Even though the MACRA Final Rule indicates CMS has eased transition requirements, the core goal remains managing under Risk.
The best method for organizational preparation remains developing MACRA Improvement Activities (formerly CPIAs), the training blueprint for managing under Risk. Medicare (they're scoring your work) wants you to address all the processes and root causes of health care cost increases by utilizing the MACRA Improvement Activities.
On the surface, the MACRA requirements appear relatively easy to meet, simply attest to at least one Performance Improvement Activity. However, if you are truly preparing for risk, the reality will be significantly more difficult. Engineering will be essential to organize initiatives across multiple provider subgroups, many patient populations and different goals – and ensuring that they push you toward higher efficiency and outcomes.
Superficially MACRA requirements appear easy. But what is fully required in large multi-specialty groups and health systems fulfill their MACRA Improvement Activities? Now is the best time to assess what you'll need because activities will run faster in the future.
Make an Inventory
First, to improve performance you will need technology. Since EMR systems were heavily invested in, the question becomes how far can they get you? What Improvement Activities can be addressed by EMRs?
EMRs may be very helpful in aspects of performance improvement, generally speaking, including:
• Reaching out to patients with educational needs (EMR population health modules);
• Identifying and reaching out to patients who have gaps in care;
• Organizing patients into high risk registries for use in tracking results (EMRs capable of customizable registry and/or population health registries);
• Following up with patients who have labs or tests with poor intermediate outcomes (EMRs capable of sorting and tracking outcomes);
• Setting up coordination of care or referrals for emergency room patients (EMRs capable of required customized template for coordination, plus integration between hospital and physician EMRs, preferably linked to physician or referral scheduling).
There may certainly be other functionalities and innovations that will improve performance at point-in-care services to patients.
What ingredients are missing above? Project management, and a strategic and operations center for Improvement Activities. These facets guide the development of Improvement Activities as well as perform these functions:
• Evaluate the progress of all Improvement Activities and each Improvement Activity individually;
• Embed the priorities for Performance Improvement through an organizational inventory and classification of Improvement Activities that are being pursued;
• Keep historical detail of all Improvement Activities with populations, provider participation, interventions and goals;
• Compare results across several Improvement Activities;
• Link Improvement Activities with current MACRA requirements as they evolve, much like quality measures;
• Include functionalities for managing innovative projects, data sharing and social exchanges among providers in Improvement Activities, to engage providers in Performance Improvement;
• Centrally direct Improvement Activities implementation, which permits multiple roles (both practice and organization) to contribute to Improvement Activity development.
In a dynamic Performance Improvement process, Improvement Activities will continually evolve, and these strategic, evaluative and execution functions will be essential to drive change.
Only Leadership AND Physicians Can Drive Real Change
To health care systems and organizations, MACRA Improvement Activities will be one of two things. (1) Substantive plans to design changes in clinical and cost performance. Or (2) "check the box" once the simple activities designed to meet the basic MACRA requirements are fulfilled.
The former will prepare providers for taking on Risk; it is also the focus of the discussion at hand.
Change requires people. If the organization pursues Improvement Activities in the traditional Quality Assurance way—creating an Improvement Activities implementation department —even the most talented and motivated of staffs will not get the results needed to move the organization to Risk.
Real change will require leadership to implement change and a team of collaborators to see to it that the change becomes cultural. Dedicated staff will be necessary for inventing, executing and evaluating Improvement Activities. But authoritative stakeholders in organizational leadership with the vision to make it permanent is essential, and the organization must be developed from the top down to reflect the priority on Performance Improvement. Provider involvement is essential; they must participate and collaborate on the design and implementation of Improvement Activities.
What tools do leaders, collaborators and providers need to make real change?
• Centralized and distributed improvement Activity project development, including defining populations and interventions, validating patients and adding data;
• Mechanisms to communicate and share Improvement Activities;
• Analytics that go beyond performance metrics to Improvement Activities and the performance changes over time;
• Feedback capabilities, to elicit recommendations and observations.
Improvement Activities will be much more feasible with functionalities to view data and run discrete projects (even experiments) to improve performance. An organization can sink from the weight of multiple Improvement Activities. Or it can take advantage of the functionality available in the market in order to make the Performance Improvement activity manageable.
A Performance Improvement Technology and Resource Wish List
For Performance Improvement activities significant enough in scope to change costs and outcomes, specialized technology and resources will be necessary. These technologies are not found in EMRs or most current Registries. But, you are likely to see them developed in a Qualified Clinical Data Registry (QCDR)which is favored by MACRA:
1. Project Management Capabilities
• Set project schedules, deadlines and measurement points;
• Validate patients for inclusion or exclusion, with reasons (with distributed functions to clinicians and/or practices);
• Define and organize Performance Improvement projects by population criteria, participation of providers, data and interventions;
• Measure results of interventions;
• Add patients into the project as defined;
• Compare Improvement Activity progress and implementation criteria;
• Renew or tailor projects.
2. Data Sharing and Communication Options
• Foster project manager communiqués;
• Allow project communication among clinicians, with secure social network communications and measurement of engagement;
• Comparative analytics for patient costs and outcomes.
3. Broad Performance Improvement Functionalities
• Allow for experimentation and evaluation of interventions used for Performance Improvement;
• Transcend traditional population health and patient outreach or process measurement for deeper Performance Improvement projects focusing on clinical outcomes and cost;
• Incorporate flexibility for innovative project design, e.g., the creation of small pre-populated registries for physician collaboration and feedback;
• Enable physician-led and centralized projects to improve results, especially clinical.
4. Wide Range of Non-traditional Data Sources
• As a starting point for performance measurement, build a database with demographic, claims and clinical data;
• Extensive use of data, such as practice QRURs, to establish baseline measurements for cost and quality, and beginning points for Improvement Activities;
• Use of patient-reported outcomes, clinician input and feedback to explain root causes of events or outcomes, and external data sources;
• A patient-centric data system that allows better monitoring of per patient risks, costs and outcomes over time.
For provider organizations that struggle just to manage the basics, the above capabilities are difficult to envision. But visionary thinking on change management and an openness to innovation is required to really make headway in health care Performance Improvement. In the current environment, incremental gains are not only unsuccessful, they are destructive to long-term tactics. It's time to generate organizational excitement over Performance Improvement and develop tools to support smaller, innovative projects that will bring clinicians on board.
Theresa Hush is CEO and co-founder of Roji Health Intelligence (formerly ICLOPS). Terry is a health care strategist and change expert with experience across the health care spectrum. Her many accomplishments in the public, non-profit and private sectors include leading the transformation of Blue Cross Blue Shield regulations in Illinois, improving access to care as Director of the Illinois Medicaid program, and serving in executive leadership for both private payers and physician organizations. An expert at creating consensus for desired change through education and collaboration, Terry helps organizations take actions that will direct their future through meaningful technology and programs.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.