CMS Incentives & Penalties

Prosk addresses many CMS guidelines for incentives payments and penalties by providing PRO as a part of PMR.

Prosk Promotes Pay-for-Performance from CMS

The Center for Medicare/Medicaid Services (CMS) established a series of reimbursements and penalties to health care providers and institutions in order to improve the overall quality of care for Medicare/Medicaid patients. Prosk provides accurate patient reported outcomes measurement that addresses many of the CMS guidelines for incentive payments and penalties.

Readmission Reductions

In an effort to reduce hospital readmissions, which cost Medicare $17.5 billion from 2007-2010, penalties for readmissions were established and CMS levied $227 million in fines in 2013. Prosk uses standard, accepted outcomes instruments as well as custom surveys to ensure effective treatment methods for chronic conditions. The Prosk outcomes report provides the patient’s current summary scores for general and specific conditions as well as comparative trend over time to measure improvement. Prosk helps avoid readmission penalties by measuring patient reported treatment progress. Becker’s Hospital CFO reported that the 10 most common Medicaid readmissions cost hospitals $2.06 billion in 2011, while congestive heart failure — the most common and expensive Medicare readmission — cost $1.75 billion alone.
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Measurable Quality of Care for Incentive Payments

The US Department of Health and Human Services Annual Financial Report of 2013 determined that Medicare overpaid $36 billion in benefits from 2007-2010. Among the reforms considered to address Medicare/Medicaid fraud is requiring additional medical data to support claims. Prosk provides patient outcomes history for one or more chronic or general health conditions. This information is one form of substantiation of patient treatment results through patient reported outcomes over time.

Star Rating Incentives

With the emergence of CMS Plan Star Rating, insurers have added incentive to provide plans consisting of “high value” network providers. Star Rating includes 36 measures across five areas. Ratings are provided to CMS insured members as a guide to plan quality for selection of supplemental coverage. Prosk directly addresses the rating dimension of managing chronic (long-term) conditions by providing measurable patient outcomes compared to normalized results. America’s Health Insurance Plans (AHIP) noted in a recent article that insurers’ networks will include only high quality providers with effective patient treatment and quality of care.
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Quality Measurement for Specific Procedures

CMS is also in the process of defining quality measurements for pay-for-performance for specific procedures, such as hip or knee replacement. The measurements are based on patient reported outcomes. Prosk is the proven solution to support determination of meeting these quality measurements.
The Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) Project examined use of PRO measurement for evaluating treatment effectiveness: “This report presents the Centers for Medicare & Medicaid Services’ (CMS’s) progress to date in developing a hospital quality measure(s) for total hip and/or total knee arthroplasty (THA and/or TKA) patients based upon patient-reported outcome surveys (PROMs). PROMs capture patients’ self-assessments of their health and provide a mechanism for evaluating the effectiveness of patient-centered care.”
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 Patient-Reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty: Hospital-Level Performance Measure(s)
YNHHSC/CORE and Booz Allen Hamilton, working for CMS and the Office of the National Coordinator for Health Information Technology (ONC), jointly developed performance measures for Total Hip/Total Knee (THA/TKA). Their findings were also published for public comment.

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Summary of Technical Expert Panel (TEP) Evaluation of Measures: Total Hip and/or Total Knee Arthroplasty (THA/TKA) Patient-Reported Outcome Hospital- and Eligible Professional-Level Performance Measures Introduction to Public Comment: Patient-Reported Outcome-Based Hospital Performance Measures following THA/TKA 1