measures that most significantly impact health outcomes. Additionally, proposed changes would encourage information sharing among healthcare providers electronically.

CMS’s intention with these changes was to substantially support the transition to value over volume-based medicine. CMS Administrator Seema Verma’s stated that the “proposals deliver on the pledge to put patients over paperwork by enabling doctors to spend more time with their patients.” The proposed changes are intended to streamline documentation requirements, with a focus on patient care, as well as to modernize payment policies. Verma states that these changes will allow those covered by Medicare to “take advantage of the latest technologies to get the quality care they need.”

Traditional healthcare models reimburse doctors depending on the volume of healthcare they provide (i.e. the number of test or services performed). It isn’t hard to see how this is not the most efficient system, nor does it always deliver the best ‘medicine’ to the patient. Enter, value-based care, with a focus on healthcare quality, not quantity. In this system, payment is based on healthcare organizations reporting on their quality and cost efficiency.

CMS’s answer to this new healthcare model is the QPP, which rewards quality Medicare clinicians with payment increases, while at the same time reducing payments to those clinicians who aren’t meeting performance standards. Clinicians have two tracks to choose from, based on their practice size, specialty, location, or patient population:

  • Merit-based Incentive Payment System (MIPS) or
  • Advanced Alternative Payment Models

Under the new rule quality measures will make up 50% of the clinicians overall MIP score. This Quality performance category measures health care processes, outcomes, and patient care experiences. Quality measures help link outcomes that relate to effective, safe, efficient, patient-centered, equitable, and timely care.

Regardless of where you come down on these proposed rules, it is hard to avoid the theme of quality. While improving the quality of healthcare is the end goal, my thoughts naturally migrate to data quality and the importance that data veracity will have in the success (or not) of the transition from volume-based care to value based care.


There is much written about how value-based pay must be data driven, but there is very little that addresses the nuances and challenges that occur on the way to becoming data driven. In healthcare, there are security challenges due to PHI and PII and interoperability are important, but there are other challenges to consider as well. Being data driven requires a clear understanding of the business definitions of the Merit-based Incentive Payment System (MIPS) Quality Data Codes. For example, if you are an ophthalmologist it will be crucial to understand the CMS’s definition of an uncomplicated cataract. Following business understanding comes data understanding – not always a straightforward task. For example, do you (and all group providers, and your coding and billing specialists) know what data is needed to identify eligible cases for the selected measures, and further is that data being collected?

This is not meant to dampen spirits; these challenges can be overcome by applying standard data management and governance practices to the data you collect and share. Data management frameworks should set data standards and assess, improve, and track data quality across a broad range of dimensions. Timely, complete, and accurate information will ensure quality data which will improve measures and advance healthcare outcomes. With an approach and framework in place you can be assured that the quality of the data used to measure value will be as high as the quality of care it is meant to incentivize. Quality is truly the triple threat that will improve healthcare.