mafp quality reporting for cash-cms incentives and your bottom line

Publication MO-11-20-PRThis material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents

presented do not necessarily reflect CMS policy

Quality Reporting for Cash: CMS Incentives and Your Bottom Line

Sandra PogonesProgram Manager, Physician Services

Primaris – Columbia, MO

November 2011

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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.

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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 Answer

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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 Change

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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 practices

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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 three

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Impact on the Bottom Line

Program Incentives Penalties

EHR-Medicare

EHR Medicare HPSA-Bonus

EHR-Medicaid

2011-2015: $44,000 Total ($18,000 Year 1)

2011-2015: +10%

2011-2021: $63,750 Total ($21, 250 Year 1)

2015: -1.0%2016: -2.0%2017: -3.0%2018: -4.0%2019: -5.0%

PQRS 2011: +1.0%2012-2014: +0.5%

2015: -1.5%2016+: -2.0%

E-Prescribe 2011-2012: +1.0%2013: +0.5%

2012: -1.0% 2013: -1.5%2014: -2.0%

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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 practice

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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)

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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 for public reporting

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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 measures

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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

healthcare

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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 possible

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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%

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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 care

1 test

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 Core3 Menu

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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 preventive/follow-up care

20%

Provide patients with timely (4 business days) electronic access to health information

10%

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 test

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Stage 2 & 3: Significant Proposed Changes

STAGE 2 (Delay until 2014?)Raise the threshold for many

objectives

Add 1 lab or radiology order to CPOE requirements (no transmission needed)

Add new CQMs

Improve performance using CDS

Move current menu items to core

EPs to record advance directives (currently only hosp)

Add Electronic Notes to documentation

Ability of pt to view and download visit within 24 hours

20% of patients must use portal/PHR

Online secure patient messaging

List of care team members available to pt

Submit immunization and syndromic data

STAGE 3Raise threshold again

Reconcile lab results with lab orders

Manage high priority conditions with lists

Electronic self-management tools offered

EHR can exchange data with PHRs

Patients. Report experience with care measures online

Online access to education in primary language

Bidirectional connection with external providers or HIE

Longitudinal Care Plan for high-priority pts

Submit patient-generated data to public health

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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 providers

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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 only

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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 2011

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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 year

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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.

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Physician Compare Website

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2011 Crosswalk for Quality MeasuresEHR PQRS measure

Description Meaningful Use CQM

#110 Patients 50+ who received flu vaccine Alt. Core

#111 Patients 65+ who have ever received a pneumococcal Vaccine

Menu

#112 Women 40-69 who had a mammogram within 24 months

Menu

#113 Patients 50-75 appropriately screened for colorectal cancer

Menu

#226 Patients 18+ screened for tobacco use w/in 24 months and received cessation counseling

Core

#237 Patients 18+ with hypertension and BP recorded

Core

In 2012 Quality Measures will be aligned for both programs

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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 period

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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 denominatorPerformance 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/Purchasing

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NCQA Accreditation Benchmarks and Percentiles--2011 (IA, MO, NE,

KS)

Measure for Medicare Patients

90th Percentile Nat’l Benchmark

YourScore

Breast Cancer Screening

84% ?

Colorectal Cancer Screening

69% ?

Advising Smokers to Quit

88% ?

Flu Shots 83% ?

Pneumococcal Vaccination

82% ?

Source: 2011 HEDIS Benchmarks and Thresholds: Mid-Year Update

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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 present

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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)

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Workflow (See Attachment 1)

Adult Patient Workflow

Pre-Appt & Check in

•Incoming labs and diagnostic tests populate EHR or entered structurally (Menu #2); sent to provider to review, then to patient 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)

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Workflow (continued)Adult Patient Workflow

Review/ Document•Allergies•Meds•Problems • Labs•Flow Sheet•PMH, FH, SH, Proc, Hosp,

•Nurse records Vitals for patients age 2+ (Core #8, Core CQM #1 and Core CQM #2)•If BMI outside parameters, nurse discusses plan or make note to physician (Core CQM #1) to discuss later in the visit•Nurse send request for clinical information to other providers (Core #14). (Best done prior to the visit by reviewing outstanding orders from CPOE functionality)•Nurse records smoking status for patients age 13+ (Core #9 and Core CQM #3). If smoker, provide cessation counseling (Core CQM #3)•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.

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Workflow (continued)

Adult Patient Workflow

Review/modify nurse notes, Problems, Recent labs•PMH, FH, SH, Proc, Hosp,

•Physician reviews problem list and documents structurally or NKP (Core #3)•Physician reviews recent labs and vitals, PMH, FH, SH •Templates used to record notes with narrative supplement as needed

Provide Care•HPI, ROS, SH, FH, PE

•Templates used to record notes with narrative supplement as needed•Physician orders in-house office testing and treatments using CPOE (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.

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Workflow (continued)MEDICATION•Update•Order•Refill/DC

•Order new meds using CPOE (Core #1). •Check drug-to-drug and drug-to-allergy (Core #2)•Check formulary (Menu #1)•Transmit electronically (Core #4) and/or print

ORDERS•Labs, x-ray, DME, consults

•Use CPOE to order labs, x-rays, other diagnostic tests, and consults ( Future stages Core #1)•Check alerts for preventive, follow-up care, and other quality measures (Core #10 & #11,Menu CQMs and PQRS) and order using CPOE

WRAP-UP•Pt. Education•Pt. Action Steps •Next Visit

•Provide educational materials for patients (Menu #6)•Generate a Clinical Summary and give to patient/send to portal (Core #13)•If patient requests a copy of medical record, notify staff.( Core #12)•Referral and consults scheduled and Summary of Care/CCD is sent electronically (Menu #8)

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Workflow (continued)

SCHEDULED TASKS

•Nightly: Set task to transmit immunization (Menu #9) and 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)

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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)

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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)

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Resources

Primaris: www.primaris.org www.PQRSMO.org

– 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 http://www.cms.gov/PQRS/Downloads/Qualified_EHR_Vendors_for_2011_PQRS_and_eRx_05-03-2011.pdf)

– Earn PQRS Incentives for 2012 (and possibly 2011)

– Assistance with performance improvement methodology

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Resources (continued)

http://www.cms.gov/EHRIncentivePrograms/

http://www.cms.gov/pqrs

http://www.cms.gov/ERXincentive/

https://www.qualitynet.org/portal/server.pt (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.gov

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Resources (continued)

QualityNet Help Desk– http://www.cms.hhs.gov/PQRI/

36_HelpDeskSupport.asp– 7:00 a.m. - 7:00 p.m. CST at 866-288-8912 or

[email protected]

Missouri Health Connection: Statewide Health Information Exchange: missourihealthconnect.org/

Missouri Health Information Technology Assistance Center (MO-HIT):

– Website: ehrhelp.missouri.edu– E-Mail: [email protected]– Phone: 877-882-9933

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Thank You!

Questions? Contact:

– Sandy Pogones

– [email protected]

Your Local Connection to

Achieving National Health Goals

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