Quality, Outcomes and Payment Reform: Primer for Urology

Scott M Gilbert, MD, MS, FACSAssociate Member/Professor

GU Oncology & Health Outcomes and Behavior ProgramsH. Lee Moffitt Cancer Center & Research Institute

@sgilbert1973scott.gilbert@moffitt.org

DisclosuresNone

Objectives/Outline

Objective 1: Briefly review the quality problems and opportunities

Objective 2: Consider examples of variable quality and outcomes in urology

Objective 3: Discuss quality initiatives and policy (payment) reforms

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McGlynn et al. N Engl J Med 2003;348:2635-45Wennberg and Gittelsohn. Science 1973;182:1102-08IOM 1999, 2001

Long-Standing Concerns with Variation in Quality and Outcomes

Procedure Lowest Median Highest

Tonsillectomy 13 43 151

Appendectomy 10 18 32

Hemorrhoidectomy 2 6 10

Hernioplasty 29 41 48

Prostatectomy 11 20 38

Cholecystectomy 17 27 57

Hysterectomy 20 30 60

Mastectomy 12 18 33

Domains of Quality Healthcare

IOM, 2001

Quality Framework

Donabedian A, Milbank Mem Fund Q 1966

Three General Ways to Operationalize Quality Improvement

Policy/Payer strategies (centers of excellence, selective referral to high-volume centers, payment levers)

Professional organization/society strategies (score-card reporting, training, certification/credentialing)

Physician quality collaboratives (quality assessment, training, process exportation)

For Example…Regionalization

Regionalization refers to the creation of an intermediary administrative and governance structure that assumes responsibility for organizing and delivering health care services to a defined population

High volume surgery associated with lower inpatient mortality, shorter LOS, lower complications and better long-term survival

Birkmeyer et al. NEJM 2002;346:1128-37Bach et al. NEJM 2001;345:181-8.

Bhindi B et al. J Urol 2014;192(3):714-20Konety BR et al. J urol 2005;173:1695-1700

Cystectomy Volume and In-patient Mortality

Levers - Regionalization

Levers - Score Cards/Public Reporting

Womble et al. J Urol 2015;194:403

Levers - Quality Collaboratives/Registries

CMS Urology Preferred Specialty Measure Set - 20151. Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

2. Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

3. Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients

4. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

5. Diabetes: Medical Attention for Nephropathy6. Oncology: Cancer Stage Documented7. Patient-Centered Surgical Risk Assessment and Communication

8. Preventive Care and Screening: Unhealthy Alcohol Use – Screening

9. Biopsy Follow-Up

Levers - Policy Interventions/Initiatives

Levers - Payment Reform

Changes associated with SRG Repeal in 2015

MACRA: Medicare Access and Children’s Health Insurance Program Reauthorization Act

Stable payment updates from 2016-2019 (0.5%) with payment restructure in 2019

2019 Base Update of

0.5%

Option 1: Merit Based

Incentive Payment System(MIPS)

Option 2:Alternative Payment Models (APM)

Maintains Fee-for-ServiceFour Categories in the Composite Performance Score (CPS):

1. Quality (replaces PQRS) (60%)2. Resource Use (replaces Value-Based Payment Modifier)

(0%)3. Advancing Care Information (replaces EHR Incentive

Program) (25%)• “Meaningful Use”

4. Clinical Practice Improvement Activities (New Category) (15%)

PARTICIPATION IN A REGISTRY WILL HELP WITH ALL OF THESE REQUIREMENTS

Option 1 – Merit-Based Incentive Payment System (MIPS)

MIPS Component 1:Quality Reporting (PQRS) (60%)

Claims reporting (G codes)– Going away

Direct reporting via an EHR– Limited number of measures

Qualified clinical data registry (QCDR)– Must report on 6 measures, including one outcome measure

• These can include approved specialty-specific measures (!)– Provides feedback/ comparisons– Results publically reported by CMS– AQUA is a QCDR as of June 2015

MIPS Component 2:Resource Use (0%)

Uses Quality (PQRS) data– Only those who have participated in PQRS are eligible

Assigns quality and cost– In the past no measures were pertinent to urology (or many other

specialties)– But the list of measures is expanding

Payments adjusted accordingly

MIPS Component 3:Advancing Care Information

(Meaningful Use) (25%)

1. Patient Health Information2. Clinical Decision Support3. Computerized Provider Order

Entry4. E-Prescribing5. Health Information Exchange

6. Patient Specific Education7. Medication Reconciliation8. Patient Electronic Access9. Secure Messaging10. Public Health

Objectives

Specialized Registry

MIPS Component 4:Clinical Practice Improvement Activities (15%)

Expanded practice accessPopulation management

– Participation in a QCDRCare coordinationPatient safety and practice assessment

QCDR & Clinical Practice Improvement Activities

Nonparticipation

• 2019 - Bonus up to 4% or down to 4% (Budget neutral)

• Bonus/penalty increases 5% in 2020, 7% in 2021 and 9% in 2022 and thereafter

Accountable care organization, bundled payment, etc– Details to be provided

Must assume ‘substantial’ financial risk– Not quantified yet

Must include substantial number of patients– 25% of total Medicare reimbursement (to start)

5% bonus per year– Increased professional fee payments in 2026

Option 2 – Alternative Payment Models

Affiliations to reach minimum ‘population’ requirements and to maintain market shareFocus on primary care measures, EMR features, access, etc.

Value Based Payment Modifier 2015

Quality Urologic Care

Launched in 2014 to help urologists with quality assessment and reportingCollect detailed national process and outcomes data for patients with urologic diseasesPrimary goal: quality assessment and improvement through local feedback to practicesSecondary goals: fuel next-generation HSR and clinical / outcomes research; inform urology policy efforts

Key principles• Software (FIGMD) to minimize data entry burden;

includes text search and NLP

• Data owned by individual practices, maintained by AUA.

• Practice-level data shared only with the individual practice, benchmarked against the aggregate data. No practice sees any other individual practice’s data.

• Incorporate patient-reported outcomes (PROs)

The AUA Quality (AQUA) Registry

• Data automatically extracted from EMR systems• Structured data (labs, medications, etc.) are identified,

and text documents (notes, reports) are scanned for additional data

• Prostate cancer was the major initial area of focus• But copy of entire chart is uploaded so relatively easy to

expand to other conditions

2017 Status

447 urology practices have signed up, representing 2798 providers47 states and territories representedTop 3 states: FL 48 practices, TX 45 practices and CA 43 practices

Data available for analysis from 91 practices, which includes 961 providers and 2.48M patients> 29,000 new prostate cancer patients from the first 36 practices 2014-16

AQUA Measures- 40 Total -

PQRS– 18 measures

Non-PQRS prostate cancer measures– 10 measures

Non-prostate cancer measures (n=12)– 2016 => BPH, cryptorchidism, T replacement, PNB complications– 2017 => stress urinary incontinence, urinary stones, non-muscle

invasive bladder cancer

AQUA Dashboard

Thank you!