As many in the healthcare industry have observed, the landscape of healthcare payment and delivery is changing rapidly. Due to rising costs and regulatory changes, both public and private payers are launching programs to monitor the quality of care that healthcare organizations deliver and are tying reimbursement dollars and other incentive payments to performance. These types of quality improvement programs are being implemented all over the United States, and Oregon in particular has taken major steps towards improving healthcare quality and reducing costs in the state.
Physician organizations in Oregon need to stay informed about the many quality improvement activities that may impact them, including programs that publicly report quality data and programs with financial ramifications through incentive dollars or payment penalties. Below we highlight four programs—two that are state-based and two that are federal—that are impacting physician organizations in Oregon in 2016.
In 2012, the Oregon Health Authority (OHA) launched a pay-for-performance program that leveraged Coordinated Care Organizations (CCOs) to monitor quality and provide payment incentives for local networks of physician organizations that work together to improve care quality and lower costs for specific patient populations. In 2013, OHA received a State Innovation Model grant from the Centers for Medicare and Medicaid Services (CMS), which strengthened the CCO pay-for-performance program for people under the Oregon Health Plan (Medicaid) and made the model available to other payers, including the Public Employee’s Benefit Board for state employees.
The OHA pay-for-performance program uses quality metrics to monitor whether physicians and group practices are improving care and lowering costs for various patient populations. Incentive payments come out of a “quality pool” and are distributed to CCOs that meet benchmarks or improvement targets on specific quality measures and have at least 60% of their members enrolled in a patient-centered primary care home. In 2014, the OHA quality pool totaled $128 million, which represented 3% of the total amount of CCOs were paid in 2014. In 2014, all 16 CCOs showed improvements in some number of measures, and 13 out of 16 CCOs earned 100 percent of their quality pool payments.
In addition to the quality pool incentive, CCOs have the ability to earn additional payments that were available through the OHA “challenge pool.” In 2014, the challenge pool totaled $5.2 million, and by meeting benchmarks on additional quality measures, some CCOs earned as much as 5% more than their maximum quality pool amount.
Why it matters: Physician organizations that are part of CCOs have the opportunity to increase revenue through careful monitoring of the quality measures included in OHA’s pay-for-performance program.
The Oregon Health Care Quality Corporation (Q Corp) is an independent, nonprofit organization dedicated to improving the quality and affordability of health care in Oregon. Q Corp uses claims data from commercial, Medicare, and Medicaid health plans that operate in the state to develop a variety of reports related to quality and utilization of health care. The most recent reports were based on data collected between July 2013 and June 2014 and includes information on 3,395 primary care providers and 2.7 million Oregonians. Q Corp works with a multi-stakeholder advisory committee to select quality, cost, and resource use measures for reporting to a variety of audiences
Q Corp’s reports on physicians organization performance include private reports that are available just for physicians and publically available reports targeted at consumers and employers. The private reports that are visible only to primary care providers give insight into physician performance against benchmarks, variations in care across their patient population, and gaps in patient care that may exist for their practice. Public reports on health care quality are available for clinics and hospitals across the state and help consumers and employers make decisions about the care they need.
Why it matters: Q Corp annually reports data publicly for physicians organizations, which impacts consumer and employer selection of providers and other healthcare partners.
State-based programs are not the only ones that will impact Oregon physicians in 2016. Individual providers and medical groups that see Medicare Part B patients should participate in the Physician Quality Reporting System (PQRS) in 2016 by reporting quality measure data to CMS in order to avoid a 2.0% negative payment adjustment in CY 2018. On top of the PQRS payment penalty, participation in PQRS impacts how CMS will also apply the Value-Based Payment Modifier, which means that non-reporters of PQRS will face an additional 2.0%-4.0% negative payment adjustment depending on the size of the group.
Why it matters: Participating in PQRS in 2016 is critical for avoiding a negative payment adjustment of up to 6% that would reduce Medicare reimbursements starting in CY 2018. For more information about the 2016 PQRS program, refer to the Able Health blog post What’s new in PQRS in 2016 as the program gears up for MIPS.
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