Does Healthcare Care About Clinical Quality Improvement?

John Lynn


We face a big challenge in healthcare. A doctor’s success is largely not dependent on the quality of care they provide a patient. We won’t dive into the details here, but our current healthcare reimbursement system pays a high quality doctor basically the same as a low quality doctor. This disconnect is what many in healthcare are trying to fix.

The leader of the charge towards paying doctors for clinical quality improvement is CMS. Don’t believe me? All we need to do is look at the recently started MIPS program within MACRA. Two of the four MIPS performance categories focus largely on clinical quality improvement: Clinical Practice Improvement Activities (CPIA) and Quality Performance (Formerly PQRS). In fact, these two performance categories make up 75% of the MIPS scoring that determines your Medicare payment adjustment. That’s what I call CMS going all in on clinical quality improvement.

Certainly I’ve heard many doctors complain that these CMS requirements don’t actually measure clinical quality. We’ll leave that assessment for another blog post, but it’s fair to say that regardless of their effectiveness, CMS is trying every way possible to reward higher quality care. In fact, it’s not just enough for a doctor to provide quality care. CMS wants the data to prove it. Many other payers are following along as well.

What’s important to realize with this clinical quality improvement scoring is that it is all based on your data. If you don’t have the data available and organized in the right way, you’re not going to meet these new quality performance requirements and you’re going to get paid less. This is one reason why health information governance has never been more important.

Having the right information at the right place at the right time matters in providing quality care, but it also matters when trying to get CMS to pay you for that higher quality care.

Whether you’re interested in MACRA incentives or not, you should keep a close eye on these MIPS quality metrics. It’s only a matter of time until CMS shares these quality scores publicly and every physician rating site will swarm to them and share them with patients. Unjust as it may be, these scores could very quickly serve as proxy for quality when patients are selecting a new doctor. How will a patient look at a doctor with a low score or no score because they didn’t participate?

The irony of this clinical quality improvement discussion is that every doctor I know wants to offer the highest quality care they can possibly give a patient. Doctors are totally aligned with the idea of providing high quality care. However, they just don’t think the current MACRA measures of quality do a good job measuring clinical quality. They’re probably right, but CMS is learning and they’ll get better over time. Let’s hope they do, because reimbursement based on clinical quality isn’t going anywhere soon. Is your organization ready?

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