Many payers are revising their reimbursement systems to reward quality, as opposed to the quantity or type of care provided. For example, within Medicare, quality measurement has been incorporated into payment systems related to hospitals, physicians, ESRD facilities, Medicare Advantage plans, and Accountable Care Organizations. Many private payers and Medicaid programs are following suit. In general, providers delivering higher quality care receive incentive payments, while those delivering low quality (and/or high cost) care, are penalized.
In addition to using quality measurement to determine payment, payers and government entities are making these data available to the public to help guide their choices of insurers or providers. For example, the state of Virginia provides data on risk-adjusted cesarean section rates for every obstetrician in the state. CMS has long posted quality data related to Medicare Advantage of Medicare Prescription Drug Plans and those data do impact which plans that people choose to enroll into. The Health Insurance Marketplaces will also be posting information on the quality ratings of plans offered through that program.
The development and use of quality measures is a critical issue and will only become more so in the future.
Available Literature and Resources