Quality Payments Program

Transitioning Medicare to Values-Based Care
Partner: Center for Medicare and Medicaid Services (CMS)
Area of Innovation: Data-processing pipeline for a pioneering federal program that incentivizes quality care

The Opportunity

As a result of the landmark Medicare Access and CHIP Reauthorization Act (MACRA), a bipartisan bill passed in 2015, Medicare reimbursements have moved towards a quality-based’ system. Before MACRA, Medicare used fee-for-service reimbursements, creating a perverse incentive structure in which clinicians and practices were paid for the volume of services provided whether or not they improved patient health outcomes. Thus, clinicians participating in Medicare were incentivized to bill for more high cost services, sometimes at the expense of the patient.

The Quality Payment Program resulting from MACRA represents a monumental shift in the way Medicare reimburses clinicians and practices for the health care services they provide. The quality-based care model will transform care for 55 million of the country’s citizens who use Medicare, many of whom are vulnerable and underserved: 18 million Medicare beneficiaries are living on incomes below 200 percent of the federal poverty level ($20,160 for a family of two adults and one child in 2016) and 9 million live with complex care needs that hinder them from carrying out everyday tasks. Historically, the Medicare program has set powerful precedents for Medicaid and private insurance markets in terms of policy reform. The success of this program could catalyze a shift towards value-based care across the entire health care system.

Solution

We built an automated and robust pipeline for ingesting and processing data from one of the largest medical records databases in the country, processing over three billion claims per year. This pipeline processes and calculates 74 distinct quality metrics for over 300,000 Medicare providers. We access the claims data housed in a legacy database at CMS, calculate the scores in a scalable and parallel system, then submit them to a portal for providers to view their scores.

Results

Medicare providers can now log in and view their quality scores for 2017. Starting in 2018, providers can access monthly updates to scores, allowing them to receive frequent feedback and adjust their clinical practices to better serve their patients.

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