An Integrated Approach to Quality Improvement Action and Reporting May 20, 2015 Tracy Swoboda, RHIA, CCS TMF Quality Innovation Network
An Integrated Approach to Quality Improvement Action and Reporting
May 20, 2015Tracy Swoboda, RHIA, CCS
TMF Quality Innovation Network
About the TMF QIN-QIOTMF Health Quality Institute has partnered with the Arkansas Foundation for Medical Care, Primaris in Missouri and the Quality Improvement Professional Organization, Inc. in Puerto Rico to form the TMF Quality Innovation Network Quality Improvement Organization (TMF QIN-QIO), under contract with the Centers for Medicare & Medicaid Services (CMS). The TMF QIN-QIO works with providers across all care settings to provide quality improvement services in the states of Arkansas, Missouri, Oklahoma and Texas, and the territory of Puerto Rico.
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TMF QIN-QIO Websitehttp://www.tmfqin.org Provides targeted technical assistance and engages
providers and stakeholders in improvement initiatives through numerous Learning and Action Networks (LANs).
The networks serve as information hubs to monitor data, engage relevant organizations, facilitate learning and sharing of best practices, reduce disparities and elevate the voice of the patient.
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All Are Welcome To join, create a free account at
http://www.tmfqin.org/. Visit the Networks tab for more information.
As you complete registration, follow the prompts to choose the network(s) you would like to join.
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Why Participate in Quality Programs? Improve quality care by assessing the quality of care
provided to patients Ensure patients get the right care at the right time Avoid negative payment adjustments Transparency
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Three Categories of CMS Programs Pay-for-Reporting – Provider incentives to
report information Pay-for-Performance – Provider incentives to
achieve targeted threshold or clinical performance
Pay-for-Value – Incentives linked to both quality and efficiency improvements
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Physician Quality Reporting System (PQRS)
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PQRS: Eligibility RequirementsMedicare eligible providers (EPs) using billing method II or reassigning benefits to critical access hospitals (CAHs)
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2015 Reporting Options
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Selecting Measures Consider clinical conditions commonly treated and care delivered (e.g., preventive, chronic, acute) Settings where care is delivered (e.g., office,
emergency department, surgical suite) Quality improvement goals for 2015 Other quality reporting programs in use or
consideredSee 2015 measures specifications documents: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
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National Quality Strategy DomainsPriorities for health care quality improvement
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2015 Cross-Cutting Measures Requirement – NEWEPs or group practices are required to report one cross-cutting measure: For at least one Medicare patient with a face-to-face
encounter Claims and Registry reporting Individual measures
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PQRS Payment AdjustmentsEPs are identified by their individual National Provider Identifier and Tax Identification Number (TIN)
› Payment adjustments are applied to the TIN
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PQRS Program Year PQRS Payment Adjustment Period
Negative Adjustment Rate
2013 2015 -1.5%
2014 2016 -2.0%
2015 2017 -2.0%
Value-Based Payment Modifier (VBM)
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What is value modifier?
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• New per-claim adjustment• Medicare fee-for-service
provider • Applied to EPs in group at
TIN
• Differential payment• Based on quality of care• Based on cost of care
Aligned with and based on participation in PQRS
• Applies only to assignment-related services
• No impact on beneficiary cost-sharing
2015-2017 Applies to Physician Payment OnlyPhysicians include: MD/DO Doctor of dental surgery or dental medicine Doctor of podiatric medicine Doctor of optometry Chiropractor
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VBM in 2015-2017Three-year phase-in process in applying the value modifier (based on PQRS performance) 2015: physicians in groups of 100+ EPs
(based on 2013 PQRS performance)
2016: physicians in groups of 10-99 EPs (based on 2014 PQRS performance)
2017: physicians in groups of 2-9 EPs (based on 2015 PQRS performance)
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VBM in 2015
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VBM in 2015, cont.
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VBM in 2015, cont.
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VBM in 2015, cont.
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Quality Tier Methodology
22MSPB: Medicare Spending Per Beneficiary
Quality Tier Approach for 2017Based on 2015 PQRS performance: Two composite scores based on the standardized
performance (e.g., how far away from the national mean)› Quality of care› Cost of care
Adjusted for specialty Identifies statistically significant outliers and assigns
them to their respective cost and quality tiers
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Quality Tier Approach for 2017, cont.
Cost/Quality Low Quality Average Quality
High Quality
Low Cost +0.0% +1.0x* +2.0xAverage Cost +0.0% +0.0% +1.0xHigh Cost +0.0% -0.0% +0.0%
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* Eligible for an additional +1.0x if reporting PQRS quality measures and average beneficiary risk score in the top 25 percent of all beneficiary risk scores.
“x” represents the upward VM payment adjustment factor.
Quality and Resource Use Reports (QRURs)Annual reports that provide physicians with: Comparative information about the quality of care
furnished, and the cost of that care, to their Medicare fee-for-service patients
Beneficiary-specific information to help coordinate and improve the quality and efficiency of care furnished
Information on how the provider group would fare under the VBM
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VBM in 2018 Mandatory for all physicians and non-physician EPs (based on 2016 PQRS performance)
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Prepare Participate in PQRS
› Group (requires registration) › Individual
Choose meaningful measures consistent with service delivery or strategic plans.
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Electronic Health Record (EHR)Meaningful Use
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Meaningful Use“Providers need to show they’re using certified EHR technology in ways that can be measured significantly in quality and in quantity.”
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013PQRS_MedicareEHR-IncentPilot_PMBR_041813.pdf
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Requirements Must have a 2014 certified EHR system Must have a patient portal After 2014, each reporting period is a full year
› Unless reporting for the first time Clinical Quality Measure (CQMs) have been removed
as a core objective
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Stages of Meaningful Use and Goals
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Stage 1 Meaningful Use Requirements
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Stage 1 Changes Optional alternate measure added
for computerized physician order entry (CPOE)
Blood pressure age limit changed to 3 years and older
Online access
Eligible Hospitals and CAHs 11 core objectives
Five of 10 menu objectives
16 total objectives
Stage 2 Meaningful Use RequirementsEligible Hospitals and CAHs 16 core objectives Three of six menu objectives 19 total objectives
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Stage 2 Changes Added laboratory and radiology
orders to CPOE Online access Automatically track medications
from order to administration All stage 1 menu objectives moved
to Core objectives Increases in required measures CDS increased to five interventions Stage 1 objectives combined with
other stage 2 objectives New menu objectives
Stage 2 Required for ‘Summary of Care at Transition’Newly Defined Common Meaningful Use Data Set Patient name Sex Date of birth Race Ethnicity Preferred language Smoking status Problems Medications Medication allergies Laboratory test(s) Laboratory value(s)/result(s) Vital signs (height, weight, BP, BMI) Care plan field(s) Procedures Care team members 34
Other Details Required in Summary of Care Encounter diagnoses Immunizations Cognitive status Functional status Ambulatory setting only Reason for referral and referring or
transitioning provider’s name with office contact information
Inpatient setting only Discharge instructions
Stage 2 Electronic ExchangeStage 2 focuses on actual cases of electronic information exchange:
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Data Elements for Eligible Hospitals and CAHs: ‘View, Download and Transmit’
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Stage 2: Conduct Security Risk Analysis Address encryption/security of data stored Implement updates necessary during the
reporting period Identify and correct deficiencies
http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/
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Stage 2 eCQMs
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CMS’s commitment to alignment eCQMs used in multiple quality reporting programs
Select eCQMs that cover at least three of the six domains, 64 eCQMs for EPs to select nine eCQMs, 29 eCQMs for EHs to select 16 eCQMs
Other programs include Hospital Inpatient Quality Reporting
Physician Quality
Reporting System
Children’s Health
Insurance Program
Reauthorization Act
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Stage 3 Meaningful Use Requirements
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Stage 3 of the CMS EHR Incentive Program is scheduled to begin in 2017, but the rule has not been finalized.
Proposing a set of 8 objectives with associated measures:
Protect Patient Health Information Patient Electronic Access to Health Information
Electronic Prescribing (eRx) Coordination of Care through Patient Engagement
Clinical Decision Support (CDS) Health Information Exchange (HIE)
Computerized Order Entry (CPOE) Public Health and Clinical Data Registry Reporting
Improving Medicare Beneficiary Immunization Rates for Influenza, Pneumococcal and Herpes Zoster
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Immunization Task Order ObjectivesImprove: Tracking Assessment and Documentation Reporting Special focus on reducing immunization health
care disparities
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TMF Quality Innovation Network
TexasArkansas
MissouriPuerto Rico
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Oklahoma
Influenza and Pneumonia: Eighth Leading Cause of Death
CDC/NCHS, National Vital Statistics System, Mortality
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Death from Pneumonia
53,282
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Death from In-fluenza
65 years and older
Less than 65 years
90%
Retrieved from: http://www.lung.org/assets/documents/publications/lung-disease-data/adult-vaccination-disparities.pdf45
Pneumoc-cocal
Influenza0
102030405060708090
100
Percentage of Medicare Bene-ficiaries Vaccinated
Percentage of Medicare Benefi-ciaries Vaccinated
54%60%
Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, P-J., O’Halloran, A., Bridges, C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults – United States, 2012. Morbidity and Mortality Weekly Report, 63(5), 95-102
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1 Million cases
Varicella / Shingles
100% effective Herpes Zoster
Vaccine
20% Vaccinated
Herpes Zoster
Retrieved from :http://www.cdc.gov/vaccines/vpd-vac/varicella/rationale-vacc.htm47
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Zoster
Influenza
Pneumococcal
0 10 20 30 40 50 60 70 80 90 100
WhiteAsianBlackHispanic
64 %
41 %
46 .%
71 %
43 .%
56 %
55 %
34 %
23 %
17 %
9 %
9 %
Medicare Immunization Rates by Type, Race and Ethnicity
Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, P-J., O’Halloran, A., Bridges, C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults – United States, 2012. Morbidity and Mortality Weekly Report, 63(5), 95-102
2019 Goals Alignment with the Healthy People 2020 Goals
› National Absolute Immunization Rates • 70 percent influenza • 90 percent pneumonia• 30 percent zoster
One million previously unimmunized Medicare beneficiaries will receive pneumonia immunization
90 percent adult immunizations will be reported to the registry
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Technical Assistance Provide evidence-based practices Share interventions and techniques to
increase community demand Promote “Screening Tool” on admissions and
discharge to improve documentation and communication
Identify or develop educational tools and resources.
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Proposed Annual Impact 61,000 Medicare beneficiaries Pneumonia vaccination: 5,850 Influenza vaccination: 52,950 Herpes Zoster vaccination: 2,200
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Performance ImprovementCycle for success: Education and engagement – PLAN Implementation – DO Measure selection and reporting – STUDY/CHECK Incentive or payment adjustment – ACT
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Questions?
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LANs
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Join any of the following TMFQIN.org networks and you can sign up to receive email notifications to stay current on announcements, emerging content, events and discussions in the online forums. Cardiovascular Health
and Million Hearts Health for Life –
Everyone with Diabetes Counts Healthcare-Associated Infections Meaningful Use Medication Safety
Nursing Home Quality Improvement
Patient and Family Quality Improvement Initiative Readmissions Value-Based Improvement
and Outcomes
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TMF QIN-QIO ContactsTMF QIN-QIO Project DirectorTracy Swoboda, RHIA, [email protected]
TMF QIN-QIO Program Specialist IIIDebbie Edson, BSN, [email protected]
Oklahoma State DirectorGayla Middlestead, BSN, [email protected]
Arkansas State DirectorJulia Kettlewell, MPH, BSN, [email protected]
Missouri State DirectorDeborah Finley, MPH, LNHA, [email protected]
Puerto Rico Program DirectorGiovanna Fox, MPH, [email protected], ext. 200
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Resources 2015 CMS PQRS Implementation Guide –
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf
CMS Incentive Programs – David S. Nilasena, MD, MSPH, MS, Chief Medical Officer, Region VI
Meaningful Use for Hospitals – Sharon Rose, RN, MAM, BSOE, CHTS-CP, West Texas HITREC, Texas Tech University Health Sciences Center
Quality Net Help Desk 1-866-288-8912 from 7:00 AM -7:00 PM CST
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This material was prepared by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-QINQIO-D1-15-26