With the healthcare industry navigating the transition from fee-for-service payment models to value-based care, startups and mature healthcare IT companies are building tools to enable this massive business change.
In many cases, the federal agency driving this transition must certify those tools, ensuring that they hew to new reporting requirements designed to link the quality of healthcare outcomes to provider reimbursements.
Madison, WI-based Forward Health Group, which develops digital tools allowing clinicians to group together patients with similar diagnoses and other attributes, says the Centers for Medicare and Medicaid Services (CMS) approved its PopulationManager software as a so-called “qualified registry” for 2017.
To understand why this approval is significant for the eight-year-old company, it’s helpful to rewind the clock back to April 2015. That’s when President Obama signed into law the Medicare Access and CHIP Reauthorization Act (MACRA), which progressed through both houses of Congress with strong bipartisan support.
Under MACRA, the CMS created the Quality Payment Program, a quality-based reimbursement program requiring clinicians and healthcare organizations to submit select patient data to the agency. Reporting parties can do so via two paths that link quality to payments. Forward Health Group’s Web-based population health measurement software supports both pathways, the company says. CMS then evaluates the data and assigns a score to the reporting party, which could result in it receiving a Medicare payment bonus, a penalty, or neither in 2019, according to the Dallas County Medical Society.
Using Forward Health Group’s software, healthcare organizations can combine information on patient populations from a range of sources: electronic health records systems, labs, claims sent to insurers, and patient-captured data, to name a few. CMS’s approval of PopulationManager as a qualified registry ensures that the information Forward Health Group’s customers send to the agency is calculated and structured in the proper way. The company’s clients include networks of hospitals and clinics, insurers, and research groups like the American Diabetes Association.
The first measurement period for what is expected to be the more popular of the two reporting pathways under the Quality Payment Program started on Jan. 1, Forward Health founder and CEO Michael Barbouche says. The path is known as the Merit-Based Incentive Payment System (MIPS).
Barbouche says that at the moment, “there’s just a lot of chaos” when it comes to helping healthcare organizations understand and adjust to the rule changes.
“Many of them are still trying to even understand the basic premise of the programs,” he says of MACRA and its various components.
A number of Forward Health Group’s customers have made “enormously significant investments” in IT, such as installing new patient records systems or upgrading them to the latest versions, Barbouche says.
“What we’re trying to do for our clients is help them … pause, catch their breath, and begin to actually monitor the overall performance of their patient population, and drive improvement,” he says.
But at the same time, the clock is ticking. Healthcare providers could do themselves lasting damage by falling into a hole early on, Barbouche says. And CMS is only likely to become more strict in the future with its standards around quality-based reimbursements, he says.
Take management of patients with diabetes, for example. Barbouche says that CMS could set a baseline percentage of a healthcare provider’s patients that are required to be in “good control.” That could involve certain thresholds around blood pressure or the blood glucose marker A1c.
“The bar may be at 55 percent this year, but it very well could move to 58 percent next
