“Value Based Care” (VBC) has become synonymous with long lists of Quality Measures (QMs), sometimes relegating PCPs to box-checkers in the interest of achieving patient outcomes. Thankfully, in launching ACO REACH, CMS strives to reduce the administrative burden of participating in VBC programs and instead focuses on aligning providers around overall outcomes by taking risk linked to Total Medical Expenditures (TME). In this blog post, I share some of the basics of how quality measurement works in the REACH program.
As part of CMS’s push for simplicity, the ACO REACH program has significantly fewer QMs – only 4 – when compared to past MSSP ACOs’ 33 QMs or MIPS’ menu of 200! What’s better, three of the four are reportable by claims, so chart chasing is no longer required – and Pearl will keep you on track through the normal course of providing outcome-oriented care.
We identify and break down the four measures below. Fortunately, all of them are quite straightforward.
Here’s a quick run-down of the four measures:
- Risk-Standardized All-Condition Readmission (ACR)
ACR looks at the fraction of hospital stays that result in a readmission within 30 days of discharge. Claims-based.
- All-Cause Unplanned Admission for Patients with Multiple Chronic Conditions (UAMCC)
UAMCC is slightly more complicated, looking at the rate per 100 person years of hospital readmissions for aged Medicare patients with two or more chronic conditions. Claims-based.
- Timely Follow-Up After Acute Exacerbations of Chronic Conditions (Timely Follow-Up)
Timely Follow-Up looks at whether doctors delivered follow-up care within the timeframe laid out by clinical guidelines for patients with an ED visit or hospitalization related to six specific chronic conditions (coronary artery disease [CAD], hypertension, heart
failure [HF], diabetes, asthma, and chronic obstructive pulmonary disease [COPD]). Claims-based.
- The Consumer Assessment of Healthcare Providers & Systems (CAHPS®) Survey
CAHPS® is a standard survey to measure the quality of patients’ experiences, administered by a CMS-approved vendor in collaboration with the ACO.
Our perspective on how to succeed on these measures and and how Pearl will help:
- Facilitating engagement with patients at admission, which is crucial for managing potential readmission and ensuring timely follow-up. Pearl is building admission, discharge, and transfer alerts into our product, so PCPs are always aware of their patients’ locations.
- Enabling proactive engagement by surfacing more urgent issues to the PCPs. This makes it easy to see who in the panel likely needs a touchpoint and what issues the patient is facing.
EXAMPLE
QM performance impacts how doctors are paid in REACH. It’s easiest to understand how this works by thinking through an example. The QM items are rolled up into a percentage score; for the sake of example, let’s say our participant has a quality percentage of 95%.
Starting in PY2023, a small slice of the capitation payment will be set aside for quality (2% in REACH; in the old model, it was 5%). As part of the regular capitation payment, CMS sends our participant doctor the quality amount times their expected percentage score (e.g. 95% of 2%, or 1.9%, meaning that the capitation payment is 2% – 1.9%, or 0.1% lower than perfect scoring). CMS reconciles that with actual QM performance at the end of the year.
The actual mechanics are a bit more involved, but the upshot is that these four measures – and the aligned economics of the REACH model – are the only quality variables doctors need to consider. This frees up doctors to spend their time thinking about how to serve their patients well, rather than running through a huge checklist in their EMR.
I want to end by underscoring the role Pearl can play in helping doctors succeed on REACH’s quality program: alerts driven by ADT feeds provide doctors with timely insight into moments when they can most effectively prevent readmissions and increase Timely Follow-Ups; and hiring a CAHPS® survey vendor also helps to ensure compliance and provides practices with feedback on their patients’ visit experience.
At Pearl, we believe in helping independent primary care providers benefit from the value they bring to the healthcare system, while creating a more equitable system, featuring greater access for patients, and higher quality care at a lower cost. We welcome similarly minded providers to join us on this mission.
About Pearl Health
Pearl Health is democratizing access to value in healthcare. Led by provider enablement, risk-bearing, and technology experts, Pearl offers software and services that help providers reimagine how they visualize, understand, and care for their patients. Pearl supports primary care organizations and providers in their transition to value-based care and surfaces data and insights that help them deliver better, more proactive care, decrease total cost of care across patient panels, and optimize performance in risk-bearing models like Medicare’s ACO REACH. Since its founding in 2020, Pearl has raised approximately $100M in funding from investors such as Andreessen Horowitz, Viking Global Investors, AlleyCorp and SV Angel, and has grown to serve providers across the United States.
Learn more at www.pearlhealth.com.
Pearl Health
Madison Klein
Head of Marketing, Pearl Health
562-310-6219
[email protected]
Pearl Health
Dan MacLeod
Director, Product Marketing, Pearl Health
240-603-2887
[email protected]
