Publication MO-11-20-PR This 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 Pogones Program Manager, Physician Services Primaris – Columbia, MO November 2011
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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
Slide 2 of 42 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 3 of 42 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 Answer
Slide 4 of 42 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 Change
Slide 5 of 42
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
Slide 6 of 42 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 three
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
Slide 17 of 42
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
Slide 18 of 42 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 providers
Slide 19 of 42 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 only
Slide 20 of 42 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 2011
Slide 21 of 42 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 year
Slide 22 of 42 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 23 of 42 23
Physician Compare Website
Slide 24 of 42 24
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
Slide 25 of 42 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 period
Slide 26 of 42 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 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
Slide 27 of 42 27
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
Slide 28 of 42 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 present
Slide 29 of 42 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 30 of 42 30
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)
•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.
•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.
•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
•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)
Slide 34 of 42 34
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)
Slide 35 of 42 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
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 37 of 42 37
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
Slide 38 of 42 38
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
Slide 39 of 42 39
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