Transitioning from Volume to Value in the Chiropractic Office
DOCUMENTATION
Christine Goertz
Is your practice strong enough to ensure continued growth and revenue in the transition to performance-based health care? The current volume-based system is being replaced by a value-based system. If your strategy focuses on expanding volume without addressing quality and value, your practice may be at risk. Success in today’s health care marketplace depends on providing the best clinical performance and outcomes compared to your competition. This is the emerging trend in how employers, health plans, and Medicare rank and reward clinicians, assessing performance against benchmarks— as well as your peers. Most important, this is increasingly how patients rank and select health care providers.
The best way to meet this mandate is through participation in clinical data registries. Clinical data registries are databases that collect information from clinicians to describe the natural history of disease, determine clinical effectiveness, ascertain the costeffectiveness of health care services, and measure and monitor safety and quality.1 Information from registries is used for many purposes, including informing patients and their clinicians as they decide the best course of treatment, providing performance results to payers, and improving care thr ough research. Registries are increasingly used by health care professions to establish the value of the care they provide and will become even more important as the world moves rapidly toward performance-based payment systems.
Because registries capture specific data relevant to a particular area (e.g., low back pain) across multiple organizations, registries allow clinicians to see a more complete picture of care than is typically available from a single EHR system.2 In addition, information from clinical registries is used to compare the effectiveness of different treatments for the same disease or condition and to evaluate different approaches to a procedure. For example, the use of evidence-based practice guidelines can be evaluated by asking questions like, “How many patients are receiving recommended treatment(s)?” The information from registries is also used to support health care education, accreditation, and certification. Finally, information from registries is increasingly used to ensure that payment is adjusted based on the quality of care provided and to give patients the information they need to make better choices.
In 2014 CMS established a new tier of registries, the Qualified Clinical Data Registries (QCDR). A QCDR is defined as a CMSapproved entity that collects medical and/or clinical data for the purpose of patient and disease fracking to foster improvement in the quality of care furnished to patients. Qualified Clinical Data Registries go beyond the role of clinical registries, which
“The current volume-based system is being replaced by a value-based system. If your strategy focuses on expanding volume without addressing quality and value, your practice may be at risk. 5 J
are simply a pass-through measure reporting for the Physician Quality Reporting System (PQRS), to powerful catalysts for data-driven health care performance improvement.3 QCDRs provide clinicians with timely feedback, benchmarking with others performing the same or similar functions, and a wider range of performance measures to report on, including non-PQRS measures. QCDRs further expand on the number of individual performance measures available for Quality Payment Program participation.4-5 CMS maintains a list of credited QCDRs, which can be accessed at www.cms.gov.
Currently, many health plans have claims-linked registries (proprietary payer databases) and adjust reimbursement based on metrics they create. QCDRs are developed and managed by clinicians and gather data on measures that are meaningful to patient care. The pairing of clinical expertise and measure development sets the QCDR apart from claims-linked registries. But more interesting is the distinction that the QCDR’s quality measure reporting is inclusive of all patients, not just a specific health plan subset. This puts the QCDR at a strategic advantage
to encourage clinicians to use it as the centerpiece for better care and patient outcomes. Apart from technology, the QCDR has a strong strategic advantage in creating a central platform for both Medicare and non-Medicare quality-based reimbursement programs.
In 2017, sweeping changes are set to happen with an overhaul of physician payment. The Medicare and CHIP Reauthorization Act (MACRA) replaces die Sustainable Growth Rate (SGR), which sets payments for physicians with the Quality Payment Program (QPP). One aspect of the QPP is the Merit-based Incentive Program (MIPS), which consolidates and replaces three existing reporting programs: PQRS, Value-Based Payment Modifier (VM), and Meaningful Use.6 The Meaningful Use program was replaced by the Accessing Care Information category (ACI), PQRS was reconfigured as Quality, and the VM was renamed and modified as the Resource Use/Cost category. MIPS also adds a new category of Improvement Activities (IA). QCDRs are a key reporting option for satisfying the Quality, ACI, and IA categories under MIPS.6
The QCDR is a transformative tool for organizations diat haven’t even reported PQRS or that are still in the follow-up to EHR adoption. MACRA has financial ramifications for clinicians who fail to document clinical metrics and patient outcomes.6 The QCDR allows clinicians the time to leam through the data and process of performance improvement and become comfortable with technology, benchmarking, and process change. Public reporting and growth in the number of available outcomes measures are emphasis areas for the Quality Payment Program path of the MIPS. The MIPS QCDR program continues to promote the role of clinical registries in health care improvement through performance measurement and reporting.
What are the benefits of participating in a registry?
• Provide information to patients and families about their care, including treatments that have worked well for patients with similar characteristics
• Benchmark your performance results against others locally, regionally, or nationally
• Benchmark performance improvement initiatives in your clinic
• Receive relevant information on evidence-based care, tools, and products
• Identify higher and lower risk patients, enabling better prediction of outcomes
• Track and monitor important performance metrics tied to payment
• Contribute to research that impacts clinical practice
Currently, the only clinical data registries established with chiropractic practice in mind were developed by the Spine Institute for Quality™ (Spine IQ™). Spine IQ™ has established two clinical data registries that each include more than performance measures—one for low back pain and one for neck pain—with the aim of increasing the patient-centered value of spine care by leveraging multidisciplinary models, measures, education, and research through the use of clinical data registries.
“The QCDR is a transformative tool for organizations that haven’t even reported PQRS or that are still in the follow-up to EHR adoption. J J
Spine IQ’s low back pain registry has been approved by the CMS as a QCDR (www.spineiq.org). Strong participation in the Spine IQ™ Low Back Pain QCDR by doctors of chiropractic offers the potential of positioning chiropractic as a leader in evidence-based spine care. By changing how spine care is delivered, the Spine IQTM QCDR can help achieve the lauded triple-aim goals of improved care, improved outcomes, and reduced costs.
References:
1. What is a clinical data registry? National Quality Registry Network (NORN), www.thepcpi.org. Accessed Dec 3, 2016.
2. Informational Guide to the Qualified Clinical Data Registry (OCDR) for Program Year 2016. National Quality Registry Network (NORN). February, 2016.
3. CMS Quality Initiatives Patient Assessment PORS Qualified Clinic Data. Registry Web page https://www.cms. govMedicare/QualityInitiatives-Patient-Assessment-Instruments/PORS/OualifiedClinical-DataRegistry-Reporting.html. Accessed Dec. 3, 2016.
4. Centersfor Medicare andMedicaid Services. Physician Quality Reporting System, http://www. cms.gov/Medicare/Quality-InitiativesPatient-Assessmentlnstnmients/PORSHow To Get Started.html
5. CMS 2016 QCDR Self-Nomination Toolkit http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessmentlnstruments/PORS/ Downloads 20160CDR Criteria Toolkit.zip. Accessed Dec. 3, 2016.
6. CMS Quality Payment Program Website, www.qpp.cms.com. Accessed Dec. 3, 2016.
Dr. Goertz received her DC from Northwestern Health primarily Sciences ofMinnesota. University Her on 25-year research and and her research policy PhD from career relevant the hasfocused to University the conservative management of spine-related disorders. She is Vice Chancellor for Research and Health Policy at Palmer and CEO of the Spine Institute for Quality
(Spine 10).
