What Is The Merit-Based Incentive Payment System

In 2012, the ACA found an excessive amount of readmissions of patients that were hospitalized within 30 days for the same medical conditions. This factor viewed under the ACA as a quality issue and CMS implemented value-based incentive payments based on performance in a set of quality measures. The plan is to implement a pay for performance (P4P) in formulas used by Medicare to reimbursement providers. “The objective is to link reimbursement to quality and efficiency as an incentive to improve the quality of health care, as well as reduce system-wide costs” (Shi and Singh, 2015). In addition to the P4P, nonprofit hospitals also focus on continual improvement, data and cost containment throughout the organization (Adamopoulos,

One of the biggest impacts on the healthcare industry is the transition from a fee-for-service model to a value-based payment model. This transition is emphasizing the importance of utilizing data captured electronically in EHRs, HIEs, and other clinical and business systems to improve patient care. Payers are implementing payment incentives and penalties based on performance in defined quality and safety metrics through programs such as Blue Cross’ Pay for Performance (P4P) or CMS’ Value-Based Purchasing (VBP). These programs, along with other factors, are resulting in a growing that utilizes data analytics and business intelligence to provide healthcare leaders and physicians with insight into their quality and safety metric status.

The surveys are meant to be specific and consistent and are not just used to evaluate the organizations for improvement but are also to educate in the best practice standards adopted throughout health care and to help staff in ways to continually improve an organizations performance. For this purpose, in 1996 the Quality Check website was launched to help the Joint Commission provide information regarding the performance of accredited organizations to consumers and organizations. Users are able to search for accredited or certified organizations; they can locate organizations by either type of service or geographical area and lists of certified organizations as well as a hospital’s performance measures can be obtained.

This standardized dialect is also pertinent for medical schooling and teaching in addition to clinical research and studies conducted by scholars, scientists, and physicians by providing a valuable foundation for domestic and coast-to-coast operation evaluations. CPT is used to describe doctor’s services, a vast amount of administrative services in addition to operating services executed in medical facilities, treatment care centers, and outpatient divisions. Providing support for clerical duties and functions such as processing medical claims and initiating strategies and procedures for the evaluation of clinical care is another cause of relevance for CPT. The system also meets the need for tracking trends and identifying improvements, plus progression goals and scaling the value of healthcare services received by patients. The CPT coding system provides physicians throughout the United States with a consistent method for classifying and coding clinical procedures which in return provides a more efficient tool for recording and reporting task that were completed. Physicians, scholars and payors, have been dependent upon CPT to interconnect with other fellow associates, patients,

Quality Improvement Organizations (QIOs), work in partnership with the Centers for Medicare and Medicaid Services (CMS) to advocate for safe, efficient, and quality healthcare for Americans. Working at the community level, QIOs collaborate with providers and interact with beneficiaries to improve patient outcomes. Additionally, QIOs support new models of care and promote healthcare goals endorsed by the National Quality Strategy, and CMS Quality Strategy. CMS has strategically placed QIOs in several regions nationwide, and Mississippi is served by Information and Quality Healthcare (IQH). IQH founded in 1971 as a non-profit organization has strived to improve the quality of care received in Mississippi. IQH participates in a tobacco cessation helpline, behavioral health services, and diabetes education for Medicare beneficiaries.

The advantage of VBPS program is that it promotes and reimburses for all treatments that are planned to help to bring better health outcomes for Medicare patients. This program also plays a part in reducing the rate of unnecessary tests and referrals that are unrelated to treating of patients’ conditions. The program gives incentive rewards to healthcare facilities that are successful in reporting the high quality of cares and better patients’ health outcomes. It also serves as supports and guidelines for healthcare facilities to build needed infrastructures to improve their quality of services (Minemyer, 2016).

This component will replace the existing Physician Quality Reporting System which pays for reporting whereas with the Merit-based Incentive Program there will be an actual evaluation of the performance and scores are allotted according the submitted reports by the healthcare providers. In the reporting process, there are more than 200 quality measures under existing PQRS program of which clinicians and stakeholders have an option of choosing a set of quality measures to report for a pre-determined

Pay-for-performance programs are expected to expand across the United States health care in the near future, especially with the implementation of the Affordable Care Act. The pay-for-performance is going to continue to increase the quality of health care that the patient receives from their

Benchmarking for clinical performance measurement involves collecting and reporting data on practices’ clinical processes and outcomes. Measuring clinical performance can create buy-in for improvement work in the practice and enables the practice to track their improvements over time. This information should also be used to identify and prioritize improvement goals and to track progress toward those goals. In addition, these data should be used to monitor maintenance of changes already made ("Module 7. measuring," 2013). Benchmarking can also be utilized to do a comparison between other health care organizations, provide areas where training could improve staff functions.

Merit pay is a short-term, pay-for-performance plan, with a typical life span of three to four years, in which employers provide rewards, usually in terms of a raise for past performance, for employees who perform their jobs effectively, which will lead to higher performing employees which will in turn lead to a better work environment and higher overall productivity. The concept of merit pay is most often mentioned in the context of educational and/or government civil service reform. With a merit-based pay system, the employer pays, with the idea that the employer will reward more productive employees with merit increases. This concept came about in an attempt to sustain high performance levels in the workplace linking merit increases, or increases in base pay, to employee performance ratings, which are taken at the end of a performance year, usually by a direct supervisor. Due to the ever increasing changes of supply and demand in business, in order to remain feasible, the merit pay system is expected to change consistently with the needs presented to the companies, whether it be foreign competition, consumer demands, producer limitations, etc.

The issue of quality improvement should be addressed with a multi-faceted approach. Once implemented, continuous oversight and monitoring must be conducted by an experienced staff member/case manager who can verify data in the EHR, as well as conduct a daily Braden Score assessment and confer with the staff nurse and physician, as needed. While HAPU/Braden

Constance, evidenced based practice (EBP) and quality are important and they are becoming a focus of healthcare payment models that reward for better quality and outcomes. With the repeal of the Sustainable Growth Rate (SGR) legislature and the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the United States has changed the rules around what determines how much health care providers are paid for services. Starting in 2019, providers including physicians and advanced practice nurses (APNs), will receive payments that are adjusted by the cost associated with, and the quality outcomes of the care provided to their patients for services rendered during 2017 (MACRA, 2015). It is important that all care providers

Additionally, Medicare requires healthcare providers to meet clinical quality standards to be eligible for reimbursement. For physicians, the Physician Quality Reporting System (PQRS) provides a standard tool for eligible professionals to report information about quality of cares to Medicare. The information includes patients’ outcomes, perceptions, and right timing of cares. It raises the question: why should physician participate in the PQRS? Just like other programs, which motivate participations to increase their quality of services, PQRS will provide a financial incentive for certain health care professionals, including psychologists. Medicare Part B requires those professionals to report the quality of care to PQRS. If fail to do

The Institute of Medicine (IOM) Committee to Design a Strategy for Quality Review and Assurance in Medicare defines quality of care to be “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Ransom, Joshi, Nash & Ransom, 2008). Making sure to have current knowledge on healthcare services is crucial to the quality of care provided, and health care professionals are expected to continuously stay updated on the changing trends. The IOM later released six aims for improvement, or also known as the six dimensions of quality, which are safe, effective, efficient, timely, patient-centered, and equitable.

The first quality initiative that could increase patient satisfaction and potentially reduce healthcare cost is the national data warehouse. According to Brennan, Cafarella, Kocot, McKethan, Morrison, Nguyen, Shepard & Williams II (2009), “this type of quality analysis needs to be valuable to both payers and consumers. For payers, quality analysis helps them potentially understand payment mechanisms, quality providers, regional differences and medical management techniques. For consumers, there is a better understanding of practice and potentially cost differences of providers. So, the primary purpose for creating a national data warehouse will be to develop key quality measures that all parties can agree on.” The second quality initiative that could increase patient satisfaction and potentially reduce healthcare cost is creating one common contract between all health plans and providers (Brennan et al., 2009). According to Brennan et al., (2009), “to accomplish this, a national group comprised of government personnel and knowledgeable provider contractors from the health plans will set national guidelines. Regional contracting groups will be entirely made up of current health plan contractors and will do the local contracting under