Society for Maternal-Fetal Medicine Special Statement: Clinical quality measures in obstetrics.

This article provides an updated overview and critique of clinical quality measures relevant to obstetrical care. The history of the quality movement in the United States and the proliferation of quality metrics over the past quarter-century are reviewed. Common uses of quality measures are summarized: payment programs, accreditation, public reporting, and quality improvement projects. We present listings of metrics that are reported by physicians or hospitals, either voluntarily or by mandate, to government agencies, payers, "watchdog" ratings organizations, and other entities. The costs and other burdens of extracting data and reporting metrics are summarized. The potential for unintended adverse consequences of the use of quality metrics is discussed along with approaches to mitigating adverse consequences. Finally, some recent attempts to develop simplified core measure sets are presented, with the promise that the complex and burdensome quality-metric enterprise may improve in the near future.

Scaling up quality in an anesthesia practice.

The resources necessary to improve anesthesia quality and meet reimbursement and regulatory thresholds are scarce, particularly for smaller practices. We examined how small practice integration into a firm with greater resources can facilitate improvements. A mixed-methods analysis was conducted using the data from the US Anesthesia Partners data warehouse, Merit-based Incentive Payment System (MIPS), commercial insurers' surgery length of stay (LOS) databases, anesthesia-specific patient satisfaction surveys, and interviews with practice leadership before and after integration. All integrated practices improved their quality improvement infrastructure and achieved higher MIPS scores, with increased clinician and leadership satisfaction. Patient satisfaction exceeded national benchmarks in all groups, based on 398 392 returned surveys in 2021. Hospital LOS for common operations was shorter, based on a statewide database. This case study demonstrates that partnership with an organization with greater resources can advance anesthesia quality.

Nephrologist Performance in the Merit-Based Incentive Payment System.

RATIONALE & OBJECTIVE: The Merit-Based Incentive Payment System (MIPS) is the largest quality payment program administered by the Centers for Medicare & Medicaid Services. Little is known about predictors of nephrologist performance in MIPS. STUDY DESIGN: Cross-sectional analysis. SETTING & PARTICIPANTS: Nephrologists participating in MIPS in performance year 2018. PREDICTORS: Nephrologist characteristics: (1) participation type (individual, group, or MIPS alternative payment model [APM]), (2) practice size, (3) practice setting (rural, Health Professional Shortage Area [HPSA], or hospital based), and (4) geography (Census Division). OUTCOMES: MIPS Final, Quality, Promoting Interoperability, Improvement Activities, and Cost scores. Using published consensus ratings, we also examined the validity of MIPS Quality measures selected by nephrologists. ANALYTICAL APPROACH: Unadjusted and multivariable-adjusted linear regression models assessing the associations between nephrologist characteristics and MIPS Final scores. RESULTS: Among 6,117 nephrologists participating in MIPS in 2018, the median MIPS Final score was 100 (interquartile range, 94-100). In multivariable-adjusted analyses, MIPS APM participation was associated with a 12.5-point (95% CI, 10.6-14.4) higher score compared with individual participation. Nephrologists in large (355-4,294 members) and medium (15-354 members) practices scored higher than those in small practices (1-14 members). In analyses adjusted for practice size, practice setting, and geography, among individual and group participants, HPSA nephrologists scored 1.9 (95% CI, -3.6 to -0.1) points lower than non-HPSA nephrologists, and hospital-based nephrologists scored 6.0 (95% CI, -8.3 to -3.7) points lower than non-hospital-based nephrologists. The most frequently reported quality measures by individual and group participants had medium to high validity and were relevant to nephrology care, whereas MIPS APM measures had little relevance to nephrology. LIMITATIONS: Lack of adjustment for patient characteristics. CONCLUSIONS: MIPS APM participation, larger practice size, non-HPSA setting, and non-hospital-based setting were associated with higher MIPS scores among nephrologists. Our results inform strategies to improve MIPS program design and generate meaningful distinctions between practices that will drive improvements in care.

Clinicians With High Socially At-Risk Caseloads Received Reduced Merit-Based Incentive Payment System Scores.

To understand how clinicians with high caseloads of socially at-risk patients fare under Medicare's new outpatient Merit-based Incentive Payment System (MIPS), we examined the first (2019) round of MIPS performance data for 510,020 clinicians. Compared with clinicians with the lowest socially at-risk caseloads, those with the highest had 13.4 points lower MIPS performance scores, were 99 percent more likely to receive a negative payment adjustment, and were 52 percent less likely to receive an exceptional performance bonus payment. The lower performance scores were partly explained by lower clinician reporting of and performance on technology-dependent measures, which may reflect a lack of practice-level technological capability. If the Complex Patient Bonus were in effect, the performance scores and likelihood of receiving an exceptional performance bonus (payment of clinicians with the highest socially at-risk caseloads) would have increased by 4.7 percent and 2.8 percent, respectively; however, the proportion receiving negative payment adjustments would have remained unchanged. The Complex Patient Bonus appears unlikely to mitigate the most regressive effects of MIPS.

Medicare reimbursement and orthopedic surgery: past, present, and future.

PURPOSE OF REVIEW: This paper reviews the history and structure of Medicare reimbursement with a focus on aspects relevant to the field of orthopedic surgery. Namely, this includes Parts A and B, with particular attention paid to the origins of Diagnosis Related Groups (DRG) and the physician fee schedule, respectively. We then review newer policies affecting orthopedic surgeons. RECENT FINDINGS: Recent Medicare reforms relevant to our field include readmission penalties, the evolution of bundled payments including the mandatory Comprehensive Care for Joint Replacement (CJR) and Surgical Hip and Femur Fracture Treatment (SHFFT) programs, and the new mandatory Merit-based Incentive Payment System (MIPS) pay-for-performance program. Providers are facing an increasingly complex payment system and are required to assume growing levels of financial risk. Physicians and practices who prepare for these changes will likely fare best and may even benefit.

Traditional Payment Models in Radiology: Historical Context for Ongoing Reform.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on quality and alternative payment model participation. The general structure of payment under MACRA is included in the statute, but the rules and regulations defining its implementation are yet to be formalized. It is imperative that the radiology profession inform policymakers on their role in health care under MACRA. This will require a detailed understanding of prior legislative and nonlegislative actions that helped shape MACRA. To that end, the authors provide a detailed historical context for payment reform, focusing on the payment quality initiatives and alternative payment model demonstrations that helped provide the foundation of future MACRA-driven payment reform.

Alternative Payment Models in Radiology: The Legislative and Regulatory Roadmap for Reform.

The Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on the Merit-Based Incentive Payment System and incentives for alternative payment model participation. It is important that radiologists understand the statutory requirements of MACRA. This includes the nature of the Merit-Based Incentive Payment System composite performance score and its impact on payments. The timeline for MACRA implementation is fairly aggressive and includes a robust effort to define episode groups, which include radiologic services. A number of organizations, including the ACR, are commenting on the structure of MACRA-directed initiatives.