Guest post: HHS’ 2020 Top Management and Performance Challenges

by Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC

Each year, the Department of Health and Human Service (HHS) Office of Inspector General (OIG) publishes a list of the top management and performance challenges facing the department. These top six challenges reflect overarching issues that affect multiple HHS programs and responsibilities:

1. Safeguarding public health
2. Ensuring the financial integrity of HHS programs
3. Delivering value, quality, and improved outcomes in Medicare and Medicaid
4. Protecting the health and safety of HHS beneficiaries
5. Harnessing data to improve health and well-being of individuals
6. Improving collaboration to better serve our nation

The OIG notes that HHS continues to reform Medicare and Medicaid to promote quality, efficiency, and value of care. Virtually every type of healthcare service is being affected by changes, which comes with an array of program integrity challenges. The changes also offer opportunities for a better quality of care, better health outcomes, reduced administrative burden on providers, lower costs, and improved transparency and choices for consumers.

The Hospital Value-Based Purchasing (VBP) Program is a CMS initiative that rewards acute-care hospitals with incentive payments for the quality care provided to Medicare beneficiaries. According to an article in the New England Journal of Medicine Catalyst, the hospital VBP program encourages hospitals to improve the quality and safety of acute inpatient care for Medicare beneficiaries and all patients by:

1. Eliminating or reducing adverse events.
2. Adopting evidence-based care standards for best patient outcomes.
3. Changing the protocol for improving patients’ care experiences.
4. Increasing care transparency for consumers.
5. Recognizing hospitals for high-quality care at a lower cost to Medicare.

CMS rewards hospitals based on the quality of care provided to Medicare patients and how closely best clinical practices are followed. Therefore, hospitals need to pay attention to enhancing patients’ experience of care during hospital stays. Moreover, CMS bases hospital performance on an approved set of measures and dimensions grouped into specific quality domains, which are as follows:

1. Safety (25%)
2. Clinical care (25%)
3. Efficiency and cost reduction (25%)
4. Patient and caregiver-centered experience of care/care coordination (25%)

The two largest and most complex programs at HHS are Medicare and Medicaid. Both programs cover a broad array of health conditions, providers, and settings; offer benefits in multiple formats, and operate pursuant to intricate regulatory schemes and statutory directives.

In my opinion, CMS and the OIG have implemented targeted flexibilities addressing payment and coverage for services and items to reduce disease spread and expedite the delivery of medically needed care during the COVID-19 public health emergency.

An increasing number of providers are participating in value-based healthcare models, and an increasing number of Medicare and Medicaid beneficiaries are enrolling in managed care options. New models across the healthcare spectrum are being tested and introduced by CMS Innovation Center, from hospitals to hospices, from urban areas to sparsely populated rural areas, and from integrated delivery systems to small primary care practices. I believe strengthening program integrity and delivering on the promise of innovative technology is beneficial to ensuring Medicare and Medicaid’s effectiveness in delivering value and overcoming challenges. 

Editor’s note: Kuqi is a member of the ACDISCDI Leadership Council, PHIMA, and the American Urological Association, and a volunteer for the AHIMA Foundation Research Network. Contact her at albakuqi88@gmail.com. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.