Scorecard Strategy: Drill Down to Metrics that Matter

As Medicare undergoes big changes, internally generated scorecards are becoming essential tools for physicians and practices to monitor performance and track progress toward goals.  

Survival tool

As implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) continues, cardiologists are adjusting to shifts that will increasingly affect their reputations as providers and how they are paid for their services. There are two key steps that practices must take to optimize both, says Cathie Biga, RN, MSN, president of Cardiovascular Management of Illinois in Woodridge. First, understand how the Centers for Medicare & Medicaid Services (CMS) will be parsing clinicians’ performance data; and second, develop scorecards to serve as tools that both individuals and the practice can use to track progress toward goals.

The vast majority of U.S. physicians will participate in MACRA’s Merit-based Incentive Payment System (MIPS), where earnings will be affected by the number of points they score across domains: quality; advancing care information, which focuses on use of electronic health records (EHRs); clinical improvement activitie; and cost. Whether participating as individuals or as groups, the goal will be to score as many as possible of 100 achievable points. Those scoring 70 or higher will be eligible for a portion of the financial bonuses that CMS will award in 2019. Providers who score between 31 and 70 points can avoid any penalty and perhaps achieve a small incentive due to the zero-sum mechanics of the program.

One important step is to develop and enact a points-earning strategy, and to start as soon as possible. Ask yourself, “Where will our points come from, and how will we actually get them?” Next, use scorecards to monitor how well the practice is delivering quality care and value compared to peers. Physicians are going to need scorecards to survive, says Biga, because it will help them predict their MIPS results. “By the time you get your score [from CMS], it will be too late,” she says. “The year will be over, and you may be surprised with your results.”

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Data, data everywhere

“With EHRs we have today, we have tons of data, but often we don’t have much [usable] information,” says Katie Lund, RN, MBA, executive director of value-based care at the Piedmont Heart Institute in Atlanta. Scorecards programmed to extract data from the EHR can help cardiologists and administrators home in on data that impact patient outcomes, financial rewards and practice growth while tuning out distracting “noise” from less useful metrics.

“Report cards are fundamental to changing or improving the care we deliver,” says Lund. “If you don’t know how you are performing, you don’t know how to improve.”

For the scorecards to serve this purpose though, the EHR must contain complete, correctly documented and accurately placed data. “Your ability to succeed or fail… will be based on your ability to document in the right spot, and the EHR’s ability to pull [data] from the right spot,” explains Lund.

Just as scorecards can provide an early warning system for MIPS results, they also can include signals for staff to investigate discrepancies before they become problems that affect reimbursement. For example, in Biga’s practice, a physician saw his weekly score for counseling patients about tobacco cessation had dropped off. It turned out his new medical assistant had entered the data into the wrong EHR field. Similarly, Biga has had physicians contest their scores for ACE inhibitor- and ARB-prescribing quality metrics. “The physician may say, ‘No, no, no! I give all the right drugs,’ but maybe they’re putting that in a typed note rather than in the correct structured field,” she says. In both cases, a little education can go a long way toward fixing a problem before data are transmitted to CMS.

The EHR–scorecard link demonstrates the importance of working closely with vendors. Practices should develop their own scorecards, say Biga and Lund, but don’t forget that the data Medicare will use to generate MIPS scores will come straight from the EHR—yet another reason scorecards should be synchronized with the EHR.

“One foundational piece with MACRA Quality Payment Program is that you have to do more than perform high-quality care,” Lund says. “It’s documenting everything in the right places and then working with the EHR vendor to map it to the appropriate fields.”

Aim for consistency

Biga’s practice generates about eight scorecards regularly. Some drill down on hospital-related measures, such as cost of care and length of stay, while others aim to show physicians how well they are documenting and coding from the perspective of risk. Others track Coumadin/INR data, medication refills and patients with low ejection fractions. For MIPS-related scorecards, Biga generates weekly scorecards while Lund’s practice produces scorecards monthly. The frequency is less important that the consistency, they say. Each practice should find its own rhythm for regular use of scorecards to catch problems and take corrective action.

Biga shares MIPS-relevant scorecards with the management team. When “red flags” show up, she contacts the physicians involved immediately. She sometimes includes the whole care team in conversations about scorecard findings. Lund concurs: “The whole care team has to be responsible for driving these measures.”

Whether clinicians are enrolling in MIPS as individuals or the practice is participating as a group, it’s important to study scorecard data at both levels. Every clinician needs to know his or her individual score on the tracked metrics, Biga recommends. “If it’s all group scoring, people just say, ‘I know it’s not me. It has to be them.’”

At Piedmont, physicians see scorecards that show them “how they’re doing against their peers,” says Lund. “Cardiologists have a healthy competition,” Lund explains. “That made a world of difference for us, as far as engaging them and slightly altering their behavior. I work with a great group of doctors, all folks who want to do the right thing.”

“You have to know how individuals are doing” to raise the group’s score, says Biga, but she warns that sharing scorecards takes diplomacy. She gives physicians their individual scores “in small doses” with one or two areas highlighted and a clear explanation: “Here’s what’s being measured, described in English. Here’s your score vs. the national benchmark. You got a 6. You could have gotten a 10.”