From Payment for Quantity to Payment for Quality: How soon?


Of all the “au courant”  health care issues creating buzz and concern, the issue of shifting the manner in which providers are paid from a system built upon fee-for-service ( or, quantity of services) to a new system structured upon the (final) quality of services has traction for the long term.  To many commentators this train is imminently leaving the station or already is moving away from the platform.

Or is it?

There is no doubt that the ACA itself has pushed this issue front and center, and there is no doubt that quality based reimbursement is on the horizon.   The issue, it seems to me, is just how close we are to a real change in the way we measure particular outcomes and satisfaction, and how close providers are, in reality, to being paid based upon these measures.

The push from CMS to address unnecessary readmissions, “never” events, hospital acquired infections, and Medicare spending-per-beneficiary from admission to 30 days from discharge does demonstrate the efforts to move from “quantity to quality.”  Nonetheless, CMS’ programs remain firmly at the station with the doors wide open.

So, what is happening to drive the system to pay for quality?

There is movement, and significant movement at that, although it has yet to reach a tipping point.  The tipping point will be reached, eventually.  Accountable Care Organizations in the Pioneer and Medicare Shared Savings Programs contain quality measures that must be satisfied prior to participants receiving payment.  CMS also has focused much attention on global payments, and in January of this year announced an arrangement with the State of Maryland in which Maryland will shift practically all of its hospital revenue over a 5 year period into a global payment model and also will satisfy certain quality benchmarks.  CMS wants to take what it will learn from Maryland and apply it elsewhere.

For years data have been collected based upon audits and surveys.  That data are now capable of being measured.  Patient surveys are now part of the equation, as well.  As the data commingle, and as ACOs’ data get analyzed over time, CMS hopes that it will be able to define “quality” in a manner that rewards those who provide quality for less.   Conversely, of course, those who do not will be paid less, in theory.

Private payers are said to be shifting away from FFS/quantity to “quality-based” payments.  Anthem BCBS has reviewed a global payment mechanism through what it calls an “alternative quality contract.”

Change will occur, but perhaps not at the rapid rate that some may expect for 2014.  In a year or two?  We will see.