with the performance period. In keeping with the intent of transparency and accountability, hospital performance is publicly reported using a quality star rating system in Hospital Compare (https://www.medicare.gov/hospitalcompare/About/Complications.html). The Hospital Inpatient Quality Reporting Program is based on measures relating to mortality and complications; health care–associated infections; patient safety, patient experience; process; and efficiency and cost reduction. Early in the development of this process stakeholders and quality alliances, including nursing, submitted public comments regarding the proposed rules that would implement the VBP provision. Fiscal year (FY) 2020 rules were based on eligible hospital discharges that occurred between July 1, 2015 and June 30, 2018. Rates of readmission include measures of unplanned hospital visits after an outpatient procedure and hospital return days, and the readmission measures are estimates of the rate of unplanned readmission to an acute care hospital in the 30 days after discharge from hospitalization. Patients may have had an unplanned readmission for any reason (https://www.medicare.gov/hospitalcompare/Data/Hospital‐returns.html).
The work of developing and endorsing performance measures that meet the intent of this provision are the result of work in which various entities, alliances, and individual stakeholder organizations continue to engage. Measure development remains some of the more important and most challenging work in policy related to ACA. Measures, if appropriately defined, can quantify the quality of the care delivered for payment, and they also focus attention on issues that are major factors in whether patients survive medical or surgical interventions and hospitalizations. Measurement burden is a significant issue that has led to much greater reliance on only using measures that can be electronically collected. This burden and the realization that large number of measures being reported have resulted in significant measure‐reduction efforts and elimination of some measures that are most relevant to nursing care, but can be difficult to capture in electronic medical records. Equally challenging is the expensive pilot testing and subsequent endorsement and measure maintenance processes to demonstrate the adequacy and accuracy of such measures for reporting to the public, and for payment. Nurses have great opportunities for influence in the development and adoption of measures that reflect the outcomes and patient experiences of care, including care delivered by nurses.
Encouraging Integrated Health Systems
The ACA provided incentives for physicians and other providers to join together to form ACOs, which allow physicians and other providers to better coordinate patient care and improve health care quality, help prevent disease and illness, and reduce unnecessary hospital admissions. When an ACO provides high‐quality care while reducing costs to the health care system, rules allow the ACO to keep some of the money saved. Key stakeholder groups, including nursing, engaged in public comments in response to controversial ACO rules proposed by CMS prior to the establishment of most of the ACOs currently in existence. Although ACOs clearly would benefit from the services of registered nurses (RNs), advanced practice registered nurses (APRNs), and other clinicians, certain exclusions in the rules minimize the impact of such groups in recognizing their contributions or sharing cost savings.
While most programs within the ACOs are still difficult for APRNs to participate in effectively, the Primary Care First Model Options is a set of voluntary five‐year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First prioritizes the doctor–patient relationship: enhancing care for patients with complex chronic needs and high need as well as for seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes (https://innovation.cms.gov/innovation‐models/primary‐care‐first‐model‐options).
Primary Care First Model Options will begin in 2021 in 26 states. Practices will be incentivized to deliver patient‐centered care that reduces acute hospital utilization. Primary Care First is oriented around comprehensive primary care functions: (a) access and continuity; (b) care management; (c) comprehensiveness and coordination; (d) patient and caregiver engagement; and (e) planned care and population health. Eligible providers must meet numerous qualifications, including being primary care practitioners (MD, DO, CNS, NP, and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine; providing primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location; and having primary care services that account for at least 70% of the practice's collective billing based on revenue.
Paying Providers Based on Value, Not Volume
Provisions in the ACA tie provider payments to the quality of care they provide. Providers are expected to see their payments modified so that those who provide higher‐value care will receive higher payments than those who provide lower‐quality care. This provision took place in progressive stages. In FY 2013–2015, hospitals became accountable in both reporting and receipt of payment for specific domains of care that expanded to include an additional domain each year. These domains include the clinical process of care domain measures such as venous thromboembolism prophylaxis, appropriate surgical use of postoperative antibiotics, and urinary catheter removal postoperatively; the patient experience of care domain such as nurse communication, doctor communication, hospital staff responsiveness, pain management, medicine communication, and discharge information; the outcome domain measures such as acute myocardial infarction (AMI) 30‐day mortality rate, heart failure (HF) 30‐day mortality rate, pneumonia (PN) 30‐day mortality rate, central line–associated bloodstream infection (CLABSI); and in 2015 the efficiency domain, which focuses on Medicare spending per beneficiary. CMS assesses each hospital’s performance by comparing its scores on achievement and improvement related to each measure of performance (https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/Value‐Based‐Programs/HVBP/Hospital‐Value‐Based‐Purchasing). The following quality domains and weights are being applied for FY 2020: clinical outcomes (25%); person and community engagement (25%); safety (25%); and efficiency and cost reduction (25%).
The Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. MACRA required CMS to create the Quality Payment Program that repealed the Sustainable Growth Rate formula; changed the way that Medicare rewards clinicians for value over volume; streamlined multiple quality programs under the new Merit‐Based Incentive Payments System (MIPS); and gave bonus payments for participation in eligible alternative payment models (APMs).
MIPS was designed to tie payments to quality and cost‐efficient care, drive improvement in care processes and health outcomes, increase the use of health care information, and reduce the cost of care. Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Clinicians included in MIPS and APMs include nurse practitioners if they meet the thresholds required. These thresholds have been lowered over time to encourage greater participation. Performance in MIPS is measured through the data clinicians report in four areas: quality, improvement activities, promoting interoperability (formerly advancing care information), and cost. MIPS was designed to update and consolidate previous programs, including Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value‐Based Payment Modifier (https://qpp.cms.gov/mips/overview).
