Physician-Payer Quality Collaborative | MSMS

As health care transitions away from traditional fee-for-service, physicians in practice today face rigorous reporting requirements from a number of quality improvement incentive programs. Between initiatives like Physician Quality Reporting System (PQRS), Meaningful Use (MU), the Healthcare Effectiveness Data and Information Set (HEDIS) and others, physicians must monitor and report several hundred performance measures to multiple sources with little to no alignment nor intersection.

The burden of complying with several hundred performance measures is compounded by the volume and variety of health information technology (HIT) vendors in the market. The lack of interoperability and standardization across vendor platforms adds significantly to the costs and effort needed to share quality data. As the health care industry moves toward electronic automation, this is a problem faced by physician practices, physician organizations and health plans alike.

Vision for PPQC

The Executive Council created the Physician-Payer Quality Collaborative (PPQC) to engage government and commercial payers in an effort to focus quality improvement efforts around a core set of measures and standardize performance report and feedback with health plans. The PPQC is a physician-led activity, facilitated by MSMS and its partners on the Executive Council with technical support from Michigan Health Information Network Shared Services (MiHIN).

There are three components that form the vision of the PPQC:

Report Once  Physician organizations would only need to report quality measures one time to one location for all payers and all patients 
Measure Superset A data file containing all the information necessary, including supplemental clinical data, to calculate all measures from established measure sets
Incentive Alignment All payers agree to channel new incentives to a core set of measures, with common performance thresholds, that are evaluated on an all-payer and all-patient basis

 

Three Action Teams were created to champion these goals.  Each team includes representatives from various physician organizations and health plans across Michigan. The Action Teams are:

Data Capture & Collection This team is reviews physician organizations’ practices and makes recommendations for a seamless process to capture and transport quality data from providers to payers, and to facilitate feedback from payers to providers. 
Quality Measures This group is analyzes quality measures to develop consistent definitions for numerators, denominators, or exclusion statements between national level measure sets to streamline reporting for all patients and all payers.
Harmonize Financial Incentives The final team is analyzes ways to introduce aligned incentives that can facilitate improvement across a subset of quality measures, while accounting for disparate levels currently achieved by providers across payers and regions of Michigan.

Core Quality Measures

While hundreds of quality measures are currently used by various national quality reporting programs, the PPQC Quality Measures Action Team identified a subset on which to focus initial efforts.  All payers report HEDIS measures, many of which require supplemental clinical data.  Furthermore, payers often select HEDIS measures to include in incentive programs for providers.  The PPQC identified a “Core Set” of 27 measures that had significant overlap between all or most national and local quality reporting programs, including the State of Michigan’s State Innovation Model (SIM) initiative:

Adult BMI Assessment Childhood Immunization Status
Well Child Visits 15 month
Well Child Visits 3-6 years
Colorectal Cancer Screening Immunizations for Adolescents
Adolescent Well Care Visits
Follow-up for ADHD
Appropriate Treatment for URI
Appropriate testing for pharyngitis
Lead Screening
Imaging Studies for Low Back Pain
CDC: Hemoglobin A1c Testing
CDC: Hemoglobin A1c Poor Control
CDC: Eye Exam Performed
CDC: Medical Attention for Nephropathy
CDC: Blood Pressure Control
Controlling High Blood Pressure Weight Assessment and Counseling
Tobacco Use Screening and Cessation
Screening for Depression and Follow-Up Anti-depression Medication Management
Avoidance of Antibiotics for Bronchitis
Prenatal & Postpartum Care
Breast Cancer Screening
Cervical Cancer Screening
Chlamydia Screening
 

PPQC Quality Measures and Descriptions>>


The core measure set will be used to inform Michigan’s health information technology and exchange infrastructure for standardization of data entry or report submission. The use of a core measure set will reduce the administrative complexity to track physician performance data and ease the burden of quality reports, including the necessary clinical supplemental data.  Moreover, a core set of quality measures will allow for greater analytical effectiveness for payers and physician organizations.


Technical Pilot and Data Formats

MSMS will facilitate a technical pilot with the help of MiHIN for Executive Council partners to test the “report once” all payer, all patient superset concept using the agreed upon expanded BCN file format for the core measure set. The first phase of the pilot will be conducted in 2016 to ensure it can be sent electronically via the MiHIN networks and routed to the appropriate payer for their patient beneficiaries.

The second phase of the pilot will focus on the generation of Quality Reporting Document Architecture (QRDA) files, a national standard for quality measure submission included in Meaningful Use, and the standardization of “gaps in care” feedback to provide the most timely and actionable data possible.

The Executive Council partners that will participate include Northern Physician Organization, Oakland Southfield Physicians, United Physicians, Wayne State University Physician Group and West Michigan Physician Network. All results will be reported back to the Executive Council and other partners will become participants as they express their readiness.


Incentive Alignment

All payers offer uniquely structured financial incentive programs which reward physician organizations for reporting and performing well on selected quality measures. The PPQC recommends an additional incentive program with partial alignment across all payers utilizing the core measures that would be evaluated on an all-patient, all-payer basis. 

This all-payer, all-patient approach differs significantly from the status-quo, in which providers report measures to a payer using only patients from that particular payer. Physician organization representatives expressed frustration on behalf of their practices to comply with different incentive programs for each contracted health plan which all require different clinical workflows. Moreover, physician organizations stated the complexity of multiple incentive programs results in prioritizing of efforts which can cause some payers to classify practices or physicians as low performers based on how their beneficiaries are prioritized.

MSMS will continue to convene payer representatives to discuss these challenges and encourage the creation of an all-payer, all-patient incentive approach to provide greater clinical consistency when treating patients.