Understanding Your QRUR

Meghan Donohue and Mary FranzenQualis Health

Dec. 9, 2015

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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

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Housekeeping Items

• Please chat questions to “All Participants.” We will be answering questions as we go and at the end of the presentation.

• If you have downloaded your QRUR, you might want to refer to it during the presentation.

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Save the DatePublic Health Reporting for Meaningful Use in WA:

How to Meet 2015 RequirementsJanuary 12, 2016

12 – 1 pm PTRegister here

Speakers to include:

Travis Kushner, MPAPublic Health Data Exchange Program Coordinator,Office of the State Health Officer

Topics will include:

• Technical requirements to submit MU Objective 10: Public Health Reporting, including immunization registry reporting, syndromic surveillance reporting, and specialized registry reporting.

• Process for submitting data in WA and options available to EPs in 2015.

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Save the DateIt’s not too late!

Options for 2015 PQRS ReportingJanuary 26, 2016

11:30-12:30 PT / 12:30-1:30 MTRegister here

Speakers to include:

Kelley Carnwath, MPH, CPHITQuality Improvement PrincipalQualis Health

Mary Franzen, MPHQuality Improvement Consultant Qualis Health

Topics will include:

• 2015 PQRS reporting requirements• The financial risks and rewards of PQRS

participation• Submission options for individual and group

PQRS reporting• The future direction of value-based Medicare

payments

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PANELISTS

Today’s SpeakersMODERATOR

Kelley Carnwath, MPH, CPHITQuality Improvement PrincipalQualis Healthkelleyc@qualishealth.org

Meghan DonohueClinical Outcomes AnalystQualis Healthmeghand@qualishealth.org

Mary Franzen, MPHQuality Improvement ConsultantQualis Healthmaryf@qualishealth.org

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Objectives

By the end of today’s presentation, you will be able to:

• Better understand the Value Modifier program

• Interpret data in your QRUR• Identify opportunities for quality

improvement

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MACRA

MIPS

PQRS

VM

MU

APM

ACO

SHIP

MACRA, MIPS, and Modifiers…Oh My!

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Who is subject to the Value Modifier?

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Say Hello to Group X

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Say Hello to Group X’s QRUR

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Why should Group X look at their QRUR?

Groups can use QRURs and available drill-down reports through PQRS to:

• Verify EPs were correctly assigned to group’s TIN

• Compare their performance to others nationwide

• Validate the assigned beneficiaries and the basis for attribution

• Understand which beneficiaries are driving performance on cost and quality measures

• Identify beneficiaries in need of greater care coordination

• Explore provider-specific quality reporting to pinpoint improvement opportunities

• Raise awareness of cost and quality concerns

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Overall Performance

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Impact of Performance on Reimbursement

AF represents an adjustment factor to ensure the program remains budget-neutral.

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Attributed Beneficiaries

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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.

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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 ---

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Sample Performance ChartMeasure

Reference Measure Name

Your TIN’s

Eligible Cases

Your TIN’s Performance

Rate Benchmark

Benchmark -1 Standard Deviation

Benchmark +1 Standard

DeviationStandardized

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

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Required Care Coordination MeasuresPerformance

CategoryMeasure

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-1 Acute Conditions Composite 8,076 7.00 7.53 1.81 13.24 0.09 Yes

-

Bacterial Pneumonia 8,076 1.02 11.20 1.76 20.63 --- No

Urinary Tract Infection 8,076 9.37 7.25 0.00 15.08 --- No

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

CMS-2 Chronic Conditions Composite 3,495 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 Readmissions CMS-3 All-Cause Hospital

Readmissions 1,597 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.

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Two Hospitalization

Measures

Hospitalizations for benes attributed through claims quality and per capita cost measures

Hospitalizations for benes attributed through Medicare Spending per Beneficiary

measure

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Cost Measures: All Practices

All measures are risk-adjusted using beneficiary HCC scores, price standardized to remove geographic variation in labor costs, and specialty-adjusted based on group composition.

Measure Definition Attribution Methodology

Domain One

Medicare Spending per Beneficiary

Total Part A and Part B Costs for 3 days before, during, and 30 days after inpatient episode

TINs providing the most Part B inpatient services as measured through allowable charges

Per Capita Costs All Part A and Part B Costs

1. Primary care physicians providing the most primary care services

2. Non-primary care physicians providing the most primary care services

Domain Two

Per Capita Costs for Beneficiaries with Specific Conditions

Same as above; only includes individuals with COPD, CAD, HF, Diabetes (Four Separate Measures)

Same as above

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Overview of Cost Domain

Note: Standardized score calculated as

(Group Score – National Mean)_________________________(National Standard Deviation)

Cost DomainNumber of Cost

Measures Included in Composite Score

Standardized Performance Score (Cost Tier Designation)

Cost Composite Score 6 -0.28 (Average)

Per Capita Costs for All Attributed Beneficiaries 2 0.54

Per Capita Costs for Beneficiaries with Specific Conditions 4 -0.85

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Sample Cost TableCost

DomainCost

Measures

Your TIN’s Eligible

Cases or Episodes

Your TIN’s Per Capita

or Per Episode Costs

BenchmarkBenchmark -1 Standard Deviation

Benchmark +1 Standard

DeviationStandardized

Score

Included in

Domain Score?

Per Capita Costs for All Attributed Beneficiaries

Per Capita Costs for All Attributed Beneficiaries

8,076 $9,998 $10,907 $8,066 $13,749 -0.32 Yes

Medicare Spending per Beneficiary

1,597 $22,712 $20,475 $18,877 $22,073 1.40 Yes

Per Capita Costs for Beneficiaries with Specific Conditions

Diabetes 2,465 9,329 $15,826 $11,466 $20,185 -1.49 Yes

Chronic Obstructive Pulmonary Disease (COPD

947 $12,760 $24,854 $17,524 $32,185 -1.65 Yes

Coronary Artery Disease (CAD)

932 $15,020 $18,234 $13,132 $23,336 -0.63 Yes

Heart Failure 1,206 $32,836 $28,033 $19,606 $36,460 0.57 Yes

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Framework for Risk-Adjustment

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Overview of HCC Risk Adjustment

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Sample Patient HCC Determination

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Determining Patient Risk Scores

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Expected Costs for Individual PatientsMultipliers are constants for each beneficiary demographic group.

Note: Community risk scores are based on diagnoses from the previous calendar year as shown on the previous slide. New Enrollee Risk Scores are based solely on beneficiary demographic factors such as

age, disability, income, and institutionalization status and used only when there are fewer than 12 months of Part B coverage.

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Aggregating Provider Expected Costs

Dr. Smith had actual costs of approximately $16,000 per patient, but those costs

translated to $4,665 when risk-adjusted

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Cost drill-down: 201Download your Supplemental Exhibits

Rank order attributed beneficiaries by cost. You will notice that about 10% of patients incur about 50% of costs and that 20% of patients incur about 80% of costs.

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Cost drill-down: 201(Continued)Most Expensive 20% Least Expensive 80%

Patient Profile

• Many chronic conditions; likely seeing multiple specialists

• Over age 85 or under age 65

• Significant post-acute needs

• One-two chronic conditions

• Little to no inpatient utilization

Quality Improvement Opportunities

• Improved care coordination and chronic disease management

• Increased hospice referrals

• Decreased use of low-value services such as unnecessary scans

• Same-day appointment access to avoid ED use

What’s Next?

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Review QRUR Before December 16, 2015

• If you have any questions regarding the status of your 2014 PQRS reporting or are concerned about potentially receiving the PQRS negative payment adjustment in 2016, please do not hesitate to submit an informal review request.

• All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) which is available now through December 16, 2015 at 11:59 p.m. Eastern Time. 

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Use the information in your QRUR

• Guide your 2015 PQRS submission• Upcoming Webinar on 2015 PQRS reporting on

Jan. 26, 2016

• Identify areas for improvement

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Sample Performance ChartMeasure

Reference Measure Name

Your TIN’s

Eligible Cases

Your TIN’s Performance

Rate Benchmark

Benchmark -1 Standard Deviation

Benchmark +1 Standard

DeviationStandardized

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

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Sample Performance ChartMeasure

Reference Measure Name

Your TIN’s

Eligible Cases

Your TIN’s Performance

Rate Benchmark

Benchmark -1 Standard Deviation

Benchmark +1 Standard

DeviationStandardized

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

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Areas for Improvement

• Cardiac care and adult immunization• CMS has identified cardiac care and adult

immunization as areas of special focus• Prevent more serious, more costly conditions in the future

• Qualis Health has specific programs for practices to improve in these areas

• 2015 PQRS reporting will require cross-cutting measures• Includes some cardiac and adult immunization measures

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Areas for ImprovementABCS measuresA – Aspirin for IVD PQRS # 204

B – Blood Pressure Control PQRS # 236

C – Cholesterol PQRS # 316

S – Smoking Cessation PQRS # 226

Adult immunization measures

Preventive care and screening: influenza immunization

PQRS # 110

Pneumonia vaccination status in older adults PQRS # 111

Included in cross-cutting measures for 2015 PQRS reporting

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Model for Improvement

• Choose one measure or one area of improvement• Ask three fundamental questions

• What are we trying to accomplish?

• How will we know if that change is an improvement?

• What changes can we make that will result in that improvement?

• Develop an aim statement• State the aim clearly

• Use numerical goals (“75% of our Medicare Part B patients”)

• State the timeframe and site of work (“by Feb. 29 at our downtown clinic”)

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Plan-Do-Study-Act

• Plan – Define your goals and decide what you will do to try to reach them.

• Do – Implement the change on a small scale.

• Study – What did you learn? • Act – Change the plan as

necessary, or adopt, to meet your goals.

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Helpful CMS Resources

2014 QRUR

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2014-QRUR.html

How to Obtain a QRUR

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html

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Q & A

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For survey: https://www.surveymonkey.com/r/SZXRCF8

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/WA-HITC-QH-2047-12-15

ContactKelley Carnwath

Quality Improvement Principalkelleyc@qualishealth.org

206.288.2574

Meghan Donohue Clinical Outcomes Analystmeghand@qualishealth.org

206.288.2440

Mary Franzen Quality Improvement Consultant

maryf@qualishealth.org206.288.2554