1

Going For the Gold

Value-Based Purchasing

Deanna Graham

QI Consultant - Qualis Health

Teresa Cirelli, CPC, CPMA

Idaho Medical Association

May 2016

2

Qualis Health

• A leading national population health

management organization

• The Medicare Quality Innovation Network - Quality

Improvement Organization (QIN-QIO) for

Idaho and Washington

The QIO Program

• One of the largest federal programs dedicated to

improving health quality at the local level

2

3

Today’s Objectives

• By the end of this session you will• Understand the Gold Standard for Medicare Physicians

and EP Quality reporting programs

• Know how to interpret your Value Based Modifier

• Be able to identify ways to use Quality Improvement

methods to improve your value based modifier.

• Go for the Gold!

• Resources

• www.idmed.org - Presentation

• http://hit.qualishealth.org/resources - March 2016 White paper

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/Downloads/Attribution-Fact-

Sheet.pdf - CMS Two Step Attribution Fact Sheet

4

Medicare Gold Standard

• What is the Gold Standard for Medicare

Value Based Purchasing?

Measure Quality of Care/PQRS

Demonstrate Meaningful Use

Provide High Quality and Low Cost Care

3

5

Step 1: Determine Eligibility2016 Eligible Professionals

6

PQRS Value Modifier EHR Incentive Program

Eligible for

Incentive

Subject to Payment

Adjustment

Included in Definitionof “Group”

(1)

Subject to

VM (2)

Eligible for Medicare

Incentive

Eligible for Medicaid

Incentive

Subject to Medicare

Payment Adjustment

Medicare Physicians

Doctor of Medicine X X X X X X X

Doctor of Osteopathy X X X X X X X

Doctor of Podiatric Medicine X X X X X X

Doctor of Optometry X X X X X X

Doctor of Oral Surgery X X X X X X X

Doctor of Dental Medicine X X X X X X X

Doctor of Chiropractic X X X X X X

Practitioners

Physician Assistant X X X X

Nurse Practitioner X X X X

Clinical Nurse Specialist X X X

Certified Registered Nurse Anesthetist) X X X

Certified Nurse Midwife X X X X

Clinical Social Worker X X X

Clinical Psychologist X X X

Registered Dietician X X X

Nutrition Professional X X X

Audiologists X X X

Therapists

Physical Therapist X X X

Occupational Therapist X X X

Qualified Speech-Language Therapist X X X

X

XX

X

6

2016 Incentives and 2018 Payment

Adjustments

4

7

2016 Incentives and 2018 Payment

Adjustments (cont.)

8

Framework for Gold Medal Performance

in Value Based Reimbursement

5

9

PQRS Roadmap to Reporting

1. Determine Eligibility

2. Choose a Reporting Mechanism

3. Select Measures

4. Successfully Report

10

PQRS Success

• PQRS typically requires submission of 9 or

more measures covering at least 3 NQS

domains and cross-cutting measures for

EPs with billable face-to-face encounters.

6

11

Value ModifierQuality-Tiering Methodology

12

Quality-Tiering Approach for 2018 VM

Physicians, PAs, NPs, CNSs, & CRNAs in Groups of

Physicians with 10+ EPs

7

13

Framework for Success in Value

Based Reimbursement

14

The Value of the QRUR

Groups (TINs) can use QRURs and available

drill-down reports through PQRS to:

• Understand performance on cost and

quality measures

• Benchmark your results

• Validate assigned beneficiaries and the

basis for attribution

• Validate correct assignment of EP’s

• Identify beneficiaries in need of greater

care coordination

• Explore provider-specific quality reporting

to pinpoint improvement opportunities

• Raise awareness of cost and quality

concerns

8

15

Overall Performance

High Quality/

Low Cost

Gold Medal Performance = High Quality/Low

Cost Outcomes

16

Impact of Performance on

Reimbursement

AF represents an adjustment factor to ensure the

program remains budget-neutral.

9

17

Overview of Quality Domain

Note: Standardized score calculated as

(Group Score – National Mean)

_________________________

(National Standard Deviation)

All measures are weighted equally within each domain and

all domains are weighted equally within the average domain score

Quality Domain

Number of Quality

Measures Included

in Composite Score

Standardized Performance Score

(Quality Tier Designation)

Quality Composite Score 16 -0.13

Effective Clinical Care 11 -0.80

Person and Caregiver-Centered Experience and Outcomes 0 ---

Community/Population Health 1 -0.13

Patient Safety 1 -0.22

Communication and Care Coordination 3 -0.31

Efficiency and Cost Reduction 0 ---

18

Sample Performance Chart

Measure

Reference Measure Name

Your

TIN’s

Eligible

Cases

Your TIN’s

Performance

Rate Benchmark

Benchmark

-1 Standard

Deviation

Benchmark

+1 Standard

Deviation

Standardized

Score

Included

in

Domain

Score?

111 Preventive Care

and Screening:

Pneumococcal

Vaccination for

Older Adults

774 89.78% 45.42% 14.41% 76.42% 1.43 Yes

- Diabetes Mellitus

(DM): Composite

(All or Nothing

Scoring)

867 55.09% 25.50% 12.96% 37.43% 2.36 Yes

204 Ischemic Vascular

Disease (IVD):

Use of Aspirin or

Another

Antithrombotic

389 58.55% 70.56% 46.12% 95.00% -0.49 Yes

236 Hypertension

(HTN): Controlling

High Blood

Pressure

437 82.43% 73.99% 54.77% 93.22% 0.44 Yes

- Coronary Artery

Disease (CAD):

Composite (All or

Nothing

Screening)

328 43.01% 68.09% 53.61% 82.56% -1.73 Yes

10

19

Required Care Coordination Measures

Performance

Category

Measure

Reference Measure Name

Your

TIN’s

Eligible

Cases

Your TIN’s

Performance

Rate Benchmark

Benchmark

-1 Standard

Deviation

Benchmark

+1

Standard

Deviation

Standardized

Score

Included

in

Domain

Score?

Hospitalization

Rate per 1,000

Beneficiaries

for Ambulatory

Care-Sensitive

Conditions

CMS-1Acute Conditions

Composite8,076 7.00 7.53 1.81 13.24 0.09 Yes

-

Bacterial

Pneumonia8,076 1.02 11.20 1.76 20.63 --- No

Urinary Tract

Infection8,076 9.37 7.25 0.00 15.08 --- No

Dehydration 8,076 10.62 4.10 0.00 8.58 --- No

CMS-2Chronic Conditions

Composite3,495 40.73 50.43 26.19 74.66 0.40 Yes

-

Diabetes

(composite of 4

indicators)

2,465 2.48 18.07 0.00 38.07 --- No

Chronic Obstructive

Pulmonary Disease

(COPD) or Asthma

947 36.87 70.23 25.43 115.03 --- No

Heart Failure 1,206 136.94 99.75 48.72 150.77 --- No

Hospital

ReadmissionsCMS-3

All-Cause Hospital

Readmissions1,597 16.45% 15.94% 14.55% 17.34% -0.37 Yes

Supplemental Exhibits offer additional patient-level detail on

these measures and can be used to identify potential quality

improvement opportunities.

20

Framework for Success in Value

Based Reimbursement

11

21

Scenario: HTN Report

22

Scenario

• New hypertension report shows this

team only has 45% of their

hypertensive patients in control

• How can they make this rate

improve?

12

2323

Plan

DoStudy

Act

Model for ImprovementWhat are we

trying to accomplish?

How will we know that a change is

an improvement?

What change can we make that will result in improvement?

24

What are we trying to accomplish?

Developing an Aim

• State the aim clearly

• Use numerical goals

• State the time frame and site of the work

Example: “By December 31, 2016, 80% of hypertensive patients will have their blood

pressure in control.”

13

25

SMART Aim Statements:

• Specific - Is the statement precise about what the team hopes to achieve?

• Measureable - Are the objectives measureable? Will you know if the changes resulted in improvement?

• Achievable - Is this doable in the time you have? Are you attempting too much? Could you do more?

• Realistic - Do you have the resources needed (people, support, time, $$$ ?)

• Timely - Do you identify the timeline for the project - when will you accomplish each part?

26

Form a TeamStep 1

14

27

Check report validity prior

to releasing to care teams

for action.

• Sample chart reviews

• Complementary reports

• Pilot release to a single

care team

Report

Validate

Release

Validate Quality Reports

Step 2

28

Types of Reporting Errors

• Patients ARE in your report but should not be AND

• Patients included in the report for whom the information in the report is incorrect

Inclusion Errors

• Patients ARE NOT in your report but should be

Exclusion Errors

15

29

Model for ImprovementStep

3

What are we trying to

accomplish?

Aim statement: 80% of our hypertensive patients will have their last BP under control

by December 31, 2016

How will we know that

Change is an Improvement?

Within three months, we will see a significant improvement in the number of patients with a HTN diagnosis that have

their last BP under control.

What changes can result in an improvement?

Initiate morning huddles, standardize workflows, train team on appropriate BP

measurement and documentation, initiate motivational interviews, follow up visits and

phone calls ………..

30

PDSA

•MAs complete self management tool with HTN patients

• Run chart of week’s progress

• Train MAs on self management

• Weekly team meeting: adopt, adapt, abandon?

Act Plan

DoStudy

16

31

Track Progress, Update Reports as Necessary

Step 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Rat

e

Dr. Great's HTN Control

Rate Median Goal

b. Start f/u calls on progress

a. Start self-management

32

Summary of Steps for Quality

Improvement

Track progress, update reports as necessary

Act on reports with Model for Improvement

Validate quality reports

Form a team

17

33

34

New and Exciting Information

ICD-9

Medicare Access and CHIP

Reauthorization Act (MACRA)

18

35

Increase Quality With

ICD-10-CM Coding

• Code all conditions treated or considered in

current encounter

• Code to the highest specificity

• Use unspecified or unknown as last resort

• New ICD-10 codes = continuing clinical

documentation improvements

• CMS edit changes coming October 2016

36

MACRA

• Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)

• Ended Sustainable Growth Rate (SGR)

• Established new reimbursement methodology

• Combines current quality reporting into new system

• MACRA payment reforms• Merit-Based Incentive Payment System (MIPS)

• Alternative Payment Models (APMs)• Accountable Care Organizations (ACOs)

• Patient Centered Medical Homes

• Bundled payment models

19

37

Merit-Based Incentive Payment System

(MIPS)• What is MIPS?

• Annual measurements starting in CY2017

• Four performance categories

• Score can significantly change Medicare reimbursement each year

• Combines parts of PQRS, VM and Medicare EHR reporting programs into one program

• Quality

• Resource use

• Clinical practice improvement

• Meaningful use of certified EHR technology

38

20

39

Merit-Based Incentive Payment System

(MIPS)

• Payment year determined two years after

performance year• Performance year – Payment year

2017 2019

2018 2020

2019 2021

Components of the MIPS Score

MIPS (0-100 points) Effective January 1, 2019

Advance Care/

Meaningful Use

(25%)

Quality

PQRS/VM

(50%)

Cost/

Resource Use

(10%)

Clinical Practice

Improvement

(15%)

40

MIPS Resources

• CMShttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/Value-Based-Programs/MACRA-

MIPS-and-APMs/Quality-Payment-Program.html

• Quality Payment Program Fact Sheethttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/Value-Based-Programs/MACRA-

MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf

• Small Practiceshttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/Value-Based-Programs/MACRA-

MIPS-and-APMs/Small-Practices-Fact-Sheet.pdf

21

41

Summary• Achieve low cost, high quality

results to take home the gold.

• Work throughout the year to get the

best results.• Report

• Review

• Improve

• Value Based Purchasing Programs

are changing, but not going away.

42

Q & A

22

43

For more information: www.Medicare.QualisHealth.org

This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho

and Washington, 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. ID-D1-QH-2299-04-16

Contact

Deanna GrahamQuality Improvement Consultant

deannag@qualishealth.org(206)-383-5951

44

(208) 344-7888 www.idmed.org

Idaho Medical Association

Contacts

Teresa Cirelli, CPC, CPMAteresa@idmed.org

Kim Burgen, CPCkim@idmed.org

23

45

Attributed Beneficiaries

46

Fewer Benes Than You Were Expecting?

Beneficiaries may be attributed elsewhere if:• Bulk of primary care services in your TIN provided by NPs or PAs

• CMS does not have accurate provider/specialty information for TIN

• Primary care services are not accurately coded and billed

Beneficiaries are not attributed to any medical group if:• They were enrolled in only Part A or only Part B for any portion of the

year

• They were enrolled in Part C for any portion of the year

• They resided outside the United States for any portion of the year

• They had no allowable Medicare charges for primary care services for

the year

Supplemental Exhibits list both the providers in your TIN and

the patients assigned to your TIN. It is important to validate

the accuracy of these lists in case CMS made a mistake.