The reaction to MACRA Pick Your Pace speaks volumes about the state of preparedness for the upcoming Quality Payment Program (QPP). Some see Pick Your Pace as a reprieve, others see it as a parachute, and a select few see it as a way to get a head start on their peers. There’s a danger to being in the first two camps. Neither fully recognizes that CMS will differentiate practices on Resource Use. As a result, they have no impetus to implement Clinical Practice Improvement Activities (CPIAs) focusing on Care Coordination; but this is an area that will impact each aspect of the MIPS Composite Score.
Yes, Pick Your Pace indicates that you can ease into some of the quality reporting aspects of the new program. But don’t be fooled into thinking this is a trial run. Without Care Coordination efforts in place, your resource scores will be low (high costs generate fewer points on the decile scale), and other components of your MIPS composite will be impacted as well.
CPIAs can have a multiplier effect on your composite, and the impact can be substantial. Although the four components (Quality, Resource Use, CPIA, and Advancing Care Information) of the MIPS composite are weighted separately, CPIAs can impact the three other components, if used wisely. Your CPIA selections can affect every aspect of your MIPS composite score, positively or negatively.
This MIPS scoring effect is particularly apparent when viewed in the context of Care Coordination. CPIAs are grouped in nine different categories, six of which have been specifically been called out in the proposed MACRA legislation. One of those six is Care Coordination, aimed at ensuring that the patient gets the right care at the right time, whether in a single practice or in a larger network. For example, closing referral loops ensures that patients with concerning diagnoses (e.g. chest pain, breast mass) have seen a specialist and that the primary care provider acknowledges receipt of the specialist’s findings. Similarly, communication and/or visits following a hospitalization or surgical procedure can help detect complications at early stages, before they become catastrophic.
This push should come as no surprise, as other CMS initiatives and innovation models seek to address issues associated with Care Coordination. For example, the Comprehensive Care for Joint Replacement (CJR) program is intended to address the concerning variation in costs associated with hip and knee replacements. This difference is not associated with the cost of the procedure itself—those are defined by the Medicare Physician Fee Schedule. (Granted, there is variation according to geography and other factors—the price for a knee replacement isn’t listed on the board above the cashier—but those do not account for the difference.) No, the variation is due to complications. Infections, re-operations and re-admissions vary three-fold across facilities. When including pre- and post- surgical care, costs can range from $16,500 to $33,000.
The Role of CPIAs in Care Coordination
Your goal is clear: create a Care Coordination improvement plan using CPIAs. You’ll improve your Resource score by keeping costs lower than your peers, and you’ll also be doing right by your patients. We shouldn’t forget that behind all of the costs associated with re-operations, infections and re-admissions, there’s a human being who needs to heal.
Care Coordination CPIAs can be categorized into three basic groups:
- Measure and Improve
To strengthen your Care Coordination infrastructure through CPIAs, select activities from each of these groups to create a linear process that achieves measurable results:
1. Participate with a Qualified Clinical Data Registry (QCDR)
The ability to aggregate multiple data sources will be particularly relevant to coordinating care. EHRs may be able to tell you everything you need to know about what happens in your practice, but relying on your EHR alone is the antithesis of a Care Coordination initiative. Resource Use focuses on dozens of episode-based costs, in addition to per-capita costs—those do not start and stop with you, and to identify the gaps, you need a patient-centric view.
For example, in the CJR, communication between surgeon and providers delivering post-surgical care (e.g. physical therapists, occupational therapists, nutritionists, etc.) can identify whether the patient is meeting treatment goals. If the patient’s functional status is not improving, this may lead to complications with the joint or in other aspects of patient health (e.g. decreased activity leading to depression or exacerbation of other chronic conditions).
To identify such issues, partner with a Qualified Clinical Data Registry (QCDR), which has the ability to aggregate data from multiple sources, as well as track costs and outcomes over time. From there, a QCDR can help you determine where you can improve, and how. In addition to your long-term goals, QCDRs also offer an immediate advantage. One of the CPIAs in the Care Coordination group is to participate with a QCDR—as its own CPIA. In other words, you get credit right off of the bat, just for proving that you’re committed to your program. Regardless of which CPIAs you choose, a successful initiative depends on determining your goals, measuring your results and developing strategies to improve.
2. Prepare by Defining Your Process
There are several Care Coordination CPIAs requiring participants to define and document processes. To those who have engaged in Patient-Centered Medical Homes, this should sound familiar, as similar activities are required for PCMH recognition. It’s easy to see why PCMH participants receive full credit for the CPIA component, as those activities are very similar to what has been proposed. For example:
- Implementing processes for documenting all Care Coordination activities, including which staff members are involved, and their specific roles;
- Updating plans of care regularly with the patients and caregivers;
- Implementing regular Care Coordination training;
- Establishing standard operations for managing transitions of care, including local lines of communication to ensure information flows during transitions, which may include setting up relationships with community or other hospital-based services.
3. Measure and Improve Where It Matters to You
The final step is to determine which of the remaining Care Coordination CPIAs make the most sense for you. This will depend on the nature of your practice; the measurement-driven CPIAs will not apply to everyone. To determine your best options, examine your previous quality reporting metrics, as well as your Quality and Resource Use Reports (QRURs), as they can provide you with direction.
If your previous quality reporting results suffered because you were unable to locate (or access) the necessary results to fulfill a quality measure, there is a CPIA specifically devoted to communicating test results and flagging abnormal results. Your QCDR can track when tests were ordered and highlight instances where results were not received. That’s your cue to figure out if the test was never performed, or if there’s a gap in the process that’s preventing the necessary information from getting to the people who need it in order to make informed clinical decisions. You can see that correctly implemented CPIAs are felt in other areas of the MIPS composite score, and more importantly, may make a substantial difference in your patients’ health.
In the four-pronged MIPS scoring methodology, the role of CPIAs is to facilitate better care, and is based on attestation, rather than data submission and scoring. Nevertheless, don’t be fooled into thinking that attestation or Pick Your Pace will grant you a reprieve from implementing Clinical Practice Improvement Activities, or that you can succeed just by checking a box. With the right QCDR partner, you can deploy your CPIAs strategically so that in addition to fulfilling the CPIA scoring component, they provide the infrastructure to coordinate care, improve the other components of the MIPS composite, and prevent events that can be detrimental to your patients and their families.
Founded in 2002, ICLOPS has pioneered data registry solutions for performance improvement in health care. Our industry experts provide comprehensive Solutions that help you both report and improve your performance. ICLOPS is a CMS Qualified Clinical Data Registry.
Image Credit: Carin Araujo