Everyone agrees that healthcare is exceptionally complex, but in this regard, it’s not profoundly different from other industries. Like other industries, healthcare is made up of thousands of intertwined processes that result in an exceedingly intricate system. If we focus our efforts on the processes of care one at a time, we can fundamentally change the game, face challenges head on and ultimately drive sustained clinical improvement. This is certainly easier said than done, but as Pareto’s principle (aka the 80/20 rule) informs us, 20% of those processes is responsible for 80% of the impact. So the challenge facing every healthcare organization or change agent is to identify and focus Quality Improvement efforts on that highly impactful 20%.

One of the biggest questions healthcare teams face in their quality improvement efforts is “Where do we start?” Teams always acknowledge that there are opportunities throughout their healthcare systems to improve processes and eliminate waste…but therein lies problem. With such a large, intricate system filled with so many interwoven processes, it’s challenging to decide on the starting point. What providers and their teams need is guidance to direct efforts to where they will have the biggest impact on patient outcomes. 

Quality improvement (qi) is the science of Process management

The payment model shift to focus on quality

It has never been more important for healthcare providers and their teams to focus on Quality Improvement. Aside from the obvious top-ranking desire to provide the best care possible to patients, the payment model is undergoing a long overdue shift to focus more on the quality of healthcare being delivered. Soon the days of “see a patient, bill a code, get X reimbursement” will be gone. In order to maintain the highest reimbursement rates possible, providers now need to demonstrate that they’re also providing quality care to their patients. Failure to deliver high quality healthcare will result in reduced reimbursement rates.

On April 15, 2015, the "doc fix bill" or MACRA (the Medicare Access & CHIP Reauthorization Act) repealed the flawed Sustainable Growth Rate (SGR), used to determine physician reimbursement, and replaced it with a new pay-for-performance program. This is the first time in the history of the Medicare program that Health & Human Services has set explicit goals for alternative payment models and value-based payments.

Medicare set (and exceeded) a 2016 goal of tying 30 percent of payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs), advanced primary care medical homes or bundled payment arrangements. By the end of 2018, at least 50 percent of payments will be tied to these models.


One of these new value-based payment programs is MIPS or the Merit-based Incentive Payment System, which relies heavily on performance measures. Historically, CMS has taken data from two years prior to tabulate penalties. Information on where providers stand with what were formerly known as their Meaningful Use, PQRS and Value-based Modifier metrics from this year will determine provider Medicare Part B reimbursement rates two years later.

Strategic, focused efforts to understand these reimbursement changes is absolutely vital.

As of 2017, providers are now being measured annually in (4) MIPS performance categories:

  • Promoting Interoperability (formerly Meaningful Use, then Advancing Care Information)

  • Cost (formerly Value-based Modifier for Cost)

  • Quality (formerly PQRS, Physician Quality Reporting System)

  • Improvement Activities (based on the Patient Centered Medical Home [PCMH] model)

Failure to participate in this program when required, or performing poorly, could mean as much as a 9% reduction in Medicare reimbursement rates! And top performing providers could eventually see as much as a 37% increase*.
This is where M-CEITA can help. As Michigan’s federally designated Regional Extension Center (REC), the Michigan Center for Effective IT Adoption works with Michigan providers to accelerate the selection, adoption, and meaningful use of health information technology to improve the quality and efficiency of care delivered in our state. We’re experts in teaching providers and their teams how to leverage technology to optimize care delivery. From increasing the identification of diseases to engaging patients, managing their care and improving outcomes, M-CEITA has the knowledge, expertise and tools to assist providers in any clinical quality improvement initiative. Working on these initiatives now will not only improve the quality of care delivered but will also help to protect your bottom line as alternative payment models become a reality.

For more information and/or support for MIPS or the Quality Payment Program (QPP) in general, visit www.qppresourcecenter.org