Advocate Aurora Health, a nonprofit system with hospitals and clinics in Illinois and Wisconsin, has launched a concerted effort to reduce the number of quality measures its providers have to report on. For instance, it slashed family medicine measures from 96 in 2021 to 26 in 2022.
During the same time period, Advocate Aurora cut internal medicine measures from 66 to 18, and pediatrics measures from 43 to 22. How and why did they do it? Speaking at the spring NAACOS conference, Carrie Nelson, M.D., Advocate Aurora Health’s senior vice president and chief medical officer for population health and health outcomes, detailed the effort her team is undertaking to reduce the burden of quality measurement on clinicians.
First, some background: Advocate Aurora has 27 hospitals, and 1.3 million lives in some form of a value-based arrangement, predominantly full capitation. It has about 185,000 in Medicare Shared Savings in upside and downside risk ACOs. Its physician engagement approach is different in Illinois than in Wisconsin, Nelson explained. In Illinois, they have about 4,600 physicians in a clinically integrated network, and many of those are aligned. They own their own practices, but they work with Advocate Aurora on all its value-based arrangements. About 1,300 of those are employed by Advocate Aurora. In Wisconsin, they have many more physicians who don't participate in their value-based programs. “We've had to get very creative in working across that pluralistic platform,” Nelson said. “We've been able to pay out over $100 million over 10 years for performing in these arrangements, both on the quality side and on the financial side, because it's really both of those things that feed that incentive pool.”
Advocate Aurora has gone through a lot of changes over time in terms of how it thinks about quality, Nelson said. Its work in this space precedes the whole ACO infrastructure. “We had a plethora of measures. We had far too many measures that just detracted from actually delivering on the most important measures that matter,” she added. “So we looked at this in the last year or so and decided we need to align with what CMS has, as well as how HEDIS measures things, because of the different ways our contracts are structured, and how the measures line up. Sometimes we just have to be somewhere in the middle of what those measurement systems would dictate in order to help our physicians make sense of all of this.”
Nelson stressed that Advocate Aurora also wants to make sure that they were very focused on those measures that drive to value-based care. “Medicare Advantage stars, in particular — there are big incentives associated with performance and Medicare Advantage stars. We needed to really combine all those individual pair requirements and get more simplistic about the workflows that would enable those levels of performance and reduce the administrative burden,” she explained.
Advocate Aurora launched the new Primary Care Physician measurement set this year and will be launching new specialty measures in 2023. Some of the measures they dropped were measures that were sort of “gimme” measures that almost all of the physicians could depend on doing well on, and that would help their scores, which help calculate their incentive payments. With fewer measures now, each of the measures has more weight associated with it, so performance is going to be that much more important, Nelson explained.
Referring to the measure cuts they have made so far, she said it's challenging to tell colleagues they are cutting their pet project out of the program. “At the same time, incentives aren't our only lever, and in some ways, I get concerned that the incentives we've built into our program have actually diminished the implicit drive to perform,” she said. “As an example, our Wisconsin Medical Group never had incentives, and they perform extremely well on quality, and they also have public reporting, so transparency is something we need to use more of.”
Advocate Aurora’s plan is to use only the quality measures that it sees as having the highest value and impact to improving patient outcomes, Nelson said. “We need to reduce that burden of measurement. We have redundant measures and ways of measuring the Medicare population versus the commercial population, and all the increased complexity associated with that. We want to align with what really creates that incentive fund because that's where we get better engagement with our physicians, and we can increase the incentive fund in a way that helps our primary care physicians to do well and be sustainable. We do believe that this incentive fund has actually enabled more primary care physicians to remain independent and to not have to join a medical group if that's not a good fit for them.”
Nelson noted that Advocate Aurora and the industry as a whole have been working on those measures for a long time. “I've been doing this work since the late 1990s, and it's the same measures I was focused on when I first started this career,” she said, “so while we need to create focus, we also need to get to where these things are hard-wired, that we have a team-based approach, that we know what levers to pull at what point in the year to get everybody to the right level of performance, to move on to something much more compelling and interesting.”