The process of measuring the performance against a set standard is benchmarking, a simple concept that plays a major role in improving the quality. Today, the need of benchmarking in healthcare is more than ever. Currently, the numbers related to US healthcare create a sense of urgency and demand a future-proof strategy to overcome the mounting challenges. Despite being one of the most developed countries, US is way behind other developed countries.
According to a report by Commonwealth Fund, US had the most number of deaths preventable using existing health care standards as compared to other 18 countries studied. A position paper in Annals of Internal Medicine in one of its publication positioned the US last below Australia, Canada, Germany, New Zealand, and the United Kingdom in several categories like quality, access to, and equity of care. Why is it that the US being one of the richest countries is underperforming in healthcare? What do the policy experts need to change?
One of the most suitable definitions of quality is:
“A broad measure covering the extent to which the care delivered is effective and well-coordinated, safe, timely, and patient-centered”
To achieve Quality patient-centric care, few indicators are needed, which should be selected according to certain criteria such as:
Creating room for improvement
On November 2, 2011,CMS launched Medicare Shared Savings Program (MSSP) as authorized by Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). Participating in ACOs gives healthcare providers an opportunity to come together voluntarily and work towards the ultimate goal in health care: coordinate care and improve quality for their patient population.
Medicare Shared Savings Program: Initial Benchmarking
The sole aim behind establishing MSSP was encouraging coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unwanted costs. Promoting accountability, it encouraged investments in healthcare and redesigned care process and the ACOs that could lower growth in healthcare cost while meeting the performance standards of quality care, were rewarded.
Initially, CMS would set benchmarks based on expected costs for beneficiaries assigned to the ACO for three years, before their agreement started. For small ACOs and the ones with minimal experience accepting downside risks and their savings is maximum 50% each year, no penalties are levied even if the savings are not realized. The second option is for better-established organizations, and they each get a maximum of 60% savings, each year. Their losses up to 2% of their benchmark would be considered, and the benchmark would increase every year, for three years and all the expenditures are adjusted using the CMS-HCC model for risk and inflation over time.
Quality Reporting for ACOs
As mentioned above, providing quality healthcare is not easy. And therefore, examining ACOs to gauge how they’re doing in this field is not an easy task. CMS has prescribed 34 nationally recognized quality measures falling in four key domains:
These 34 quality measures are reported through a combination of CMS claims and administrative data (EHR incentive program), a CMS-provided web portal (GPRO) and a patient experience of care survey.
New MSSP Benchmark Policy
This June, CMS released its final rule about MSSP benchmarking along with some other changes. The key change is to incorporate regional expenditure data into rebased benchmarks. CMS will define region based on ‘regional service area’, which includes all counties where one or more beneficiaries assigned to the ACO reside.
Initial agreement period: Beginning in 2017, CMS plans to adjust historical benchmarks for ACOs entering, or during initial three-year agreement periods. The agency will keep on setting historical benchmarks based on Medicare FFS expenditures for assigned beneficiaries, instead of all beneficiaries. CMS will continue to make adjustments based on participant list changes, deviating from the idea to make program-wide adjustments using expenditure ratio based on a single reference year and option, as opposed to continuing to analyze the plan.
Subsequent agreement period: The Final rule replaces the national trend factor with regional trend factors. The idea for a regional service area will be defined to include any county, where one or more assigned beneficiaries reside. CMS will ask for county level data for regional average FFS expenditure across four categories:\
Better outcomes possible with Benchmarking
The motivation to perform better than the past will guide us towards a revamped healthcare system. Today, we see different factors hindering with the transformation of healthcare value-based care. But as we all know, nothing is perfect, no system is in the best shape, it is made better. Thus, it is imperative that decision-makers make the most effective use of the resources to redesign the health care in the ‘American Dream.’
Healthcare isn’t about how much money is being spent on it, but how efficiently it is being spent! Healthcare isn’t about just building a care delivery mechanism but about creating equitable and affordable access to all health services. Today we need to leverage technology and find what is best for our patients. We need to create technology which our doctors can use like they use cell phone.
Healthcare is one of the most sensitive industry. Every inch of effort counts therefore, before making any decisions in healthcare, we should remember Martin Luther King Jr.’s words.
“Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”
Keeping the past in mind, let us build the healthcare of our dreams. Let us make the healthcare affordable and equitable.
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