ACLP Quality & Safety SIG members have been tackling C-L Psychiatry’s ‘holy grail’—to demonstrate our value. They plan to publish a White Paper this year inviting discussion on defining quality measures and goals of care. In a short ACLP News preview series, they have been highlighting pathways for moving forward. Here, in the final part, SIG chair David Kroll, MD, FACLP, describes how…
Winners and losers in the changing quality payment game
Before we start, here’s a quick glossary:
CMS = Centers for Medicare and Medicaid Services
MIPS = Merit-Based Incentive Payment System
MIPS Measures = Quality measures that are eligible to be included in MIPS contracts.
Most C-L psychiatrists don’t spend a lot of time thinking about how well they are performing on quality measures in any given year.
One of the perks of working in a ‘cost center’ department (i.e., a department or service line that isn’t necessarily expected to make a profit in traditional fee-for-service contracts, as opposed to a ‘revenue center’ department) is that a C-L Psychiatry service’s ability to sustain operations is less likely to be directly tied to how much income it generates from medical billing.
Quality measures (i.e., reportable metrics that factor into the total reimbursement that an individual health provider or group of health providers receives from CMS in a quality payment contract) may therefore seem less relevant to day-to-day operations, especially compared to so many other things that compete for our attention.
But they do matter. The money at stake in quality payment contracts (both with CMS entities and with private insurance companies, which tend to follow CMS’s lead in many ways) is a lot, enough to impact how many projects, or services, or people the hospital systems that employ us get to invest in—and how many they don’t.
Psychiatrists, on the whole, do not perform well on quality measures. Compared to physicians in other specialties, we tend to get fewer bonus payments, and more penalties, in quality payment contracts. This is probably due to a combination of factors. There are not a lot of behavioral health measures in the MIPS program to begin with, and many of the behavioral health measures that do exist are either highly flawed or do not realistically reflect the quality of care at the level of the provider who is being measured.
But MIPS in its current form is going away. CMS has announced a plan to sunset MIPS and replace it with a more modern program called MIPS Value Pathways, or MVPs. In theory, MVPs simplify the process of applying quality measures in specialty care because MVP measures come in the form of specialty-, disease-, or procedure-specific blocks. Lower extremity joint repair, for example, has its own MPV, which contains measures that are hand-picked for relevance to the clinicians that spend a lot of their time performing that particular service. Kidney health and heart disease are some other examples. Oh—and behavioral health.
So, is it time to cue the balloons? In some ways, it looks like CMS quality payment contracts are about to get simpler for those of us who specialize in behavioral health services (many of whom have been stuck reporting on measures that are totally unrelated to the work they do—like colorectal cancer screening rates—before this). But that doesn’t necessarily make it a win. We still don’t know whether MVPs are going to be good or bad for psychiatrists in the end, and there is reason to be cautious.
Baked into every MVP is a new kind of quality measure called a ‘cost measure,’ which measures the total costs of care associated with the condition (or groups of conditions) covered by that MVP. The behavioral health MVP is not finalized yet, but the two cost measures that are currently undergoing field testing apply to depressive disorders and inpatient care of psychotic disorders. If these cost measures are finalized (and it is expected that they will be), many clinicians will be measured on the average total cost of psychiatric care over a one-year period for their patients with depressive disorders, or the average total costs of psychiatric care for inpatients with psychotic disorders, beginning with the start of their admissions and extending for a short period of time after they are discharged.
This is not inherently a bad idea. We know that higher quality care often means lower total costs of care—especially in the long-term—because patients who are doing well are less likely to need more intensive services. Meanwhile, incentivizing low-cost approaches to treating depression aligns in many ways with the mission of C-L Psychiatry, i.e., helping hospital systems manage the psychiatric treatment needs of its population without relying on a specialist for every touch point (collaborative care is a prominent example of this alignment).
But, at the same time, depression is heterogeneous, and some patients really do need more intensive services whether or not their clinicians are providing optimal care. That should not be disincentivized, and the risk adjustment models that theoretically should normalize the playing field for those who care for patients with complex needs may or may not be adequate. The financial return on investment for high-quality depression care is also rarely seen in decreased direct psychiatric treatment costs. It’s seen instead in lower total medical expenses (which are not tracked as part of the cost measure) and other societal benefits.
As with any arrangement where large amounts of money are changing hands, there are going to be winners and losers in the quality payment game. Now the rules are changing again. There is reason to be concerned that the projected changes may further disadvantage the position of behavioral health clinicians, but C-L Psychiatry services may also find new opportunities to prove their worth at a table where the pie always seems to be getting smaller.
Missed the two previous articles in this series? See: