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, CCStracy.swoboda@area-B.hcqis.org361-258-1053

TMF QIN-QIO Program Specialist IIIDebbie Edson, BSN, RNdebbie.edson@area-B.hcqis.org512-750-8754

Oklahoma State DirectorGayla Middlestead, BSN, RNgayla.middlestead@area-B.hcqis.org405-315-7981

Arkansas State DirectorJulia Kettlewell, MPH, BSN, RNPJkettlewell@afmc.org501-212-8740

Missouri State DirectorDeborah Finley, MPH, LNHA, CPHQdfinley@primaris.org573-817-8300

Puerto Rico Program DirectorGiovanna Fox, MPH, BSgfox@qipro.org787-641-1240, 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