MAFP Quality Reporting for Cash-CMS Incentives and Your Bottom Line


Published on

Published in: Health & Medicine, Business
  • Be the first to comment

  • Be the first to like this

MAFP Quality Reporting for Cash-CMS Incentives and Your Bottom Line

  1. 1. Quality Reporting for Cash: CMS Incentives and Your Bottom Line Sandra Pogones Program Manager, Physician Services Primaris – Columbia, MO November 2011Publication MO-11-20-PRThis material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with theCenters for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contentspresented do not necessarily reflect CMS policy
  2. 2. Who is Primaris Founded in 1983 by the Missouri State Medical Association, Missouri Hospital Association and Missouri Association of Osteopathic Physicians and Surgeons Among other roles, Primaris serves as the federally- designated Quality Improvement Organization (QIO) for the state of Missouri. – Mission of QIOs: To improve the effectiveness, efficiency, economy and quality of services delivered to Medicare beneficiaries. – QIO contract-related services are free to providers.Slide 2 of 42 2
  3. 3. Objectives Establish the importance of Quality Reporting to physicians Analyze financial impact of CMS incentive programs Outline requirements for Meaningful Use, PQRS and e- Prescribe Present a cross-walk for quality reporting and examine specifications for a sample measure Propose a workflow plan to incorporate quality measurement into daily practice Question and AnswerSlide 3 of 42 3
  4. 4. Case for Quality Reporting & Improvement Success of Practice – Sense of Accomplishment/Professional Achievement – Improved Productivity/Set Practice Priorities – Move away from Defensive Medicine to Evidence-Based Service to Patients – Improved Outcomes, Prevention, Diagnosis, Remediation – More engaged, self-responsibility – Improved Satisfaction, Better Coordination Benefit for the Population – Efficacious care and Improved Population Health – Less waste, right incentives—Drive ChangeSlide 4 of 42 4
  5. 5. Where do CMS Quality Measures Come From? National Quality Forum (NQF) measures are at the center of quality measures. – Experts in the clinical area and stakeholders are convened to define quality and standards through consensus process – Measures are adopted that are important, scientifically acceptable, useable, relevant, and feasible to track – Caregivers adopt and apply measures to improve their own practice – Measures provide benchmarks and best practicesSlide 5 of 42
  6. 6. Three Separate and Distinct CMS Programs EHR Incentive Program (―Meaningful Use‖ of an EHR) PQRS Incentive Program (Physician Quality Reporting System—formerly PQRI) E-Prescribe Incentive Program EPs MAY participate in all programs for incentives and MUST participate to avoid payment penalties. Only Medicare EHR incentives and e-prescribe incentives are mutually exclusive. Otherwise, eligible providers can collect from all threeSlide 6 of 42 6
  7. 7. Impact on the Bottom Line Program Incentives Penalties EHR-Medicare 2011-2015: $44,000 Total 2015: -1.0% ($18,000 Year 1) 2016: -2.0% 2017: -3.0% EHR Medicare 2011-2015: +10% 2018: -4.0% HPSA-Bonus 2019: -5.0% 2011-2021: $63,750 Total EHR-Medicaid ($21, 250 Year 1) PQRS 2011: +1.0% 2015: -1.5% 2012-2014: +0.5% 2016+: -2.0% E-Prescribe 2011-2012: +1.0% 2012: -1.0% 2013: +0.5% 2013: -1.5% 2014: -2.0%Slide 7 of 42 7
  8. 8. Incentives Paid As of 10/1/2011 almost $870 million has been paid to hospitals and professionals for EHR incentive program – 114,000 providers have registered (EPs and hospitals) – 8397 EPs have attested; 95% verified – 302 hospitals have attested; all verified PQRS and eRx combined paid $382 million in 2009 – Approx. 120,000 professionals participated – Average payment was $1956 per professional and $18,525 per practiceSlide 8 of 42 8
  9. 9. Other Initiatives with Financial Impact Accountable Care Organizations – Quality measures combined with cost savings to share incentive payments Patient-Centered Medical Homes – Quality-based bonus payments to physicians who are NCQA-certified – Missouri Foundation for Health/Healthcare Foundation of Greater KC/BCBS GKC (2011+) – Missouri HealthNet – Medicaid (2011+) – CMS ―Comprehensive Primary Care Initiative (Sept 2011)Slide 9 of 42 9
  10. 10. Value-Based Reports for Individual Physicians Value-based modifier is required for specific physicians by 1/1/2015 and all physicians by 1/1/2017. Initial performance year is 2013. Physicians in IA, KS, MO and NE will receive individual reports late in 2011/early 2012 – PQRS measures reported – Some additional clinical measures derived from claims data – Compare average per capita costs among physicians – Compare total per capita costs for patients with COPD, heart failure, CAD and diabetes – Reports will be refined for future Value-based reports and forSlide 10 of 42 public reporting 10
  11. 11. EHR ―Meaningful Use‖ Incentive Program Two routes for participation: Medicare or Medicaid – Medicare includes mostly physicians, doctors—PFS services – Medicaid also includes NPs, PAs—30% threshold (20% Peds) Hospital-based EPs excluded EHR must be certified EPs must use their EHR to – Meet specified objectives – Electronically exchange information – Submit quality measuresSlide 11 of 42 11
  12. 12. EHR Incentive Program (continued) Being implemented in stages of increasingly sophisticated use of EHR technology and higher thresholds of performance Measures and objectives apply to all patients First stage is mainly ―reporting‖ Subsequent stages move toward real goals: – Patient: Improved Outcomes and Satisfaction – Practice: Improved Productivity, Quality of Life, Prosperity – Population: Improved health and affordability of healthcareSlide 12 of 42 12
  13. 13. Stage 1 Meaningful Use Core Set of 15 objectives that all EPs must meet Menu Set of 10 objectives of which EP must select 5 Clinical Quality Measures must be reported – 3 Core Measures (Weight Screening, Tobacco Screening/Cessation Counseling, BP Measurement – 3 Alternate Core if Core don’t apply (Flu vaccine, Childhood weight screening, Childhood Immunization Status – 3 Additional Menu Measures selected from 38 possibleSlide 13 of 42 13
  14. 14. Core Objectives Core Objective Threshold Use CPOE 30% Implement drug-to-drug and drug-to-allergy interaction checks Enable E-Prescribing 40% Record demographics including ethnicity and race 50% Maintain up-to-date problem list 80% Maintain active medication allergy list 80% Record and chart changes in Vital signs 50%Slide 14 of 42 14
  15. 15. Core Objectives (continued) Core Objective Threshold Record smoking status 50% Implement one clinical decisions support rule Enable Capability to exchange key clinical information among providers of 1 test care Provide patients with an electronic copy of health information 50% of requests Provide clinical summaries for each office visit 50% Protect electronic health information Security Risk Analysis Report Clinical Quality Measures 3 Core 3 MenuSlide 15 of 42 15
  16. 16. Menu Set of Objectives (Choose 5) Menu Objective Threshold Implement drug-formulary checks Enable Incorporate lab data as structured data 40% Generate lists of patients by condition for Quality Improvement 1 list Send reminders to patients (Age 65+ or 5 and under) for 20% preventive/follow-up care Provide patients with timely (4 business days) electronic access to 10% health information Identify/provide patient-specific education resources 10% Perform medication reconciliation 50% Provide summary of care record for transition and referrals 50% Submit electronic data to immunization registries 1 test Submit syndromic surveillance data to public health agencies 1 testSlide 16 of 42 16
  17. 17. Stage 2 & 3: Significant Proposed Changes STAGE 2 (Delay until 2014?) STAGE 3 Raise the threshold for many objectives Raise threshold again Add 1 lab or radiology order to CPOE Reconcile lab results with lab orders requirements (no transmission needed) Manage high priority conditions with lists Add new CQMs Electronic self-management tools offered Improve performance using CDS EHR can exchange data with PHRs Move current menu items to core Patients. Report experience with care EPs to record advance directives (currently measures online only hosp) Online access to education in primary Add Electronic Notes to documentation language Ability of pt to view and download visit Bidirectional connection with external within 24 hours providers or HIE 20% of patients must use portal/PHR Longitudinal Care Plan for high-priority pts Online secure patient messaging Submit patient-generated data to public List of care team members available to pt healthSlide 17 of 42 immunization Submit and syndromic data
  18. 18. Physician Quality Reporting System PQRS requires reporting of clinical measures to CMS Annual program, rules/measures change every year PQRS incentives are independent of other CMS programs Eligible professionals include physicians, NPs, PAs, therapists Incentives based on Medicare Part B PFS allowable charges – effectively excludes RHC/FQHC providersSlide 18 of 42 18
  19. 19. PQRS Participation Options Individual eligible professionals may report – 3 individual PQRS measures, OR – 1 measures group (14 different Measures Groups) – A group consists of 4-9 clinically-related measures – Reportable through Claims or Registry option—not EHR May also participate as a Group: – Registration required for group reporting (deadline passed for 2011) – Group must report 26 measures Additional incentive (0.5%) for Maintenance of Certification Program—professional bodies onlySlide 19 of 42 19
  20. 20. PQRS Reporting Options for Individuals Claims – designed for paper-based systems – Physician/billing clerk enters QDCs on each claim – Submit daily – Some EHRs or PMS have alerts to assist reporting Qualified Registry - designed for sub-optimal EHRs – Provider reports data to a registry – Registry may be integrated as part of the EHR and pull data directly – Registry submits aggregate data on behalf of provider – Done once per year – May be a cost Qualified EHR – ultimate goal for EHR functionality – EHR pulls data – Provider submits raw data directly to CMS – Done once per year – Only 28 qualified EHRs for 2011Slide 20 of 42 20
  21. 21. E-Prescribe Incentive Program To earn an incentive: – Requires reporting of G-code during specified encounters where an Rx was transmitted electronically to a pharmacy – Refills and e-faxes do not count – Eligible providers include physicians, practitioners and therapists – Must use a ―Qualified‖ or ―Certified‖ e-Rx system – Report on a minimum of 25 unique eligible visits – Refills and faxes do not count Reporting Mechanisms: – Claims, Registry, or EHR to earn incentives – Annual program; Changes are made every yearSlide 21 of 42 21
  22. 22. E-Prescribe Incentive Program (continued) Avoid e-prescribe penalties by: – Be a successful e-prescriber (Report 10 cases via Claims before 6/30/2011) – Is not a physician, NP or PA by 6/30/2011 or has no prescribing privileges – If <10% of an EP’s allowed charges from 1/1/2011 through 6/30/2011 are comprised of codes in the denominator. – If the EP has <100 cases containing an encounter code in the measure’s denominator from 1/1/2011 through 6/30/2011. – Files a hardship exemption by 11/1/2011.Slide 22 of 42 22
  23. 23. Physician Compare WebsiteSlide 23 of 42 23
  24. 24. 2011 Crosswalk for Quality Measures EHR PQRS Description Meaningful measure Use CQM #110 Patients 50+ who received flu vaccine Alt. Core #111 Patients 65+ who have ever received a Menu pneumococcal Vaccine #112 Women 40-69 who had a mammogram within 24 Menu months #113 Patients 50-75 appropriately screened for colorectal Menu cancer #226 Patients 18+ screened for tobacco use w/in 24 Core months and received cessation counseling #237 Patients 18+ with hypertension and BP recorded Core In 2012 Quality Measures will be aligned for both programsSlide 24 of 42 24
  25. 25. Quality Measures--Analysis Each measure has a denominator that defines the population included. e.g. Pneumoccoccal Vaccine – Denominator: All Medicare patients greater than or equal to 65 years at the beginning of the measurement period. Patients must have at least one face-to-face office visit during the measurement period. Each measure has a numerator that defines the portion of population that met the measure – Patients who received a pneumococcal vaccination before the end of the measurement periodSlide 25 of 42 25
  26. 26. Quality Measure Analysis (continued) Some measures have exclusions that remove a patient from both the numerator and denominator: – Medical reason for not having the vaccination, such as Allergy or Adverse effect Reporting Rate: Accurately identifying all patients in the denominator Performance Rate: Numerator/Denominator – Currently incentives are based only on Reporting—no threshold for performance—yet – Performance rate will factor into bonuses for ACOs, PCMHs, and Value-based Modifiers/PurchasingSlide 26 of 42 26
  27. 27. NCQA Accreditation Benchmarks and Percentiles--2011 (IA, MO, NE, KS) Measure for Medicare 90th Percentile Nat’l Your Patients Benchmark Score Breast Cancer Screening 84% ? Colorectal Cancer 69% ? Screening Advising Smokers to Quit 88% ? Flu Shots 83% ? Pneumococcal 82% ? Vaccination Source: 2011 HEDIS Benchmarks and Thresholds: Mid-Year UpdateSlide 27 of 42 27
  28. 28. What’s Required for Quality Measurement Structured Data Capture in Defined Fields – Drop-down Lists - Dates – Checkboxes - Positive/Negative – Numerical values NOT—scanned documents, dictation, narrative notes Requires workflow change and team approach to accomplish change efficiently Find a balance between structured/unstructured – May supplement with non-structured data – Underlying coding/data capture must be presentSlide 28 of 42 28
  29. 29. National Standards for Coding Underlying Standard Codes – ICD-9 / ICD-10 – CPT-4 – Healthcare Common Procedure (HCPCS) – Systematized Nomenclature of Medicine (SNOMED) – HL7 Standard Vaccination Code Set (CVX) – Logical Observation Identifiers (LOINC) for lab data – Nations Council for Prescription Drug Programs (NCPDP)Slide 29 of 42 29
  30. 30. Workflow (See Attachment 1) Adult Patient Workflow Pre-Appt •Incoming labs and diagnostic tests populate EHR or entered & Check structurally (Menu #2); sent to provider to review, then to patient in portal (Menu #5) •Record demographics (Core #7) including race, ethnicity, preferred language •Ask if pt. wants portal access, record email, and provide instructions (Menu #5) •Record patient preference on how to receive reminders (Menu #4) •Ask about preventive services received elsewhere and record structurally (such as flu & pneumococcal vaccines, mammograms, colonoscopies). Update smoking status. (Clinical Quality Measures and PQRS)Slide 30 of 42 30
  31. 31. Workflow (continued) Adult Patient Workflow Review/ •Nurse records Vitals for patients age 2+ (Core #8, Core CQM #1 and Core Document CQM #2) •Allergies •If BMI outside parameters, nurse discusses plan or make note to •Meds physician (Core CQM #1) to discuss later in the visit •Problems •Nurse send request for clinical information to other providers (Core #14). • Labs (Best done prior to the visit by reviewing outstanding orders from CPOE •Flow Sheet functionality) •PMH, FH, •Nurse records smoking status for patients age 13+ (Core #9 and Core SH, Proc, CQM #3). If smoker, provide cessation counseling (Core CQM #3) Hosp, •Nurse reviews allergies and documents structurally or NKA (Core #6) •Nurse reviews medications and documents structurally or NKM (Core #5) •Nurse reconciles medications if transferred from another provider (Menu #7) •Nurse reviews alerts for overdue care (Core #11) and follows standing orders to administer, documents on templates.Slide 31 of 42 31
  32. 32. Workflow (continued) Adult Patient Workflow Review/modify •Physician reviews problem list and documents structurally or NKP nurse notes, (Core #3) Problems, •Physician reviews recent labs and vitals, PMH, FH, SH Recent labs •Templates used to record notes with narrative supplement as needed •PMH, FH, SH, Proc, Hosp, Provide Care •Templates used to record notes with narrative supplement as needed •HPI, ROS, SH, •Physician orders in-house office testing and treatments using CPOE FH, PE (Core #1) • Lab tech records in-house results structurally (Menu #2) ASSESSMENT •Add new diagnoses and problems to problem list using ICD-9 codes or drop-down lists (Core #3). Update chronic problems.Slide 32 of 42 32
  33. 33. Workflow (continued) MEDICATION •Order new meds using CPOE (Core #1). •Update •Check drug-to-drug and drug-to-allergy (Core #2) •Order •Check formulary (Menu #1) •Refill/DC •Transmit electronically (Core #4) and/or print ORDERS •Use CPOE to order labs, x-rays, other diagnostic tests, and consults •Labs, x-ray, ( Future stages Core #1) DME, •Check alerts for preventive, follow-up care, and other quality consults measures (Core #10 & #11,Menu CQMs and PQRS) and order using CPOE WRAP-UP •Provide educational materials for patients (Menu #6) •Pt. •Generate a Clinical Summary and give to patient/send to portal Education (Core #13) •Pt. Action •If patient requests a copy of medical record, notify staff.( Core #12) Steps •Referral and consults scheduled and Summary of Care/CCD is sent •Next Visit electronically (Menu #8)Slide 33 of 42 33
  34. 34. Workflow (continued) SCHEDULED •Nightly: Set task to transmit immunization (Menu #9) and TASKS syndromic surveillance data (Menu #10) to state registries •Monthly: Run CQM and PQRS reports (Core #10). Generate patient lists (Menu #3) and send reminders (Menu #4) and schedule follow-up care. •Monthly: Discuss quality reports at staff meetings. Test strategies for improvement. Assign responsibilities to all team members. Re-measure. •Annually (or when EHR changes are made): Conduct security risk assessment (Core #15)Slide 34 of 42 34
  35. 35. Bottom Line Financial impact of quality measurement is high— incentives, penalties, value-based purchasing Close scrutiny of health care spending—accountability Physicians will be profiled and data publicly reported on the ―Physician Compare‖ website—reputation You improve what you Measure – Identify gaps in performance and take steps to correct – Meet professionally-recognized standards – Apply improvement methodology (Plan-Do-Study-Act)Slide 35 of 42 35
  36. 36. Quality Reporting & Improvement Builds a culture of ―excellence‖ among team.: ―The healthcare organization that seeks merely to meet minimal standards may not ever reach any higher, and certainly will not achieve excellence.‖ Janet Brown, RN, CPHQ, The Healthcare Quality Handbook, 2010/2011 edition) ―Quality is not an act, it is a habit.‖ (Aristotle, Philosopher, Scientist, Physician, 384 BC – 322 BC)Slide 36 of 42 36
  37. 37. Resources Primaris: – Funding to assist 74 Missouri physicians to report PQRS using their Qualified EHR as part of our national QIO 10th Scope of Word (began August 2011). Free onsite and/or remote assistance. – Qualified EHRs include e-MDs, Aprima, Greenway, Pulse, Sage, Success EHR, others. See me for details! (Complete listing of PQRS Qualified EHRs at 11_PQRS_and_eRx_05-03-2011.pdf) – Earn PQRS Incentives for 2012 (and possibly 2011) – Assistance with performance improvement methodologySlide 37 of 42 37
  38. 38. Resources (continued) (for hardship exemptions--follow the Communications Support Page link) National Provider Calls and Special Open Door Forums Office of the National Coordinator (ONC) for Health Information Technology: http://healthit.hhs.govSlide 38 of 42 38
  39. 39. Resources (continued) QualityNet Help Desk – – 7:00 a.m. - 7:00 p.m. CST at 866-288-8912 or Missouri Health Connection: Statewide Health Information Exchange: Missouri Health Information Technology Assistance Center (MO-HIT): – Website: – E-Mail: – Phone: 877-882-9933Slide 39 of 42 39
  40. 40. Thank You! Questions? Contact: – Sandy Pogones – Your Local Connection to Achieving National Health GoalsSlide 40 of 42 40