analysis on acos

8/7/2019 Analysis on ACOs

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___________________________________________________________

ANALYSIS OF THE CMS PROPOSED RULE FOR

THE MEDICARE SHARED SAVINGS PROGRAM ANDACCOUNTABLE CARE ORGANIZATIONS (2011)

___________________________________________________________

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule

regarding the Medicare Shared Savings Program: Accountable Care Organizations (76 Federal

Register19528 [March 31, 2011]). The proposal would implement section 3022 of theAffordable Care Act, which contains provisions relating to Medicare fee-for-service payments

under Parts A and B, including the ability of certain specified providers and suppliers to

participate in Accountable Care Organizations (ACOs). Comments are due June 6, 2011, and

CMS will respond to comments in the final rule, which is expected later this calendar year. Thepolicies adopted in the final rule are slated to take effect January 1, 2012.

ACOs are one mechanism established in the Accountable Care Act to improve the systemof care under Medicare. If successful, ACOs would spread to the private sector in coming years.

An ACO is an umbrella organization made up of providers (combinations of hospitals, physician

groups, and other health care facilities) that agree to be accountable for the quality, cost, andoverall care of their assigned fee-for-service Medicare beneficiaries. Although the focus is on

primary care, an ACO takes responsibility for a beneficiarys entire continuum of care. The

purpose is to incentivize the provision of coordinated, quality care with better outcomes by

sharing cost savings with providers. The ACO is a new, more developed approach that follows

many other ways to organize health care (e.g., original HMOs). Other separate approaches toaddress cost growth while assuring appropriate services will be piloted over the next several

years by the Center for Medicare and Medicaid Innovation, another part of the Medicare SharedSavings Program.

I. STATUTORY BACKGROUND

Section 3022 of the Affordable Care Act amended Title XVIII of the Social Security Act

(SSA) (42 USC 1395 et seq.) by adding a new section 1899 requiring CMS to establish aShared Savings Program that promotes accountability, coordinates items and services under

Medicare Parts A and B, and encourages a commitment to high quality and efficient service

delivery. Under the Shared Savings Program, groups of specified providers and suppliers willwork together in ACOs to manage and coordinate fee-for-service care to Medicare beneficiaries.The ACOs may share in realized savings and receive financial incentives provided they meet

certain quality performance standards. Section 1899(a)(1) requires the program to be established

by January 1, 2012.


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Accept accountability for the quality, cost, and care for assigned Medicare fee-for-servicebeneficiaries

Agree to participate for a 3-year period

Adopt a formal legal structure that would allow the organization to receive and distributepayments for shared savings

Include a sufficient number of primary care physicians to meet the primary care needs ofassigned beneficiaries

Care for at least 5,000 assigned beneficiaries

Provide CMS with necessary information regarding participating professionals

Have in place administrative and clinical organization and leadership

Define processes to promote evidence-based medicine and patient engagement, report onquality and cost measures, and coordinate care (such as through the use of telehealth,

remote patient monitoring, and other such enabling technologies)

Be patient-centered, as shown by the use of patient and caregiver assessments or the useof individualized care plans

SSA 1899(b)(2)(A-H)

Legal Structure

CMS states in the proposed rule that it has attempted to balance its requirement of a

formal legal structure with other agency goals of flexibility, cost minimization, and programparticipation by nonprofit, community-based organizations. CMS has thus proposed that ACOs

must only satisfy applicable state laws and be capable of performing all ACO functions

including: (1) receiving and distributing shared savings and repaying any shared losses, and (2)establishing, reporting, and ensuring compliance with program requirements including quality

performance standards. CMS proposes that ACOs each have a tax identification number (TIN)

(or a set of TINs from all the practices constituting the ACO), but does not propose to haveACOs enroll in the Medicare program, in contrast to this requirement for each ACO participant.

CMS also proposes requiring ACOs to have a shared governance structure that providesall ACO participants (not just those professionals and hospitals involved with formation) withproportionate control over decision making. ACO participants directly providing health care

services must have at least 75% control of the ACOs governing body, and the governance

mechanism must include some Medicare patient representatives.


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Agreement Period

CMS is proposing to limit participating agreements in the first round of the Shared

Savings Program to 3 years, the minimum allowable by statute. CMS also proposed to require 60

days advance written notice of an intent to terminate the agreement, at which point the ACO will

be subject to a 25% withhold of shared savings in order to offset any future losses.

Minimum of 5,000 Beneficiaries

Under the proposed rule, should an ACOs assigned population fall below 5,000 during

the course of the agreement period, CMS would issue a warning and place the ACO on acorrective action plan. The ACO would remain eligible for shared savings over the course of the

performance year for which the warning was issued. If the ACO fails to meet the eligibility

criterion of having more than 5,000 beneficiaries by the completion of the next performance

year, the ACOs participation agreement would be terminated and the ACO would not be eligibleto share in savings.

Reporting

CMS is proposing that ACOs be subject to substantial monitoring and reporting

requirements, including public reporting of quality data to ensure transparency. ACOs wouldalso be required to provide documentation in their program application describing plans to

(1) promote evidence-based medicine, (2) promote beneficiary engagement, (3) report internally

on quality and cost metrics, and (4) coordinate care. CMS is seeking comment on whether more

prescriptive criteria would be appropriate for future rulemaking. ACO applications must alsoinclude a description of processes in place for internal reporting on quality and cost measures.

IV. QUALITY PERFORMANCE MEASURES

The quality of care furnished by an ACO will be measured using nationally recognized

measures in five key domains: patient/caregiver experience, care coordination, patient safety,preventive health, and at-risk population/frail elderly health. CMS is proposing an initial set of

65 measures across these domains (see CMS Table 1, Proposed Measures for Use in Establishing

Quality Performance Standards for Shared Savings in the First Year).

These measures and reporting mechanisms are intended by CMS to be aligned with the

measures in other CMS programs such as the Electronic Health Records (EHR) initiative and the

Physician Quality Reporting System (PQRS). An ACO that successfully reports the qualitymeasures required under the Shared Savings Program would also be deemed eligible for the

PQRS bonus.

ACOs must report completely and accurately on all measures within all domains to be

deemed eligible for shared savings. The stated purpose of this is to require ACOs to address all

domains and be accountable across the continuum of care. CMS also proposes giving aperformance score to an ACO for each measure: performance below the minimum attainment


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level would earn zero points, while performance at or above the minimum attainment level but

less than the performance benchmark will receive points on a sliding scale.

V. SHARED SAVINGS

Shared savings amounts will be determined based on algorithms tied to an ACOs qualityperformance score and its savings rate. CMS proposes two models for shared savings: a shared

savings model (one-sided model) and a shared savings/losses model (two-sided model).Under the one-sided model, an ACO would receive a smaller percentage share in savings. Under

the two-sided model, an ACO willing to bear risk and repay losses to the Medicare program

would receive a greater percentage of any shared savings (see CMS Table 8, Shared SavingsProgram Overview).

CMS proposes that ACOs be required to report quality measures and meet performance

criteria for all 3 years within the 3-year agreement period. For the first year of the program,however, CMS proposes requiring only full and accurate reporting to set benchmarks and

encourage participation. Scales and standards with a minimum attainment level will be in effectfor subsequent years.

If an ACO satisfies quality performance criteria and its annual expenditures fall below a

certain Expenditure Benchmark, then it is eligible to share in cost savings. The cost savings inwhich ACOs may share fall within a range between the Minimum Savings Rate (for the one-

sided model, the Minimum Savings Rate ranges from 2% of the Expenditure Benchmark for

ACOs over 60,000 beneficiaries and 3.9% for ACOs of 5,000 beneficiaries; for the two-sided

model, the minimum is a flat 2%) and the Maximum Sharing Cap. ACOs using the one-sidedmodel are entitled to receive up to 50% of the net savings beyond the Minimum Savings Rate up

to the Maximum Sharing Cap of 7.5% of the Expenditure Benchmark. ACOs using the two-sided

model are entitled to up to 60% of the gross savings beyond the Minimum Savings Rate and upto the Maximum Sharing Cap of 10% of the Expenditure Benchmark.

ACOs may not participate in any other shared savings program or demonstration underthe Center for Medicare and Medicaid Innovation or Independence At Home Medical Practice

pilot program, to ensure that savings are not counted twice.

VI. IMPLICATIONS FOR PATIENTS

A central goal of ACOs is to protect Medicare beneficiaries by providing them with

better, patient-centered care and preventing them from having to retell their stories and medicalhistories to each treating provider. The proposed rule includes a list of criteria for demonstrating

patient-centeredness:

A beneficiary experience of care survey in place and a description in the ACOapplication of how the ACO will use the results to improve care over time.

Patient involvement in ACO governance.


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A process for evaluating the health needs of the ACOs assigned population, includingconsideration of diversity in their patient populations, and a plan to address the needs oftheir population.

Systems in place to identify high-risk individuals and processes to develop individualized

care plans for targeted patient populations, including integration of community resourcesto address individual needs.

A mechanism in place for the coordination of care.

A process in place for communicating clinical knowledge/evidence-based medicine tobeneficiaries in a way that is understandable to them. This process should allow for

beneficiary engagement and shared decision-making that takes into account the

beneficiaries unique needs, preferences, values, and priorities.

Written standards in place for beneficiary access and communication and a process in

place for beneficiaries to access their medical record.

Internal processes in place for measuring clinical or service performance by physiciansacross the practices, and using these results to improve care and service over time.

CMS is also proposing to ensure that Medicare beneficiaries be given notice of provider

membership in an ACO, maintain their choice of provider, and retain privacy protections.

CMS would require participating ACO providers to notify Medicare fee-for-servicebeneficiaries at the time they seek services that the provider is participating in an ACO.

Providers must offer beneficiaries information about the ACO, including how the ACO would

improve the care that they receive, and post signs indicating ACO participation.

CMS would also allow beneficiaries to retain their choice of providers even if they

receive care from a physician, hospital, or other facility participating in an ACO. CMS proposesto prohibit ACOs from developing any policies that would restrict a beneficiarys ability to seek

care from providers and suppliers outside of the ACO, including expressly limiting patients to

certain providers, managing utilization, or requiring prior authorization for Medicare services. In

this same vein, CMS has also proposed strict restrictions to ACO patient communications andmarketing activities that are confusing or misleading and would not forward the goal of patient-

centeredness. The agency is proposing that all marketing materials, communications, mailings,

calls, or community events that are used to educate, solicit, notify, or contact Medicare

beneficiaries or providers/suppliers regarding the ACO and its participation in the SharedSavings Program be pre-approved by CMS.

Because Medicare beneficiaries may seek care from their choice of providers, they may

receive services over the course of a year from a number of different ACOs and even from

professionals who do not participate in the Shared Savings Program at all. For this reason, CMSproposes to assign beneficiaries to an ACO retrospectivelyat the end of the performance

yearbased upon utilization data. CMS finds that prospective assignment would be plagued


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with inaccuracies and could encourage providers to limit their care improvement activities to a

subset of patients who are believed to be assigned to them. CMS would assign beneficiaries to anACO under a plurality rule: placing responsibility for a patients care on the ACO where a

patient received a plurality of his or her primary care services.

To better coordinate care among ACO providers, under the proposed rule an ACO wouldbe permitted to request personal health information (PHI) about a patient from CMS claims data.

Before doing so, however, ACOs would be required to provide written notice to beneficiariesduring an office visit that it would request the beneficiarys PHI from CMS and allow

beneficiaries to opt out.

VII. LEGAL ISSUES

The expansive ACO and Medicare Shared Savings Programs have broad legal

implications. Consequently, as part of a coordinated, inter-agency effort, several federal agencieshave issued companion proposals. There will be a 60-day public comment period for these

proposals.

Self-Referral, Anti-Kickback, and Fraud and Abuse Waivers

CMS and the HHS Office of the Inspector General (OIG) jointly issued a Notice onWaivers in Connection with Sections 1899 and 1115A of the Social Security Act. The notice

proposes to waive the Physician Self-Referral Law, the federal anti-kickback statute, and certain

civil monetary penalties law provisions for specified financial arrangements involving ACOs.

The OIG would also waive fraud and abuse laws so that the Center for Medicare and MedicaidInnovation could carry out its mission of testing new payment and service delivery models.

Specifically, the notice addresses the application of the following federal laws toparticipating ACOs:

The Physician Self-Referral Law (SSA 1877(a)), which prohibits physicians frommaking referrals for Medicare designated health services, including hospital services,to entities with which they or their immediate family members have a financial

relationship, unless an exception applies.

The federal anti-kickback statute (SSA 1128B(b)), which provides criminal penaltiesfor individuals or entities that knowingly and willfully offer, pay, solicit, or receive

remuneration to induce or reward the referral of business reimbursable under any federal

health care program.

The civil monetary penalties law (SSA 1128A(b)(1) and (2)), which prohibits a hospitalfrom making a payment, directly or indirectly, to induce a physician to reduce or limit

services to Medicare and Medicaid beneficiaries under the physicians direct care.


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CMS and the OIG are proposing to waive the above laws in three specific circumstances:

The distribution of shared savings payments by an ACO to its participants.

The distribution of shared savings payments to other individuals or entities for activities

necessary for and directly related to the ACOs participation in the Shared SavingsProgram.

Financial relationships that are necessary for and directly related to the ACOsparticipation in the Shared Savings Program and fully comply with an exception to thephysician self-referral law (waiver of the anti-kickback statute and civil monetary

penalties law only).

The notice requests public comments on other areas where this waiver authority might be

appropriately exercised, including ACO start-up costs, continuing operating expenses, and non-

shared savings relationships between ACO members or outside entities.

Antitrust Policy Statement

In addition, the Federal Trade Commission (FTC) and Department of Justice (DOJ)jointly issued a Proposed Statement of Enforcement Policy Regarding Accountable Care

Organizations Participating in the Medicare Shared Savings Program on antitrust enforcement of

ACOs. The proposed antitrust policy would apply to collaborations, not including mergers,among independent providers seeking to participate in the Shared Savings Program (effective for

post-March 23, 2010, activities).

The policy includes a proposed Safety Zone for ACOsmeaning that they will not be

challenged by federal agencies for antitrust violations absent extraordinary circumstances. AnACO program applicant with a share above 50% for any common service that two or more

ACOs provide to patients in the same area meets a Mandatory Review Threshold. Such anapplicant must obtain a letter from one of the federal antitrust agencies stating that competitive

concerns are not raised and a challenge is not anticipated. The DOJ and FTC have committed to

provide a 90-day expedited review of ACOs that meet the 50% mandatory review threshold.

Federal Tax Guidance

The Internal Revenue Service (IRS) anticipates that tax-exempt organizations (such as

nonprofit hospitals and other health care organizations) will form ACOs and may have questions

about the application of federal tax law to the new structures. Accordingly, the IRS has issued anotice soliciting comments as to whether its existing guidance is sufficient or, if not, whatadditional guidance is needed.

Under current federal tax law, a tax-exempt organization must ensure that earnings do notfinancially benefit organizational insiders or other private parties. Nonprofit hospitals

participating in an ACO may receive payment under the Shared Savings Program which,


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although not expected by the IRS to result in such prohibited inurement or impermissible private

benefit, may create confusion.

* * * * *

AOTA is currently analyzing the implications of the proposed rule for therapy anddrafting comments. Please email us at [email protected] with your thoughts.

________

Resources

Proposed Rule: Medicare Shared Savings Program: Accountable Care Organizations, 76 Federal

Register19528 (March 31, 2011)

CMS Fact Sheet: Improving Quality of Care for Medicare Patients: Accountable CareOrganizations (March 31, 2011)

CMS Fact Sheet: What Providers Need to Know: Accountable Care Organizations (March 31,

2011)

CMS Fact Sheet: What Patients Need to Know About Accountable Care Organizations (March

31, 2011)

Federal Agencies Address Legal Issues Regarding ACOs Participating in the Medicare Shared

Savings Program (March 31, 2011)

Notice: Self-Referral and Anti-Kickback Legal Waivers (CMS and OIG, Display Copy, March

31, 2011)

Proposed Rule: Statement of Antitrust Enforcement Policy Regarding ACOs (FTC and DOJ,

Display Copy, March 31, 2011)

Notice: Guidance on Tax-Exempt Providers Participating in ACOs (IRS, March 31, 2011)

________

Attachments

CMS Table 1. Proposed Measures for Use in Establishing Quality Performance Standards for

Shared Savings in the First Year

CMS Table 8. Shared Savings Program Overview


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CMS-1345-P 174

Table 1. Proposed Measures for Use in Establishing Quality Performance Standards

that ACOs Must Meet for Shared Savings

Domain Measure Title & Description CMS Program,

NQF Measure

Number, Measure

Steward

Method of Data

Submission

Measure Type

AIM: Better Care for Individuals1. Patient/Care Giver Experience Clinician/Group CAHPS:Getting Timely Care, Appointments, and

Information

NQF #5 Survey Patient

Experience of

Care

2. Patient/Care Giver Experience Clinician/Group CAHPS:How Well Your Doctors Communicate


Experience of

Care

3. Patient/Care Giver Experience Clinician/Group CAHPS:Helpful, Courteous, Respectful Office

Staff


Experience of

Care

4. Patient/Care Giver Experience Clinician/Group CAHPS:Patients' Rating of Doctor


Experience of

Care

5. Patient/Care Giver Experience Clinician/Group CAHPS:Health Promotion and Education


Experience of

Care

6. Patient/Care Giver Experience Clinician/Group CAHPS:Shared Decision Making

NQF #5 Survey PatientExperience of

Care

7. Patient/Care Giver Experience Medicare Advantage CAHPS:Health Status/Functional Status


Experience of

Care

8. Care Coordination/Transitions Risk-Standardized, All Condition

Readmission:The rate of readmissions within 30 days

of discharge from an acute care hospital

for assigned ACO beneficiary population.

CMS Claims Outcome


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Domain Measure Title & Description CMS Program,NQF Measure

Number, Measure

Steward

Method of DataSubmission

Measure Type

9. Care Coordination/Transitions 30 Day Post Discharge Physician Visit CMS Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process

10. Care Coordination/Transitions Medication Reconciliation:Reconciliation After Discharge from an

Inpatient Facility

Percentage of patients aged 65 years and

older discharged from any inpatient

facility (eg, hospital, skilled nursing

facility, or rehabilitation facility) and seen

within 60 days following discharge in the

office by the physician providing on-

going care who had a reconciliation of the

discharge medications with the current

medication list in the medical record

documented.

NQF #554 Group PracticeReporting

Option (GPRO)

Data Collection

Tool

Process

11. Care Coordination/Transitions Care Transition Measure:Uni-dimensional self-reported survey that

measures the quality of preparation for

care transitions. Namely:1. Understanding one's self-care role in

the post-hospital setting

2. Medication management3. Having one's preferences incorporated

into the care plan

NQF #228 or

alternate

Survey or Group

Practice

Reporting

Option (GPRO)Data Collection

Tool

Patient

Experience of

Care


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CMS-1345-P 176


Number, Measure

Steward


Measure Type

12. Care Coordination Ambulatory Sensitive ConditionsAdmissions:

Diabetes, short-term complications(AHRQ Prevention Quality Indicator

(PQI) #1)

All discharges of age 18 years and olderwith ICD-9-CM principal diagnosis code

for short-term complications

(ketoacidosis, hyperosmolarity, coma),

per 100,000 population.

NQF #272 Claims Outcome


Uncontrolled Diabetes(AHRQ Prevention Quality Indicator

(PQI) #14)

All discharges of age 18 years and older

with ICD-9-CM principal diagnosis code

for uncontrolled diabetes, without

mention of a short-term or long-term

complication, per 100,000 population.

NQF # 638 Claims Outcome

14. Care Coordination Ambulatory Sensitive Conditions

Admissions:Chronic obstructive pulmonary disease(AHRQ Prevention Quality Indicator

(PQI) #5)



for COPD, per 100,000 population.



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Number, Measure

Steward


Measure Type


Congestive Heart Failure(AHRQ Prevention Quality Indicator

(PQI) #8 )



for CHF, per 100,000 population.



Admissions:Dehydration(AHRQ Prevention Quality Indicator

(PQI) #10)



for hypovolemia, per 100,000 population.



Admissions:

Bacterial pneumonia

(AHRQ Prevention Quality Indicator(PQI) #11)

All non-maternal discharges of age 18

years and older with ICD-9-CM principal

diagnosis code for bacterial pneumonia,

per 100,000 population.



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Number, Measure

Steward


Measure Type


Urinary infections(AHRQ Prevention Quality Indicator

(PQI) #12)



of urinary tract infection, per 100,000

population.


19. Care Coordination/Information Systems % All Physicians Meeting Stage 1HITECH Meaningful Use

Requirements

CMS Group Practice

Reporting

Option (GPRO)

Data Collection

Tool / EHR

Incentive

Program

Reporting

Process

20. Care Coordination/Information Systems % of PCPs Meeting Stage 1HITECH

Meaningful Use Requirements

CMS Group Practice

Reporting


Tool / EHR

Incentive

Program

Reporting

Process


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CMS-1345-P 179


Number, Measure

Steward


Measure Type

21. Care Coordination/Information Systems % of PCPs Using Clinical DecisionSupport

CMS

EHR Incentive

Program Core

Measure

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool/ EHR

IncentiveProgram

Reporting

Process

22. Care Coordination/Information Systems % of PCPs who are Successful

Electronic Prescribers Under the eRxIncentiveProgram

CMS

EHR Incentive

Program Core

Measure

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool / eRx

Incentive

Program

Reporting

Process

23. Care Coordination/Information Systems Patient Registry Use CMS

EHR Incentive

Program MenuSet Measure

Group Practice

Reporting

Option (GPRO)

Data CollectionTool

Process


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CMS-1345-P 180


Number, Measure

Steward


Measure Type

24. Patient Safety Health Care Acquired ConditionsComposite:

Foreign Object Retained AfterSurgery

Air Embolism Blood Incompatibility Pressure Ulcer, Stages III and IV Falls and Trauma Catheter-Associated UTI Manifestationsof Poor Glycemic

Control

Central Line Associated BloodStream Infection (CLABSI)

Surgical Site Infection AHRQ Patient Safety Indicator

(PSI) 90 Complication/Patient

Safety for Selected Indicators

(composite)

o Accidental puncture orlaceration

o Iatrogenic pneumothoraxo Postoperative DVT or PEo Postoperative wound

dehiscence

o Decubitus ulcero Selected infections due to

medical care (PSI 07: Central

Venus Catheter-relatedBloodstream Infection)

o Postoperative hip fractureo Postoperative sepsis

CMS (HACs), NQF

#531 (AHRQ PSI)

Claims or CDC

National

Healthcare

Safety Network

Outcome


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CMS-1345-P 181


Number, Measure

Steward


Measure Type

25. Patient Safety Health Care Acquired Conditions:CLABSI Bundle

NQF #298 Claims or CDC

National

Healthcare

Safety Network

Process

AIM: Better Health for Populations

26. Preventive Health Influenza Immunization:Percentage of patients aged 50 years and

older who received an influenzaimmunization during the flu season

(September through February).

Physician Quality

Reporting SystemMeasure #110

EHR Incentive

Program Clinical

Quality Measure

NQF #41

Group PracticeReporting


Tool

Process

27. Preventive Health Pneumococcal Vaccination:Percentage of patients aged 65 years and

older who have ever received a

pneumococcal vaccine.

Physician Quality

Reporting System

Measure #111

EHR Incentive

Program ClinicalQuality Measure

NQF #44

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


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CMS-1345-P 182


Number, Measure

Steward


Measure Type

28. Preventive Health Mammography Screening:Percentage of women aged 40 through 69

years who had a mammogram to screen

for breast cancer within 24 months.

Physician Quality

Reporting System

Measure #112

EHR IncentiveProgram Clinical

Quality Measure

NQF #31

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process

29. Preventive Health Colorectal Cancer Screening:Percentage of patients aged 50 through 75

years who received the appropriate

colorectal cancer screening.

Physician Quality

Reporting System

Measure #113

EHR Incentive

Program Clinical

Quality Measure

NQF #34

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


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CMS-1345-P 183


Number, Measure

Steward


Measure Type

30. Preventive Health Cholesterol Management for Patientswith Cardiovascular Conditions:

The percentage of members 1875years of age who were discharged

alive for AMI, coronary artery

bypass graft (CABG) orpercutaneous coronary

interventions (PCI) of the year

prior to the measurement year, or

who had a diagnosis of ischemic

vascular disease (IVD) during the

measurement year and the year

prior to the measurement year, who

had each of the following during

the measurement year.LDL-C

screening

LDL-C control (


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CMS-1345-P 184


Number, Measure

Steward


Measure Type

32. Preventive Health Blood Pressure Measurement:

Percentage of patient visits with blood

pressure measurement recorded among all

patient visits for patients aged > 18 years

with diagnosed hypertension.

Physician Quality

Reporting System

#TBD

EHR Incentive


NQF #13

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process

33. Preventive Health Tobacco Use Assessment and Tobacco

Cessation Intervention:Percentage of patients who were queried

about tobacco use. Percentage of patients

identified as tobacco users who received

cessation intervention.

Physician Quality

Reporting System

#TBD

EHR Incentive

Program Clinical

Quality Measure

NQF #28

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process

34. Preventive Health Depression Screening:


older screened for clinical depressionusing a standardized tool and follow up

plan documented.

Physician Quality

Reporting System

#134

NQF #418

Group Practice

Reporting

Option (GPRO)

Data CollectionTool

Process

35. At Risk Population -

DiabetesDiabetes Composite (All or NothingScoring):

Hemoglobin A1c Control (


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CMS-1345-P 185


Number, Measure

Steward


Measure Type

36. At Risk Population Diabetes Diabetes Mellitus: Hemoglobin A1cControl (


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CMS-1345-P 186


Number, Measure

Steward


Measure Type


DiabetesDiabetes Mellitus: Hemoglobin A1cPoor Control(>9%):Percentage of patients aged 18 through 75

years with diabetes mellitus who had

most recent hemoglobin A1c greater than

9.0%.

Physician Quality

Reporting System

Measure #1

EHR Incentive


NQF #59

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Outcome

41.

At Risk Population -

DiabetesDiabetes Mellitus: High Blood Pressure

Control in Diabetes Mellitus:Percentage of patients aged 18 through 75

years with diabetes mellitus who had

most recent blood pressure in control

(less than 140/90 mmHg).

Physician Quality

Reporting System

Measure #3

EHR Incentive

Program Clinical

Quality Measure

NQF #61

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Outcome


DiabetesDiabetes Mellitus: Urine Screening for

Microalbumin or Medical Attention for

Nephropathy in Diabetic Patients

Percentage of patients aged 18 through 75years with diabetes mellitus who received

urine protein screening or medical

attention for nephropathy during at least

one office visit within 12 months.

Physician Quality

Reporting System

Measure #119

EHR Incentive

Program Clinical

Quality Measure

NQF #62

Group Practice

Reporting

Option (GPRO)

Data CollectionTool

Process


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CMS-1345-P 187


Number, Measure

Steward


Measure Type


DiabetesDiabetes Mellitus: Dilated Eye Exam inDiabetic Patients

Percentage of patients aged 18 through 75

years with a diagnosis of diabetes

mellitus who had a dilated eye exam.

Physician Quality

Reporting System

Measure #117

EHR Incentive


NQF #55

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


DiabetesDiabetes Mellitus: Foot Exam

The percentage of patients aged 18

through 75 years with diabetes who had a

foot examination.

Physician Quality

Reporting System

Measure #163

EHR Incentive

Program Clinical

Quality Measure

NQF #56

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


Heart FailureHeart Failure: Left Ventricular

Function (LVF) Assessment

Percentage of patients aged 18 years andolder with a diagnosis of heart failure

who have quantitative or qualitative

results of LVF assessment recorded.

Physician Quality

Reporting System

Measure #198

NQF # 79

Group Practice

Reporting

Option (GPRO)

Data CollectionTool

Process


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CMS-1345-P 188


Number, Measure

Steward


Measure Type


Heart FailureHeart Failure: Left VentricularFunction (LVF) Testing

Percentage of patients with LVF testing

during the current year for patients

hospitalized with a principal diagnosis ofheart failure (HF) during the

measurement period.

Physician Quality

Reporting System

Measure #228

CMS

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


Heart FailureHeart Failure: Weight Measurement

Percentage of patient visits for patients

aged 18 years and older with a diagnosis

of heart failure with weight measurement

recorded.

Physician Quality

Reporting System

#227

NQF # 85

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


Heart FailureHeart Failure: Patient Education


older with a diagnosis of heart failure

who were provided with patient education

on disease management and health

behavior changes during one or more

visit(s) within 12 months.

Physician Quality

Reporting System

#199

NQF # 82

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


Heart FailureHeart Failure: Beta-Blocker Therapy

for Left Ventricular Systolic

Dysfunction (LVSD)


older with a diagnosis of heart failure

who also have LVSD (LVEF < 40%) and

who were prescribed beta-blocker

therapy.

Physician Quality

Reporting System

Measure # 8

EHR Incentive

Program Clinical

Quality Measure

NQF #83

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


25/31

CMS-1345-P 189


Number, Measure

Steward


Measure Type


Heart FailureHeart Failure: Angiotensin-ConvertingEnzyme (ACE) Inhibitor or

Angiotensin Receptor Blocker (ARB)

Therapy for Left Ventricular SystolicDysfunction (LVSD)


older with a diagnosis of heart failure and

LVSD (LVEF < 40%) who were

prescribed ACE inhibitor or ARB

therapy.

Physician Quality

Reporting System

Measure #5

EHR Incentive


NQF #81

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


Heart FailureHeart Failure: Warfarin Therapy for

Patients with Atrial Fibrillation

Percentage of all patients aged 18 and

older with a diagnosis of heart failure and

paroxysmal or chronic atrial fibrillation

who were prescribed warfarin therapy.

Physician Quality

Reporting System

Measure #200

EHR Incentive

Program Clinical

Quality Measure

NQF #84

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process


26/31

CMS-1345-P 190


Number, Measure

Steward


Measure Type

52. At Risk Population Coronary Artery

DiseaseCoronary Artery Disease (CAD)Composite: All or Nothing Scoring

Oral Antiplatelet Therapy Prescribedfor Patients with CAD

Drug Therapy for Lowering LDL-Cholesterol

Beta-Blocker Therapy for CADPatients with Prior Myocardial

Infarction (MI)

LDL Level


27/31

CMS-1345-P 191


Number, Measure

Steward


Measure Type


DiseaseCoronary Artery Disease (CAD): DrugTherapy for Lowering LDL-

Cholesterol


older with a diagnosis of CAD who wereprescribed a lipid-lowering therapy

(based on current ACC/AHA guidelines).

The LDL-C treatment goal is


28/31

CMS-1345-P 192


Number, Measure

Steward


Measure Type


DiseaseCoronary Artery Disease (CAD):Angiotensin-Converting Enzyme

(ACE) Inhibitor or Angiotensin

Receptor Blocker (ARB) Therapy forPatients with CAD and Diabetes and/or

Left Ventricular Systolic Dysfunction(LVSD)


older with a diagnosis of CAD who also

have diabetes mellitus and/or LVSD

(LVEF < 40%) who were prescribed ACE

inhibitor or ARB therapy.

Physician Quality

Reporting System

Measure #118

NQF #66

Group Practice

Reporting

Option (GPRO)

Data Collection

Tool

Process

58. At Risk Population Hypertension Hypertension (HTN): Blood Pressure

Control

Percentage of patients with last BP

analysis on acos

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