Quality Reports and Financial Incentives

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) shifted provider payment based on productivity to a future system that encourages quality and an integrated delivery system. The legislation recognized specific payment models: Merit-based Incentive Payment System (MIPS), Alternative Payment Models (APMs), and a physician-focused payment model (PFPM). The administrative rules governing the new payment models are currently being developed1,2,3 and will not be described in this discussion. In addition, many health plans have incentives for pay-for-performance programs and Patient Centered Medical Home (PCMH) recognition. Some of the major quality reporting systems and incentive programs are described as follows.

Physician Quality Reporting System—For years, the Centers for Medicare & Medicaid Services (CMS) has encouraged physicians to report selected quality metrics on a voluntary basis. The current reporting system is the Physician Quality Reporting System (PQRS). In 2015, physicians started to receive reduced payments if they did not participate in the PQRS. It is a negative incentive, and the cost will increase over time. Specific diabetes metrics are included in the PQRS, such as A1C control, eye exams, foot exams, and the use of ARBs or ACE inhibitors in patients with diabetes. More information about the PQRS is available on the CMS website.

Patient Centered Medical Home—Primary care professional societies, including the American Academy of Family Physicians, American College of Physicians, and American Academy of Pediatrics, initially promoted the concept of the Patient Centered Medical Home (PCMH). Over time, the PCMH has evolved into standards, and it is incentivized by health plans and government organizations. Within the PCMH model, population reporting encourages health care practices to report process and outcome measures, potentially related to diabetes. The National Committee for Quality Assurance is the largest organization offering Patient-Centered Medical Home Recognition.

Meaningful Use—Meaningful use (MU) focuses on driving electronic health record (EHR) vendors to provide technology that improves quality. A section of the MU requirements is for population reporting and registry function. The primary elements are related to structural metrics to assist providers in improving either efficiency or quality.

HRSA Uniform Data Set—Federally qualified health centers and other community health centers are evaluated on a set of performance measures emphasizing health outcomes and the value of care delivered. They report these measures in the Uniform Data System (UDS), a standardized reporting system that provides consistent information about health centers.4 Similar to the CMS PQRS, the UDS includes a series of metrics related to diabetes. HRSA also has an incentive program encouraging health centers to obtain PCMH recognition.

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