Aligning Quality Reporting for

Eligible Professionals HealthInsight New Mexico

Renee G. Sussman, RN, MSN, MA Director, Health Information Technology

1

Overview

• 2015 Medicare Quality Reporting Programs

• Alignment of Quality Reporting Programs

• Implementing Programs

• HealthInsight New Mexico

2

Payment Adjustments

Value Based Payment Modifier

CQ

M

MU Attestation

PQRS Reporting

Incentive $$ & Payment

Adjustments

PQRS Physician Quality Reporting System

Measures Goals

Tracking Education Feedback

2015 Medicare Quality Reporting Programs

• Medicare EHR Incentive Program (Meaningful Use)

• Physician Quality Reporting System (PQRS)

• Value-based Payment Modifier (VM)

• Medicare Shared Savings Program

• Accountable Care Organizations

4

Patient Protection and Affordable Care Act (ACA)

of 2010 • Emphasized role of quality improvement

and measurement for health IT

• Proposed health IT as a tool

– Improve patient safety

– Reduce medical errors

– Ensure patient-centered care delivery

5

National Quality Strategy

• The National Strategy for Quality Improvement in Health Care or NQS

• Established by the Affordable Care Act

• Serves as a nationwide effort to improve health and health care

• Provide an opportunity to align quality measures and quality improvement activities

6

National Quality Strategy (Continued)

• Three Aims

– Better Care

– Healthy People/Healthy Communities

– Affordable Care

• Provide performance feedback to practitioners to improve care

7

Use license agreement April 8, 2015, valid for one year, hipaacartoons.com

8

EHR Incentive Program (Meaningful Use)

• 2009: American Recovery and Reinvestment Act (ARRA) stimulus funds

• The Health Information Technology for Economic and Clinical Health (HITECH) Act (2011)

– CMS EHR Incentive Program

– Provided financial incentives to eligible professionals/hospitals/critical access hospitals to attain “meaningful use” of certified EHR

9

HITECH: Catalyst for Transformation

10

Paper Records

HITECH Act EHRs and HIE HITECH Act

Pre-2009 2009 2015

Communication Barriers; Lack of

Information Sharing

Paper Records

EHR Incentive Program Widespread adoption and meaningful use of

EHRs

Adoption of EHRs in New Mexico

0%

10%

20%

30%

40%

50%

60%

2011 2012 2013

NM

National

11

Payment Adjustments

Value Based Payment Modifier

CQ

M

MU Attestation

PQRS Reporting

Incentive $$ & Payment

Adjustments

PQRS Physician Quality Reporting System

Measures Goals

Tracking Education Feedback

EHR Incentive Program (Meaningful Use)

• A building block to improving clinical quality which is measurable over time

• Includes:

– Menu and Core Set Measures

– Clinical Quality Measures (CQMs)

13

Clinical Quality Measures

• CMS linking payment to value

• Measure and track the quality of health care services provided

• Use data to drive:

– Better Health, Better Health Care, Lower Costs

14

Payment Adjustments

Value Based Payment Modifier

CQ

M

MU Attestation

PQRS Reporting

Incentive $$ & Payment

Adjustments

PQRS Physician Quality Reporting System

Measures Goals

Tracking Education Feedback

Physician Quality Reporting System (PQRS)

• Federally mandated Medicare Part B reporting program

• Medicare Improvements for Patients and Providers Act of 2010

– Made the program permanent

– Authorized incentive payments through 2010

• 2013 PFS Final Rule sets forth current requirements

16

PQRS (continued)

• Promotes reporting of quality information

• Intended to measure quality of care and provide feedback reports

• Applies negative payment adjustment for eligible professionals who do not satisfactorily report

17

Clinical Quality Measures and PQRS Domains

• National Quality Strategy Domains

• Measure aspects of patient care:

– Effective Clinical Care

– Communication and Care Coordination

– Patient Safety

– Efficient Use of Health Care Resources

– Population and Public Health

– Patient and Family Engagement

18

Payment Adjustments

Value Based Payment Modifier

CQ

M

MU Attestation

PQRS Reporting

Incentive $$ & Payment

Adjustments

PQRS Physician Quality Reporting System

Measures Goals

Tracking Education Feedback

VM Program

• Social Security Act required CMS to establish a Value Modifier that provides differential payment for quality

– January 1, 2015: CMS began applying this modifier to physician payments

– Upward, downward or neutral adjustment (Medicare Physician Fee Schedule, Part B)

20

VM Program (continued)

• Payment Adjustments

– 2015: groups of 100 or more EPs

– 2016: groups of 10 or more

– 2017: solo practices and two or more

• Data reported to PQRS is used to calculate the VM (2015 to avoid in 2017)

• Participate in the PQRS program every year to avoid a negative payment adjustment

21

Value-Based Payment Modifier

Measure Alignment

• Measure once, use often

– CQM component of the Medicare EHR Incentive Program

– PQRS

– Value-Based Payment Modifier

– Million Hearts™ Initiative

– Option to use the same set of measures to report

24

Measure Example

• Diabetes: Hemoglobin A1C Poor Control

– CMS (MU) #122v3, NQF 0059, PQRS 001

– Codes:

• CPT Encounter : 99211

• CPT II: 3046F (Most recent hemoglobin A1c level greater than 9.0%, Performance Met, )

• ICD- 9/10: 250.XX/E10.XXX-E13.XXX

– Domain: Effective Clinical Care

– Cross-cutting measure

26

Measure Example

• Controlling High Blood Pressure

– CMS (MU) #165v3, NQF 0018, PQRS 236

– Codes:

• CPT Encounter : 99211

• CPT: G8752 (Most recent systolic blood pressure < 140 mmHg)

• ICD- 9/10: 401.X/I10 (DX: Hypertension)

– Domain: Effective Clinical Care

– Cross-cutting measure

27

Measure Example

• Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention:

– CMS (MU) #138v3, NQF 0028, PQRS 226

– Codes:

• CPT Encounter: 99212

• CPT II: 1036F (screened/non-user)

• ICD- 9/10: N/A

– Domain: Community/Population Health

– Cross-cutting measure

28

Implementing Quality Reporting

• Selecting the right measures

• Combine efforts from both programs into one quality improvement project

• Documentation

• Understand what data elements are used to calculate a measure.

29

Measures Goals

Tracking Education Feedback

30

CQ

M

MU Attestation

PQRS Reporting

Incentive $$ & Payment

Adjustments

Measures Goals

Tracking Education Feedback

Payment Adjustments

Value Based Payment Modifier

PQRS Physician Quality Reporting System

HealthInsight New Mexico

• Serving New Mexico since 1971

• Quality improvement leader for 30 years

• NM HITREC

• HealthInsight is CMS Quality Innovation Network Quality Improvement Organization (QIN-QIO), serving NM, NV, OR and UT

– Leading health care quality improvement initiatives for a five-year period (2014-2019)

31

HealthInsight QIN-QIO

• Aim: Healthy People, Healthy Communities: Improving the Health Status of Communities

• Tasks

– Improving cardiac health and reducing cardiac health care disparities

– Reducing disparities in diabetes care

– Improving prevention coordination through meaningful use of HIT

32

HealthInsight QIN-QIO

• Aim: Better Healthcare for Communities: Beneficiary-Centered, Reliable, Accessible and Safe Care

• Tasks

– Reducing Disparities in Reducing Healthcare-Associated Infections

– Reducing Healthcare-Acquired Conditions in Nursing Homes

33

HealthInsight QIN-QIO

• Aim: Promote Effective Communication and Coordination of Care

• Task

– Coordination of Care

• Aim: Make Care More Affordable

• Tasks

– QI through Physician Value-Based Modifier and the PQRS Reporting Program

34

HealthInsight New Mexico

• Supports:

– Medical Practices

– Hospitals, CAHs, Rural Hospitals

– Surgery Centers

– Home Health Providers

– Stakeholders

– Medicare Consumers and their Families

– Public Agencies

35

What HealthInsight New Mexico Does

• Provides technical assistance and education

– Local support

– Using EHRs meaningfully to improve quality

– Navigating and meeting CMS program requirements

– Assist with alignment of programs

– Webinars, newsletters, networking

36

HealthInsight New Mexico

• Variety of federal and state contracts and grants

– CMS

– New Mexico Department of Health

– New Mexico External Quality Review (EQRO)

• Project management expertise

• Staff: analytics, communications, medical coding; clinical and quality improvement professionals

37

Questions?

Thank You!

Resources • EHR Incentive Programs:

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

• Clinical Quality Measure Basics: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html

• PQRS: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

• VM Program: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/index.html

Contacts

Renee Sussman: 505.314.9015

rsussman@healthinsight.org

Danielle Pickett: 505.998.9768

dpickett@healthinsight.org

www.healthinsight.org

This material was prepared by HealthInsight, the Medicare Quality Innovation Network Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, 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. 11SOW-B4-15-05-NM