CMS was right to hold off on CJR health IT quality measure

The Centers for Medicare & Medicaid Services is very keen on moving away from a fee-for-service healthcare system to value based reimbursement in order to improve care coordination and reduce healthcare costs. Earlier this year, the agency announced that it was speeding up plans to move to alternative payment models, tying 85 percent of traditional Medicare to quality or value and 30 percent to alternative payment models by the end of 2016; 50 percent of its payments will be alternative or population model-based by 2018.  

In a press call announcing this initiative, CMS stressed that the success of these alternative payment models lies, in major part, on EHRs and data exchange. This should no longer be a surprise to anyone; CMS has been either mandating EHRs and data sharing or encouraging it in payment rules for all sorts of providers.

To that end, it's insightful to look at what the agency did in its new bundled payment program for lower limb knee and hip replacement, the Comprehensive Care for Joint Replacement (CJR) initiative.

The CJR, a five-year model program that will begin April 2016, is arguably one of CMS' most ambitious alternative payment/bundled programs, requiring hospitals in 67 different geographic areas to be accountable for joint replacement episodes of care from surgery through 90 days after discharge. Hospitals must, among other things, coordinate care with physicians and an array of post-acute care providers.

The rule implementing the model, released Nov. 16, specifies that the use of health IT tools is a "critical component" to the effective coordination across care settings, calling it "essential" in bundled payment models. Hospitals would be subject to either bonuses or repayments based on their quality performance and cost efficiencies.

But it's striking what's missing: There's no quality measure for certified health IT in the program.

CMS wants to include one, and said in the proposed rule that it would include such a requirement starting in 2017. In the proposed rule, it asked for feedback, asking:  

  • Is successful attestation as part of the EHR Incentive Program for Medicare hospitals in the applicable reporting year the most appropriate quality measure for assessing hospital performance on the use of health IT and interoperable health information in the model? 
  • Should the model include a performance measure that would be specific to the ability of hospitals to conduct electronic care coordination using certified health IT, for instance, the measure of transitions of care which hospitals currently report on as part of the EHR Incentive Program for Medicare Hospitals?
  • What other measures could be used to assess hospital performance on the use of health IT and interoperable health information while minimizing program and provider collection and reporting burden?

In the final rule, CMS opted to hold off incorporating a health IT quality measure for the moment, deciding instead to "evaluate" the suggestions received. It stated:

"As future measures become available, such as measures which focus directly on electronic exchange between all providers participating in a bundle, we will continue to explore whether there are opportunities to address this important aspect of care delivery for model participants."

This is significant, and CMS' prudence should be noted. 

While CMS provides only general summaries of commenters' concerns about the addition of a health IT quality measure into this new CJR program, the agency at least recognized (I'd like to think) that conditioning payment in large part on exchanging electronic data with providers whom the hospitals don't control--and in the case of post-acute care, may not even have adopted EHR--is inappropriate. That did not work well in the Meaningful Use program, causing CMS to back pedal on its original patient engagement requirement.

What's more, it appears that CMS realized that the reliance on the Meaningful Use program may be misplaced here, and that a different health IT measure may be better suited to bundled payments and care coordination.

The Meaningful Use program has had its benefits, but it has not met its goals, which could be an indication that it's not necessarily the go-to measure the government should be relying on.

CMS is willing to review its options rather than rush to impose a quality measure that may not work and could even undermine its payment reform efforts.

Smart. - Marla (@MarlaHirsch and @FierceHealthIT)