Setting goals to improve quality under MIPS

Effective beginning January of this year, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) attempts to increase clinician engagement in value-based care by fundamentally changing how Medicare reimburses physicians for the care of its beneficiaries.

For most eligible physicians, new requirements mean that reimbursement is tied in part to participation in the Merit-Based Incentive Payment System (MIPS), which encompasses physician quality reporting. Reporting on clinical quality measures itself is not new; in fact, MIPS consolidates a number of more familiar Medicare initiatives, including the previous Physician Quality Reporting System (PQRS). The stakes, however, will rise. After a period of data collection, analysis, and scoring, MIPS will begin exposing eligible physicians to potential payment adjustments totaling upwards of 4% and potentially as high as 9% of their overall Medicare Part B payments. (Payments can also be adjusted down.)

At this early stage, physician reporting under MIPS and its ultimate impact on clinical quality remain to be seen. Ongoing discourse about its implementation, effectiveness, and ability to foster meaningful clinician engagement will also certainly be needed. Nonetheless, it can be helpful for policymakers and clinicians alike to recognize that, fundamentally, quality reporting—and by extension, measure performance—are exercises in the act of goal-setting. In turn, the aspirational goal of any quality reporting program should be to encourage performance within domains that improve care and benefit patients.

As a result, insights from goal-setting theory may help clinicians and policymakers improve performance under MIPS and design future policy. For example, based on work dating back 50 years, social scientists have identified five principles that frequently define successful individual and organizational goal-setting and achievement. Within this frame, goals must be clear and appropriately challenging, requisites for ensuring that they are explicitly actionable while capturing interest and motivation. Additionally, goals are more often achieved when they are undergirded by commitment, which fosters perseverance through obstacles, as well as feedback, which enables clarification and course correction. Finally, consideration of the complexity, time, and difficulty required to achieve goals (i.e., task complexity) is vital to ensuring that goals are set and pursued appropriately.

The first principle is an inherent feature of quality reporting requirements. Within a guiding framework (e.g., minimum number of measures; inclusion of outcome or other high-priority measure), MIPS fosters goal clarity by permitting eligible physicians to report on specific measures of their choosing. In contrast, however, it is less clear how the program reinforces other goal-setting principles. For example, many measures that are most relevant for improving quality are also likely to require certain degrees of challenge and commitment. However, those submitted under MIPS may either be measures that possess such features or instead those that are most common, accessible, and/or convenient to report.

While helpful, the measure applicability validation processes utilized by Medicare, which attempt to identify whether physicians are reporting appropriate measures for their practices, do not fully address this issue. Additionally, while Medicare has provided feedback to physicians reporting under previous programs, these data have not been designed to explicitly promote practice improvement.

Moreover, not all quality measures possess the same task complexity, and within internal medicine, the same kinds of measures can have very different complexity based on patient population and disease features. For example, medication-focused measures such as antidepression medication management (based on the number of patients diagnosed with major depression who remained on antidepressant treatment) and prevention and treatment of cardiovascular disease (based on the number of patients with high cardiovascular risk who are prescribed statins) may require different time commitment and patient engagement. There are also important distinctions between measures focused on incentivizing physicians to “do more” (e.g., prescribing medication, obtaining screening) versus “do less” (e.g., not prescribing antibiotics for uncomplicated acute rhinosinusitis).

How can these insights be applied to quality reporting under MIPS? In the spirit of ultimately achieving quality improvement and high performance, and not just reporting, clinicians can apply goal-setting principles in selecting measures for MIPS participation. Beyond identifying measures that can be consistently and accurately reported, clinicians could prioritize those that align with group commitment and for which actionable local feedback can reinforce or adjust behavior.

Using the frame of task complexity can also shed light on which measures may be more or less appropriate to select based on feasibility and difficulty. In turn, policymakers could consider how to integrate principles from goal-setting theory into future policy design. For example, incentivizing clinicians to report on a consistent panel of measures over multiple years could reinforce measure applicability validation processes and underscore the importance of sustained commitment in selected domains.

In the end, choices and strategies will inevitably vary by clinician and organization. However, clinicians and policymakers alike could benefit from thoughtful consideration of how goal-setting theory, which ultimately underlies the effort to identify, track, and perform on stated goals, can be applied to physician quality reporting under MIPS.