Practice Transformation for Quality Payment Program Success

As nephrology practices evolve to meet the demands of value-based care, including the requirements of the Quality Payment Program (QPP), certain operational changes must be implemented. In addition to direct patient care, providers are now being asked to perform tasks more often associated with population health managers. It is these population health management tasks that can help a clinical practice succeed in models of value-based medicine. However, in order to do this, practices must transform.

The right tools, data and roles

Health care is increasingly about the management of data. Electronic health records (EHRs) (single-patient data collection and review), care management platforms (group data collection and review), and data registries (provider and group performance against care benchmarks) all support the needed submissions to the ranking, rating and reporting mechanisms used by public and private payers. These tools, each focused on different aggregations of data, are designed to help practices to identify and understand what functional changes and process improvements can yield more success in value-based care. In a fee-for-service world, practices were encouraged to maximize patient encounters, and that continues to influence how practices operate today. As such, a large step in practice transformation involves adding or evolving clinical and office staff to take on health information management (HIM) roles—functions that facilitate the identification, collection, curation and reporting of key data about the practice along with use of the data to enhance care. The two main roles are best described as “data wrangler” (HIM professionals) and care coordinator (who may be qualified nursing staff).

The role of a data wrangler involves identifying what data is required, recognizing where in the office workflow data can be gathered, monitoring and curating the quality of the collected data, generating interim reports for process improvement and providing final reports for payers. In order to serve in these functions, the individual will need IT knowledge, regulatory knowledge and some clinical exposure.

Care coordinators gather data, enact care plans and champion process improvement activities. This work is often done outside the framework of traditional face-to-face encounters; i.e., over the phone with patients and in team meetings with physicians and clinic staff. This role draws heavily on clinical experience, case management and an understanding of population health.

To be sure, physicians and advanced practitioners also need to participate in data gathering (through EHRs), quality reviews, gap and outlier reports (through care management platforms), care plan development and monitoring, and outcomes and scorecard review (through the Clinical Quality Data Registries). The goal is for care coordinators and data wranglers to support front-line clinicians, thereby minimizing the disruption to patient care time and optimizing the reported information into actionable and easily understood data.

Steps to practice transformation success

While each practice’s transformation path will vary based on goals, capabilities and resources, there are some high-level standardized steps.

Step 1: Identify the end goal. While participating in a payer-driven quality reporting program, is the goal to understand patterns of care and maximize measured quality, offer bonuses internal to the practice, or maximize reimbursement? The degree to which one must undergo practice transformation is dependent on the answer to this question.

Step 2: Before starting, determine the data needed to successfully collect measures—i.e., denominator inclusion and exclusion criteria and numerator data—and then understand what reports will be needed based on this data. While the measures may change depending on the goal of transformation, the process of understanding how data are collected and reported is invaluable and translates across all quality improvement work.

Step 3: Clarify who will be your data wrangler and care coordinator in order to maximize data gathering, monitoring, analysis and reporting.

Step 4: Establish and understand the timeline to transformation. Incorporating quality reporting into a typical practice is a multiyear endeavor. Assuming everything goes smoothly, it can take two to three years, especially considering government programs that incentivize payments two years after reporting. The typical steps along the timeline of transformation include the following:

• Decide on measures that reflect care
• Dissect measures and confirm sources
• Hire and train HIM professionals and care managers
• Enact provider contract updates
• Make HR policy updates to ensure both financial incentives and behavior expectations are clearly established and aligned with quality data gathering and reporting
• Confirm data extraction and submission
• Monitor data integrity
• Gather feedback and make workflow adjustments

Obstacles to success

While the steps to practice transformation may appear clear cut, there are potential challenges to consider. First, practitioners and clinical staff may be resistant to embracing work outside relative value unit-based care. In addition, it is challenging to work with data to maximize performance, especially with long-standing patterns of care activity. Like any shift, sufficient time and education must be provided to maximize success for all the providers in a practice.

It is financially challenging to work under a report-now/bonus or penalty-later structure. To be sure, practices will experience new and expanded costs, which may prove financially difficult until payments are realized down the road. The transition to a value-based care model is often not an opportunity to improve return on investment as traditionally defined, but to grow the practice in accordance with industry trends—a focus on quality outcomes, efficient resource use and a superior patient experience.

Transforming a traditional clinical practice into one that can produce success with quality payment means adopting operational and cultural change—including data management, human resources changes, and process modifications and improvements. Many political and financial indicators point toward a long-term focus on value-based care, using both provider performance and care costs across populations of patients as the metrics of success. The question is, how will the typical practice evolve?