William L. Rich III, MD, FACS, described various solutions, such as data integration software with cloud-based computing, value modifiers, new clinical trial designs, new areas of research, and cultural competency in patients at high risk during retina subspecialty day at the annual meeting of the American Academy of Ophthalmology (AAO).
Value-based purchasing is not new, said Dr. Rich, who reviewed the history briefly. President George W. Bush in 2006 mandated that Medicare and Medicaid services move from payment based on volume to payment based on value. Ninety percent of hospitals responded to this with minimal financial stimuli. The mandate then was broadened to include physicians.
The Physician Quality Reporting Initiative (PQRI) was initiated and the first eight ophthalmic measures were born. Of these, five dealt with retina (two with diabetic retinopathy) and three with age-related macular degeneration.
"To get these approved, there had to be tremendous gaps in care and evidence that remedying those gaps in care would improve patient outcomes," said Dr. Rich, AAO medical director of health policy.
However, the Medicare and Medicaid Services and the National Quality Forum viewed these processes as the standard of care and called for metrics that were more meaningful. AAO then developed what Dr. Rich referred to as the "first true outcome measures" in medicine. These consisted of a return to the operating room within 30 days of cataract surgery if there was a complication, 20/40 target vision 90 days after cataract surgery, and achieving the targeted IOP in glaucoma. These, however, had no attached risk adjustments, so many patients were excluded.
The downside of this is that numerous patients at risk of poor outcomes would be excluded with no way of improving care.
"To obviate the risk adjustment problem, all patients would be stratified by risk and the data aggregated nationally with all payers nationwide," he explained.
However, the big problem with these outcome measures, Dr. Rich said, was that outcomes cannot be deduced from administrative claims data.
One approach to outcomes data was the use of registries. Although they have been used for decades, registries are expensive to develop and maintain, with no obvious source of funding. In addition, inputting data into the registry is labor-intensive. The use of electronic medical records (EMRs) was thought to be a solution to this with integration software. However, this resulted in multiple problems in data extraction from separate systems.
"The answer is something technical and scientific," Dr. Rich said. "A new approach being considered is data integration software with cloud-based computing, after the widespread adoption of EMRs."
Using this technology, data are uploaded into a "cloud" where software can intelligently pull out the clinical inputs from many different data sources, he explained.
He noted that this will affect ophthalmologists in a number of ways. This system can be used for PQRI reporting, FDA post-market approval, clinical research, personal economic analysis, licensure, American Board of Ophthalmology, and physician improvement.
Currently, AAO is working with the American Society of Cataract and Refractive Surgery to develop registries.
A second solution is a value modifier.
In addition to assessment by quality outcomes, by 2014, ophthalmologists will also be measured based on utilization of resources.
"Medicare and Medicaid Services is mandated to have a payment differential, as much as 10% in 2015, such that all doctors with good quality metrics and who achieve the quality metrics at a reasonable resource use will be rewarded," he said. "Doctors who fail to achieve quality score and/or provided service inefficiently will be penalized for all services provided for Medicare beneficiaries. This is going to be a powerful tool to change physician behavior."