The emerging emphasis on outcomes is a blessing, not a burden.
Value-based care is here to stay—and that’s a good thing, experts say.
“Think of the growing emphasis on documenting quality not as a burden, but as a platform that is being given to you,” says Mark Sanna, DC, president of Breakthrough Coaching. “That plat- form is going to allow you to document the superior outcomes of your care, increase patient access because of those outcomes, and ensure that you are reimbursed at the level you deserve.”
PQRS reporting: Just the beginning
By now, most chiropractors are aware that under the Patient Protection and Affordable Care Act (PPACA), providers who don’t participate in Medicare’s Physician Quality Reporting System (PQRS), or who report unsatisfactorily, have begun incurring negative payment adjustments to their Medicare reimbursements (see “Meet PQRS”).
“The train has already left the station,” Sanna says.
Starting this year, chiropractors participating in PQRS are required to report on two (previously three) quality measures:
- Measure 131: Pain Assessment and Follow-Up
- Measure 182: Functional Outcome Assessment
Different types of providers are required to report on different measures. Certain providers such as MDs and physical therapists must report on a much greater number of quality measures.
“Not only are chiropractors only being asked to report on two measures, they are two things that you should be measuring anyway,” Sanna says. “No chiropractor should be practicing without measuring patients’ level of pain or their ability to perform activities of daily living at each appointment.”
Right now, Medicare only requires providers to document quality measures and is not yet tying reimbursements to reported outcomes. And, providers who opt out are only seeing a 1.5 to 2 percent reimbursement penalty.
“However, that’s just a primer for what’s going to be happening in the next four to five years,” says John Falardeau, a senior policy advocate for the American Chiropractic Association (ACA). “By 2020, quality reporting will be mandatory. If you want to be reim- bursed for Medicare, that’s the way it’s going to happen.”
Gerald W. Clum, DC, of the Foundation for Chiropractic Practice (F4CP), says that until now, the health- care system hasn’t associated quality metrics with provider payments.
“This is the first move towards tying the quality of outcomes and the quality of delivery with the payment of services,” Clum says. “In the past, the simple formula for making more money in healthcare was the more procedures you did on more people, the more you got paid. Now the focus is going to be on doing the right procedures on the right patients if you want to get paid more.”
Making headway with Medicare
Steven R. Conway, DC, JD, says that PQRS was put in place to ensure providers are establishing treatment goals for patients and monitoring injury-specific care at a certain frequency and duration until established targets are met—for example, those related to criteria such as activities of daily living. “Patients need to be evaluated every time they come in, and if they meet the treatment goals, you get a carrot—and if they don’t, you get a stick.”
Conway serves as a legal consultant on ACA’s Medicare Committee. In February 2015, he and committee chair Michael Jacklitch, DC, met for the first time with leaders from the Centers for Medicare and Medicaid Services (CMS) and a number of Medicare carriers. They met again in October.
ACA President Anthony Hamm, DC, has also participated in the meetings. “Medicare is trying to figure out how to deal with us—how to handle chiropractic care as everything shifts to outcomes-based reimbursement,” Conway explains.
In the more than five years that the ACA Medicare Committee has been working with CMS and Medicare carriers, Conway says they have made “massive headway.”
“We are trying to harmonize things as far as the review of chiropractic documentation,” he says. They also have been meeting with DCs through state associations and with chiropractic students to help them understand the new and emerging requirements.
Testing the waters
PQRS is important, but experts say it’s only one aspect of the quality-based metrics that increasingly will be tied to Medicare reimbursements (see “What exactly is a ‘quality’ measure?”).
“Medicare is moving away from asking providers if they have specific types of information; instead, they are focusing on episodic care with a starting point, an ending point, and specific goals,” Conway says.
Sanna says that while PQRS reporting is a major shift driving other quality-based measures, “PQRS is like putting a toe in the water.” Ultimately, he says, a value-based modifier will be used to help determine reimbursement levels.
“Value-based reporting is driving the healthcare delivery of the future,” Sanna says. “Historically, the value for fee-based services was based on the cost of the work involved to deliver that service—the relative value unit (RVU). The usual, customary, and reasonable (UCR) charge was based on your geographic area, with malpractice, labor costs, etc., as part of the formula. Now everything is changing.”
Sanna adds that value-based care is not going anywhere, and will continue to expand.
Private insurers close behind
For chiropractors who haven’t worried much about the Medicare requirements because they don’t see a large number of Medicare-insured patients, Falardeau advises that many private insurers are likely headed in a similar direction. “We see it time and time again—as Medicare goes, private insurance generally follows.”
Conway adds: “Value-based care is a reality, and chiropractors need to fully understand the rules and requirements of Medicare documentation. It’s also important to understand that the entire insurance industry is shifting to the same level of documentation.”
Document, document, document
It’s probably not a coincidence that the PQRS reporting requirements are following in the shadow of CMS’s earlier incentives (and then penalties) for providers to adopt electronic health records (EHRs), with various phases of meaningful-use demonstration also required—and ongoing.
The increasing focus on outcomes and quality care means that chiropractic offices will need to be able to “slice and dice data in different ways to show the effectiveness of your care in a quantitative manner rather than a qualitative one,” says Matthew Richard, CIO at Mighty Oak Technology. “Up until now,” he says, “a key phrase in most chiropractors’ documentation was, ‘The patient has responded well to treatment today.’ ”
The documentation of the future will require tangible results related to pain and functional outcome measures, Richard says. “Tools will need to be brought into the documentation that measure how a patient has improved by a score of X on specific outcome assessment forms,” he explains. In addition, those outcomes will need to be integrated with billings.
The mining, aggregating, and analysis of patient data will propel value-based healthcare forward, Sanna says. “What gets measured, gets managed, gets better.”
Fuel for scope of practice
Sanna points out that the more chiropractors who participate in PQRS, the better it will reflect on the profession as a whole. “If you think as a chiropractor that what you do in your practice stops at the four walls of your practice, you’re mistaken,” he says. “Reporting on these two quality measures is so easy to do. This really has very little to do with a 2 percent Medicare penalty for not participating. This is about whether you are going to participate in the mainstream of healthcare.”
Falardeau adds: “If we can get more doctors demonstrating via PQRS that we can document quality properly, it will only help us going forward as we seek full scope-of- practice rights within Medicare.”
As the dialogues about quality care and the scope of chiropractic practice continue, it’s important for the profession to educate CMS, health insurers, and other key parties about chiropractic’s value—especially as it relates to prevention, Clum says.
“The goal is for the system to recognize that there’s more than one world when it comes to preventive care,” Clum says. “The chiropractic perspective on prevention is that the care itself is preventive. The medical model, on the other hand, focuses on ‘catch-it-early medicine’ rather than true preventive healthcare. The chiropractic approach to prevention and that of medicine are light years apart. Currently, there really is no financial reward in the healthcare system for changing behavior. That has to change.”
Tell it on the mountain
As a result of PQRS reporting and data mining, Sanna predicts that chiropractic is going to rise to the top.
“Objectively, we know that chiropractic outcomes are superior,” he says. “In patient satisfaction surveys, time after time, 94 to 95 percent of patients say they are satisfied with chiropractic care. We have excellent outcomes in terms of many of the major conditions plaguing the healthcare system today, including low-back pain, neck pain, headaches, and more.”
Once those types of outcomes are documented via PQRS and other outcomes-based reporting, greater patient access to chiropractic care should follow. “The American public should have the ability to go to a chiropractor, and that should be supported by insurance. This is big, because it’s about the ability of patients who need chiropractic care to be able to access those services,” Sanna says.
If DCs do their part by participating in PQRS and other value-based reporting programs, the chiropractic message ultimately will be heard.
“You are being given a mountaintop to broadcast to the world the value of the services you deliver,” Sanna says. “You know you have the goods—and here’s your opportunity to tell everyone.”
Tara Stultz is a writer, reporter, and editor and serves as president of Engagency Healthcare Communications. She can be reached at firstname.lastname@example.org.