In the “old days,” reporting was mostly financial and relatively easy. If you accounted for all of the volume and optimized your coding, you were good to go.
Well, welcome to the new world of value, where quality metrics loom large and the future payment stream for your organization depends not only on your providers’ performance, but more importantly, on how well your reporting structure is deployed.
Based on my experience with several large multispecialty medical groups, here are three common reporting concerns you should address:
1. ACO reporting
Currently, there are more than 400 Track 1 accountable care organizations that are required to report on more than 30 measures—which, in the aggregate, determine whether an organization will be eligible to share in any savings. The higher the aggregate quality score, the greater share of savings that can be retained by the respective provider organization.
A critical element of reporting through the group practice reporting option is how the health system selects its “groupers,” that is, the denominator of patients who should be included in any given metric. If the groupers are too broad, there is a risk that patients in the attributed group are included even though they do not have the related diagnosis.
A good example here is diabetes. In one system, the groupers were so broad that it included those patients with prediabetes, gestational diabetes, and even some who had elevated nonfasting glucoses and yet were never confirmed to have diabetes. The result of this inappropriately inflated diagnosis group is that many of these patients in the attributed population will not be considered to have diabetes by the providers and will not, therefore, have the retinal screens, Hgb A1C follow-up or urine proteinuria screens required by the ACO metric scoring.
One group with which I have worked began with an inappropriately broad definition of diabetes. Once it appropriately narrowed its groupers to only patients with definitive diabetes, it found that its denominator dropped by 50%, with obvious dramatic correction and improvement of the group’s related metrics.
A critical element here is the need to involve clinicians at every stage of the development of reporting parameters to properly establish and measure performance in a value-based world. They must lead this activity; it cannot and should not be delegated to nonclinicians. In the new value-based world, the downstream effect on revenue from these metrics is huge, and the inclusion of clinicians to clearly and appropriately define the population in an accurate manner can pay dramatic dividends.
2. Compensation plan value metrics reporting
Increasingly, more and more medical groups are incorporating value metrics into their compensation plans, with the average group putting at least 5-10% of physician compensation at risk for quality.
As opposed to ACO reporting, which includes claims-based metrics and is population-based, most compensation plan reporting depends on visit-based metrics, which measure those patients actually seen in active management. Here, the reporting data is derived directly from the electronic medical record. The creation of reports depends on a careful analysis of the practice workflow and building the report to ensure that credit is given for achievement of the desired endpoints.
For example, if colon cancer screening is used as a metric, it is imperative that the metric is satisfied electronically when the result of the colon cancer screen is recorded/filed/scanned in the EMR and the health maintenance “button” is clicked or “satisfied.” I have seen examples where the correct actions are not credited due to faulty report writing or workflow construction. Nothing will cause physician skepticism as quickly as having correctly completed actions go unrecognized when there is money on the line.
Repeated testing prior to going into production for all compensation-related metrics is crucial, as it creates a trusting relationship between the medical group and the reporting team.
3. Guideline adherence monitoring
As groups become more sophisticated, a next logical step is to move into the realm of guideline-based care. As an approach that has the potential to both improve outcomes and reduce cost, there is much to be gained.
While most medical groups employ a joint effort between informatics/IT and practicing clinicians to create the evidence-based order sets, it is not unusual for the reporting team alone to create the scorecards for reporting how often individual providers use the preferred pathway. Here again, clinician input is crucial—and its absence can be catastrophic.
A typical example is an acute urinary tract infection (UTI) order set. Inclusion of such unrelated diagnoses as hematuria and incontinence in the denominator of the report on order set usage will give the false impression that the order set is underutilized when, in fact, it would not be appropriate.
Again, it is critical that practicing clinicians are involved throughout the process to define precisely which diagnoses should trigger the use of the order set.
As value-based reporting moves to center stage in the evolution of patient care, reimbursement and provider compensation, I cannot overemphasize the critical importance of developing an accountable reporting suite. A tight collaboration between IT/decision support/informatics and clinicians is the best way to prevent errors in metric and report building. Involvement of providers in every phase is particularly critical.
When done well, the result will be accurate data, better outcomes, enhanced revenue and the all-important development of a trusting relationship with providers.
Howard Graman is vice president of AMGA Consulting Services. He was formerly the CEO of PeaceHealth Medical Group and served as both executive director and medical director at Cleveland Clinic.