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NCHIMA 66th Annual Meeting
Transforming Health Care Through the Use of
Information TechnologyAndrew Kurecki, BSN, RN
EHR Application Specialist Community Care of Western North Carolina
Objectives
• Describe Population Management
• Review federal reporting programs:– MU
– PQRS
• Introduce new programs:– MIPS
– MACRA
• Review two case studies that show how the use of registries directly impacts the health of the patients that are served by your organization
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Metrics Measures
Outcomes Standards
PerformanceResource
Use
History of Health Care in America
• Fee for Service Model
• Patients only see physicians when sick
• Doctor visits incident to illness or injury
• Re‐active more than pro‐active
• Data was used mostly for documenting encounters, reporting revenue, reporting provider productivity, and safety statistics
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Population Health Management
• Moves care from Volume‐Based (Episodic Care) to Value‐Based (Continuous care)
• Focus on the entire patient population to support health:
1. It provides additional support to patients with chronic conditions
2. It improves access to care through patient portals, extended hours, and different type of encounters
3. Proactively reach out to patients in need of services
4. Coordinate patient care between primary care providers and specialists, urgent care centers, hospitals, and pharmacies
The Institute of Health Improvement’s
Triple Aim Initiative
SafeEffective
Patient CenteredEfficientTimely
Equitable
Alphabet Soup of Reporting Data
ACA PQRS
MU VBM
APM MSSP
PCMH PCSP
QRUR ACO
NC HIE MIPS
MACRA VBPM
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Physician Quality Reporting System ‐PQRS 2016
• 281 measures in the PQRS measure set
• 3 new measures groups: Multiple Chronic Conditions; Cardiovascular Prevention (Million Hearts); and Diabetic Retinopathy
• Qualified Clinical Data Registry (QCDR) reporting option for groups
• 2018 PQRS payment adjustment is the last adjustment that will be issued under PQRS
• Starting in 2019, adjustments to payment for quality reporting will be made under the new Merit‐Based Incentive Payment System (MIPS)
PQRS Reporting Through Claims
• Requirement is to report 9 measures covering at least 3 National Quality Strategy (NQS) domains
• Patient Safety
• Person and Caregiver‐Centered Experience and Outcomes
• Communication and Care Coordination
• Effective Clinical Care
• Community/Population Health
• Efficiency and Cost Reduction
Meaningful Use – The 5 Pillars
1. Improve Quality, Safety, efficiency and reduce health disparities
2. Engage patients and families in their health
3. Improve population and public health
4. Improve care coordination
5. Ensure privacy and security of Personal Health Information (PHI)
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Meaningful Use (MU)
• Meaningful Use Stage 1 (July 2010)
‐ Data capture and sharing
• Meaningful Use Stage 2 (August 2012)‐ Advanced Clinical Processes (HIE, eRx, Lab and Image reporting)
• Meaningful Use Stage 2 –Modified (October 2015)
‐ Includes 10 final objectives
• Meaningful Use Stage 3 (being finalized now)
‐ Aligns with National health care objectives
‐ Focus on Triple Aim = reduced cost, improved access, improved quality
‐ Promote interoperability and health information exchange
On April 16, 2015 the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law1
1 Medicare Access and CHIP Reauthorization Act, HR2, 114th Congress.
sunsets at the end of 2018
sunsets at the end of 2018
Medicare Access & CHIP Reauthorization Act of 2015
(MACRA)
• It repeals the Sustainable Growth Rate (SGR) Formula
What does MACRA do?
• It changes the way that Medicare rewards cliniciansfor value over volume
• It streamlines multiple quality programs under the new Merit‐Based Incentive Payments System (MIPS) and
• It provides bonus payments for participation in eligible Alternative Payment Models (APMs)
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Start with your QRUR Report
• QRUR indicates how you will fare under Medicare's Value‐Based Payment Modifier (VBPM) program
• High Quality and Cost Scores = BONUS!
• Low Quality and Cost Scores = PENALTIES!
• That is, IN ADDITION to PQRS and MU penalties of up to 9%!
• Solo physicians and groups with fewer than 10 providers will be subject to the VBPM starting in 2017 based on their 2015 performance data
Value Based Practice Modifiers (VBPMs)
• VBPM: A budget‐neutral program created under the Affordable Care Act that increases OR decreases Medicare payments based on physician’s cost and quality scores as compared to the national average.
• The quality and cost data contained in the 2014 Annual QRURs are used to calculate the 2016 Value Modifier.
• CY 2015 is the performance period for the Value Modifier that will be applied in 2017
1. Alternative Payment Models (APMs)
2. Merit Based Incentive Program (MIPS)
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Alternative Payment Models
• Medicare Shared Savings Programs (MSSP) ‐ Accountable Care Organizations(ACOs)
• Those participating in various Capability Maturity Model Integration (CMMI) demonstrations ‐ like the Bundled Payment for Care
Improvement Initiative.
• APM participants aren’t subject to MIPS requirements
Merit‐based Incentive Payment System (MIPS)
• Beginning in 2019, MIPS consolidates Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value Based Modifier (VBPM) into one program
A single MIPS composite performance score will factor inperformance in 4 weighted performance categories:
MIPSComposite
PerformanceScore
Quality Resource use
Meaningful
use of certified EHR technology
Clinical practice
improvement activities*such as(PCMH)
21
These data are reported publicly at https://www.medicare.gov/physiciancompare
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How Much Can MIPS adjust payments
• Based on the MIPS composite performance score, physicians and practitioners will receive positive, negative, or neutral adjustments up to percentages below.
MAXIMUM AdjustmentsAdjustmentto provider ’sbase rate of
Medicare Part B payment
Merit‐Based Incentive Payment System (MIPS)22
4% 5%7%
9%
‐4% ‐5%‐7%
‐9%
2019 2020 2021 2022 onward
MIPS Scoring
Physicians will be assessed, and receive payment adjustments, based on a composite score (1‐100) based on:
Clinical Performance Improvement
• A professional who is in a practice that is a “certified” Patient Centered Medical Home (PCMH) will be given the highest score for the Clinical Practice Improvement (CPI) portion of the MIPS score (15 points)
• American Association of Family Physicians (AAFP) is advocating for functionality, not necessarily certification.
• The National Committee of Quality Assurance’s (NCQA’s) PCMH & PCSP recognized practices are eligible for full CPI credit
1. Access2. Planned care3. Risk stratified care
management
4. Patient engagement5. Care coordination6. Quality Improvement Efforts
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Preparing for MIPS in 2016• Obtain a copy of the QRUR for your organization from CMS
‐ Identifies current state of quality and resource use.
• Meet 2016 deadlines for reporting to CMS
• Optimize MU and PQRS/VBM Quality efforts‐ 75% of 2017 MIPS score
• Decide which options your organization will chose to earn Clinical Practice Improvement Points such as PCMH/PCSP recognition.‐ This counts for 15% of 2017 MIPS score
• Develop and implement best practices. Share data with your organization’s stakeholders so they can act to improve scores
2016 is a rehearsal year for at least 75% of MIPS
Payment Reform is Here
In this new world of reimbursement based on quality, not quantity,
Data is King!Accurate data is crucial for reimbursement and regulatory compliance with CMS and all other
payors.
It is also the key to improving the health of our communities.
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The Value of Data
• Higher reimbursement rates for high performing practices based on reports
• Higher Medicare reimbursement under the MIPS and MACRA programs
– Changing the way that Medicare rewards practices which focus on Value over Volume
Using the EHR to Measure Quality
• Using the Reporting Modules in the EHR:
— Canned Reports ‐ provided by vendor forMeaningful Use (MU) reporting and/or PQRS reporting
— Building Custom Reports to provide meaningful data• Consider population to be reported on• Population who have received Service: Numerator• Total population eligible for service: Denominator
— Building Registries for patients that are DUE for a service• Generating a list of patients who have not received service or need additional support for outreach will improve
performance.
Data Thinking
Steps to make your data useful:1. Ask the Question– as you build your reports,
• Focus on specific questions that you are trying to answer. Don’t try to boil the ocean.
2. Define your structure – getting it to “apples to apples” so you can do the math• How is the data currently formatted and what challenges will this create?
3. Analysis of the data – determining what really matters• What methods are best suited to arrive at answers that users can trust?
4. Involvement of key stakeholders– putting data to use: right place, time, people, presentation• Who will share the results and how will they be used?
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Sharing Data with your Practice Providers, Shareholders and Staff
• To provide meaningful information of real value, it must be:
‐ Accessible‐ Accurate‐ Timely‐ Complete‐ Cost‐effective
‐ Flexible‐ Relevant‐ Simple‐ Verifiable
Using the EHR to Measure Quality
Here are some clinical examples:
– Mammograms
– Colorectal screenings
– Pneumonia vaccines
– Flu Vaccines during the flu season
– Patients with intervascular disease with no lipid panel in the past year
– Diabetic patients not seen in 6 months
IT Specialists are from Mars
Clinicians are from Venus
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Women over 50 who have not received a mammogram
Baseline
A family practice with a 34% overall compliance rate for screening women for Cancer.
Data set for Women over 50 without a Mammogram in the past 5 years
Run Chart for This Example
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
Percentage
of patien
ts
2015‐2016
Patients over 50 who have received a mammogram in past 5 years
Practice
Provider 1
Provider 2
Provider 3
Goal =80%
Source: Patient EHR
RegistryRegistry
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Children screenings for Autism
Baseline:
A pediatric practice with a 62% overall compliance rate for screening children for Autism.
Using the EHR to Measure Quality as a SpreadsheetPercentage of Developmental Screens
by Provider per MonthJan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15
Numerator 77 82 130 155 173 173 176 174 171 148 167
Denominator 124 129 187 194 197 202 206 201 198 177 198
Practice 62.1% 63.6% 69.5% 79.9% 87.8% 85.6% 85.4% 86.6% 86.4% 83.6% 84.3%
Numerator 21 26 54 68 70 71 72 73 72 71 70
Denominator 29 35 75 75 77 79 78 79 77 77 77
Provider 1 72.4% 74.3% 72.0% 90.7% 90.9% 89.9% 92.3% 92.4% 93.5% 92.2% 90.9%
Numerator 4 3 4 4 4 4 4 4 6 5 4
Denominator 6 5 5 5 5 5 5 5 8 6 5
Provider 2 66.7% 60.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 75.0% 83.3% 80.0%
Numerator 18 17 23 23 29 29 29 27 27 27 27
Denominator 28 27 36 34 33 34 37 33 33 34 33
Provider 3 64.3% 63.0% 63.9% 67.6% 87.9% 85.3% 78.4% 81.8% 81.8% 79.4% 81.8%
Numerator 5 5 10 11 13 12 12 13 13 12 11
Denominator 9 8 14 16 17 18 18 20 20 20 19
Provider 4 55.6% 62.5% 71.4% 68.8% 76.5% 66.7% 66.7% 65.0% 65.0% 60.0% 57.9%
Numerator 18 19 24 33 37 35 37 35 32 33 33
Denominator 27 28 31 38 42 43 45 41 38 40 42
Provider 5 66.7% 67.9% 77.4% 86.8% 88.1% 81.4% 82.2% 85.4% 84.2% 82.5% 78.6%
Numerator 11 12 15 16 20 22 22 22 21 22 22
Denominator 25 26 26 26 23 23 23 23 22 22 22
Provider 6 44.0% 46.2% 57.7% 61.5% 87.0% 95.7% 95.7% 95.7% 95.5% 100.0% 100.0%
Hedis Goal: 91% 91.0% 91.0% 91.0% 91.0% 91.0% 91.0% 91.0% 91.0% 91.0% 91.0% 91.0%
Using the EHR to Measure Quality as a Graph
RegistryRegistry
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Share Data With your Practice and Patients
Reporting is required for
NCQA programs such
as Patient Centered
Medical Home (PCMH) and
Patient Centered Specialty Practices (PCSP)
Data is CRUCIAL to the success in this new world of health care reimbursement…
…and Data are the and
!
Resources
For more information about QRUR, Quality‐tiering and Value Modifiers:
‐ http://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/PhysicianFeedbackProgram/2014‐QRUR.html
For more information about PQRS:
‐ https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/PQRS/index.html?redirect=/PQRS/
For more information about Meaningful Use (MU):
‐ http://www.hrsa.gov/healthit/meaningfuluse/MU%20Stage1%20CQM/whatis.html
For more information about MACRA/MIPS:
‐ https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/Value‐Based‐Programs/MACRA‐MIPS‐and‐APMs/MACRA‐MIPS‐and‐APMs.html