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Through pay-for-reporting and pay-for-performance programs, payers such as the Centers for Medicare and Medicaid Services (CMS) rely on quality measures to incentivize and make inferences about care quality and evaluate the performance of health care delivery innovations.
The growth of pay-for-performance and value-based care (VBC) programs in the United States drives demand for quality measures as the basis for payment. One result of the growth of pay-for-performance and VBC is an overwhelming preponderance of measures. For CMS’s Merit-based Incentive Payment System (MIPS) program alone, clinicians can choose from more than 200 clinical quality measures. Even among accountable care organization programs—despite their common goal of rewarding providers who successfully contain their patients’ total cost of care while improving quality and access—measure sets vary routinely from one program to the next.
Provider performance on quality measures can have a significant impact on reimbursement. For the Medicare Advantage (MA) Star Ratings program, quality ratings impact financial performance of MA plans, with a drop of a 1/2 star resulting in a 5 percent decrease in bonus payment. Similarly, clinicians participating in CMS’s MIPS program have 30 percent of their MIPS score based on quality measure performance.