The bright spotlight on healthcare quality and outcomes is not fading. Quite the opposite: Mandatory quality reporting grows more pervasive each year, placing a continuously increasing portion of healthcare reimbursements at risk. Do you know how much reimbursement your organization is potentially leaving on the table each year due to underperforming quality metrics? If not, you are certainly not alone. 

Quality reporting and transparency in healthcare is an acute focus of the Centers for Medicare and Medicaid Services (CMS) — and increasingly, this model is being adopted by other payers, including managed-care entities.

Despite concerns and pushback (including litigation) from healthcare providers about the perceived fairness and accuracy of quality-based metrics, CMS has continued to increase its quality reporting and transparency requirements, as well as their ties to reimbursement. In rapid succession, CMS overhauled the Star Ratings methodology, launched the CMS National Quality Strategy, and announced a new episode-based alternative payment model (among many more likely to come).

In an industry as complex as healthcare, quality is not easy to measure, and outcomes are often not directly comparable from one entity to the next. Even so, every healthcare organization generally has the same mission — to provide effective, safe, efficient, patient-centered, equitable, and timely care.

Unfortunately, some factors that greatly affect these important goals are largely outside the organization’s control, such as the geographical location of the facility and its providers, the underlying health of the patient population, the demographics and income of the patient population, and community access (or lack thereof) to quality healthcare providers, to name a few.

Shine a Spotlight on the Quality of Your Healthcare Organization

As quality has steadily become a crucial component of the healthcare value equation, it is also one of the most important predictors of a healthcare organization’s current and future financial health. To position your organization for success in value-based reimbursement, embrace the quality spotlight and highlight what makes your healthcare organization special.

Discover how potential quality issues can and do cost your organization. Calculating a dollar impact for quality and patient outcomes is not always straightforward or easy. If you’re unsure, speak with your organization’s reimbursement manager and walk through the quality metrics that affect your organization’s reimbursement.

For example, in a hospital setting, look at Worksheet E, Part A, of the Medicare cost report (CMS-2552-10). You will likely find adjustments to your reimbursement for factors such as readmissions and hospital-acquired conditions, among others. As the list of monitored and reported quality metrics continues to grow, the effects cascade to other revenue streams. Notably, managed-care payers are following CMS’s lead by factoring quality metrics into their reimbursement formulas.

Uncover the story behind the numbers. Accurate and complete coding is essential in any reimbursement system, so be sure to button up those billing practices. Next, drill down further to understand what’s driving your quality metrics.

If satisfaction scores are low, what can you learn from survey responses to help improve the patient experience? If readmissions are high, could you re-deploy existing resources or reimagine care delivery (including the care delivery setting) to improve the results?

Once you determine what drives measurable outcomes for your patient population, establish clear standards for all patient-care providers and employees to follow. Be intentional with communications inside your organization to send the message that patient outcomes and quality are paramount. Make it clear that exceptional care quality is expected every time.

Cultivate a culture of quality. Healthcare providers that are known for quality have staying power. For example, have you ever seen a “Top Cancer Hospital” close? At a time when patients can find care for routine issues in retail settings, and increasingly are doing just that, healthcare providers need to find a way to stand out. Once you know what you’re good at, make sure the world knows too. Whether your hospital earns high patient satisfaction scores, a high ranking on the U.S. News Best Hospitals report, or a five-star rating on CMS Care Compare, make the most of these victories by communicating them internally and externally, clearly, prominently, and often.

Make Quality a Competitive Advantage

No healthcare provider can afford to leave money on the table over the long term. Compliance may be time-consuming and expensive, but you will be better off financially by turning quality into a competitive (and reimbursement) advantage. Wherever your healthcare organization is in its quality-improvement journey, your CRI healthcare advisor is ready to lend a hand.