The alphabet soup of clinical quality measures reporting and reimbursement 2018 updates

Data Repository Experts Since 1998
Alphabet Soup of Clinical Quality
Measures Reporting and Reimbursement
Bill Presley, Vice President,
Jodi Frei, Director of Quality
May 29, 2018

Introductions
o Jodi Frei, Director of Quality, PT, MSMIIT, Northwestern Medical Center
o William Presley, Vice President , Acmeware

Elite Sport & Health Care Reform
o Elite Sport
◦ Demonstrates great teamwork & perfected skills
◦ On the outside looks fluent & effortless
◦ But requires solid & intentional understanding of the basics:
◦ Blocking & Tackling:
◦ Understanding of Quality programs, their requirements and methodologies
◦ Passing & Running:
◦ Embracing the importance of regional measures, tactics, and performance
◦ But when to pass and when to run?
◦ Agility
◦ Ability to respond swiftly & effectively to a ever changing environment
◦ Powerful Offense with strong, reliable Defense

The Playbook
o Football is a sport with its own unique vocabulary that most
any layman would have a hard time deciphering upon first
glance. Take a whole bunch of those words and put them in
random places in diagrams of actual plays, and in essence,
you have an NFL playbook.
◦ Business Insider
◦ In this presentation
◦ We offer to you…
◦ A playbook of Health Care Reform

Agenda
o Background
o Quality Payment Reporting Initiatives
o Clinical Quality Measure Alignment
o Compare and Contrast Reporting Requirements
o Proposed Programs
o Helpful Resources

To Kick Things Off: Acronyms!
ACA - Affordable Care Act IPFQR - Inpatient Psychiatric Facilities Quality Reporting
APM - Alternative Payment Model IPPS - Inpatient Payment Prospective System
ARRA - American Recovery and Reinvestment Act IQR - Inpatient Quality Reporting
ASCQR - Ambulatory Surgical Center Quality Reporting MACRA - Medicare Access and CHIP Reauthorization Act
CEHRT - Certified Electronic Health Record Technology MIPS - Merit-based Incentive Payment System
CMS - Centers for Medicare and Medicaid Services MU - Meaningful Use EHR Incentive Program
eCQM - Electronic Clinical Quality Measures NHSN - National Healthcare Safety Network
HAC - Hospital Acquired Conditions
OPPS - Outpatient Prospective Payment System
HAI - Healthcare-Associated Infection
OQR - Outpatient Quality Reporting
HCAHPS - Hospital Consumer Assessment of Healthcare Providers and Systems
PCCEC - Patient and Caregiver-Centered Experience of care/Care Coordination
HRRP - Hospital Readmission Reduction Program
PCHQR - PPS-Exempt Cancer Hospital Quality Reporting
IA - Improvement Activities
PI - Promoting Interoperability
IACS - Individuals Authorized Access to the CMS Computer Services
QPP - Quality Payment Program
VBP - Value-Based Purchasing

Why Is Clinical Quality Reporting Important?
o Backbone of health care reform
o Cost of care is not sustainable
o Highest costs are associated with sickest populations
o Care is being deferred related to out of pocket costs
o Moving healthcare in a different direction
◦ Transition to Value Based Care

CMS Guiding Principles
Improve Quality, Outcomes and Experience
Incentivize evidence based care through “value
based payments” and transparency of outcomes
Reduce Cost
Actively purchase value (based on health outcomes),
not passively purchasing on volume of services
Improve Population Health
Expand coverage, effectively prevent and treat
chronic disease and engage people in their own care

Vision for Quality Reporting
Meaningful Measures:
Framework begun in 2017
o High Impact
o Safeguard the public
o Meaningful to Patients & Providers
o Aligned across payors and programs
o Reduce reporting burden
https://www.youtube.com/watch?v=M8eI7EWhwF0

Meaningful Measures Framework
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/MMF-Handout-2.pdf

Meaningful Measures Next Steps
o Get stakeholder input to further improve
the Meaningful Measures framework
o Work across CMS components to
implement the framework
o Evaluate current measure sets and inform
measure development

Health Care Culture Change
Past Future
Process Measures Outcomes
Cost Value
Fee-For-Service Capitated
Unit Approach Systems Approach
Silos Matrix
Reactive Innovative
Individual Team
Budget Quality
Provider-Focused Member-Focused
http://www.dhcs.ca.gov/services/Documents/ADAQualityStrategyWebinar8-22-12.pdf

Quality Payment Programs
Hospital Quality
•Promoting
Interoperability
•PPS-Exempt Cancer
Hospitals
•Inpatient Psychiatric
Facilities
•Inpatient Quality
Reporting
•HAC Payment Reduction
Program
•Readmission Reduction
Program
•Outpatient Quality
Reporting
•Ambulatory Surgical
Centers
Physician Quality
•Promoting
Interoperability
•Merit-based Incentive
Payment System
•Maintenance of
Certification
Post-Acute Care
•Inpatient Rehabilitation
Facility
•Nursing Home
•LTCH Quality Reporting
•Hospice Quality
Reporting
•Home Health Quality
Reporting
Payment Model
•Medicare Shared
Savings Program
•Hospital Value-Based
Purchasing
•Advanced Alternate
Payment Model
•Physician Feedback
•ESRD QIP
•Innovations Pilots
Population
Quality
•Medicaid Adult Quality
Reporting
•CHIPRA Quality
Reporting
•Health Insurance
Exchange Quality
Reporting
•Medicare Part C
•Medicare Part D
http://www.cms.gov/eHealth/downloads/eHealthU_PQRSQualityManagement101.pdf
= Public Reporting Focus for Hospitals/ CAHs/ Eligible Clinicians

Quality Payment Program Alignment
Value Based Care
ORYX
MU EH
IQR
MIPS
APMs
PI EP
PQRS
IQR/MU EH
IQR/ORYX/
PI EH
PQRS/
PI EP

Quality Reporting Direction
The Future - One Specification
Core Measures (Chart
Abstraction)
•Manual Chart Abstracted
•Paper-based specifications
•Translated to CMS Specification
Manual
Clinical Quality Measure
(eCQM)
•Electronically Captured
•Measure Concepts
•Electronic Codification
•Electronic Specification
•eCQM Library (One Spec)

Human vs Machine
Patient Care
documented
Capture
Manual
chart review
by
abstraction
and coding
Interpret
Manual
interpreted
results
calculated
Calculate
Manual Abstraction Process

Human vs Machine
Patient Care
documented
Capture
Data codified
and coding
reviewed
Codify
Electronically
calculate and
report
Calculate
Electronic Measure Process

Electronic Measures vs Manual Abstraction
Specifications Manual
The Specifications Manual for National Hospital
Inpatient Quality Measures
Uniform set of national hospital quality measures
Paper tools for use in abstracting data for each
collection (discharge) period are provided with the
Specifications Manual
eCQM Library
Electronically specified versions of traditionally
chart-abstracted Clinical Quality Measures
Developed specifically so Certified Electronic
Health Record Technology (CEHRT) can capture,
calculate, export, and transmit the measure data
For eReporting of eCQMs to demonstrate
meaningful use or for Quality Reporting
Programs
Data Collection Period Specifications Manual
07/01/18 - 12/31/18 Version 5.4
01/01/18 - 06/30/18 Version 5.3a
01/01/17 - 12/31/17 Version 5.2b
07/01/16 - 12/31/16 Version 5.1
Reporting Year eCQM Specifications
2018 May 2017 Update
2015 April 2014 Update

Hospital Quality Reporting Reductions
IQR EHR MU VBP HAC HRRP
0.25% MBU 0.75% MBU 2.00% DRG 1.0% DRG 3.00% DRG
MBU = Market Basket Update
DRG = Diagnosis-related group

Hospital Quality Reporting Reductions
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
2013 2014 2015 2016 2017 2018 2019
IQR EHR VBP HAC HRRP

Physician Quality Reporting Reductions

IQR
INPATIENT QUALITY REPORTING

IQR Purpose
o Provide hospital transparency about quality and safety
o Provide consumers (us) with quality of care information to make better
decisions
o Publish on CMS Hospital Compare website
o Resulting in improved quality of inpatient care to all patients
o Provides incentives to report quality of care measures

IQR Background
o Medicare Modernization Prescription Drug, Improvement and Modernization
Act (MMA) of 2003
◦ Non-submission would result in a 0.4 % reduction in APU
o Deficit Reduction Act of 2005
◦ Non-submission would result in a 2.0 % reduction in APU
o CMS issued the 2014 Inpatient Prospective Payment System (IPPS) final rules to
align IQR with eCQM.
o CMS issued the 2016 Inpatient Prospective Payment System (IPPS) mandating
eCQM for IQR program.

IQR Penalties
o Social Security Act, starting in FY 2015, penalized hospitals that fail to submit
quality information.
25% MBU 75% MBU 2.00% DRG 1.0% DRG 3.00% DRG

IQR Requirements
o Create CMS Portal and QualityNet Administrator Accounts
o Complete the Hospital IQR Program Notice of Participation
o Collect and report data:
◦ Clinical data
◦ HCAHPS data
◦ HAI measures reported through NHSN
◦ eCQM Submission
◦ Structural measures
◦ Data Accuracy and Completeness Acknowledgement
o Meet validation requirements
o Quality data published to Hospital Compare (not eCQMs)

IQR Resources
CMS Enterprise Portal
https://portal.cms.gov
Hospital Compare
www.medicare.gov/hospitalcompare
Quality Reporting Center
http://www.qualityreportingcenter.com
QualityNet
www.qualitynet.org

Promoting Interoperability Purpose
o Previously known as “Meaningful Use”, provides Medicare
and Medicaid incentive payments to qualifying physicians
and hospitals, when they adopt and use Certified
Electronic Health Record Technology (CEHRT)
o CEHRT adoption promotes:
◦ Improve quality, safety, efficiency, and reduce health disparities
◦ Engage patients and their families
◦ Improve care coordination
◦ Ensure adequate privacy and security protections for personal
health information
◦ Improve population and public health

EHR Incentive Program Background
o The American Recovery and Reinvestment Act (ARRA) established in 2009, a
framework of financial incentives to stimulate growth and improve the health
care system.
o CMS published Meaningful Use CEHRT regulations in:
◦ Stage 1 Final Rule published July 2010
◦ http://www.gpo.gov/fdsys/pkg/FR-2010-07-28/pdf/2010-17207.pdf
◦ Stage 2 Final Rule published September 2012
◦ http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html
◦ Stage 3 Final Rule published October 2015
◦ https://www.federalregister.gov/articles/2015/10/16/2015-25595/medicare-and-medicaid-programs-electronic-
health-record-incentive-program-stage-3-and-modifications

EHR Incentive Program Penalties
o Payment adjustment amounts are tied to the year hospitals do not
demonstrate meaningful use.
o Payment adjustment is tied to the percentage increase for the Inpatient
Prospective Payment System (IPPS) rate.
o Hospitals that do not meet meaningful use in 2018 will receive a 75% reduced
update.

EHR Incentive Program Requirements
o Utilization of certified EHR technology (CEHRT)
o Value Set Nomenclature Mapping
o Submission of objective measures and electronic clinical quality measures
(eCQM)
o Submission of clinical quality measure data:
◦ Option 1: Aggregate reporting of numerators and denominators in the CMS Registration and
Attestation system
◦ Option 2: Submission of QRDA files to QualityNet

Stage 2 vs Stage 3
2018 REPORTING REQUIREMENTS

Promoting Interoperability (PI) Programs
• Formerly known as EHR Incentive Program (EHs, CAHs, and Medicaid
providers) / Advancing Care Information (MIPS)
• Re-naming of programs “will move the programs beyond the existing
requirements of meaningful use to a new phase of EHR measurement with an
increased focus on interoperability and improving patient access to health
information.”
• In FY 2019 IPPS Proposed Rule, CMS is proposing a new performance-based
scoring methodology for Hospital PI Programs beginning with CY 2019
reporting

Promoting Interoperability Program for EHs and CAHs
o Previously known as Medicare/Medicaid EHR Incentive Program for EHs and
CAHs
o CY 2018 Objective Measure Requirements
• Hospitals have the option of attesting to either Modified Stage 2 or Stage 3
• 2014 Edition CEHRT: Modified Stage 2 Objectives and Measures
• 2015 Edition CEHRT: Stage 3 Objectives and Measures
• Hospitals also have the option to report Stage 2 Objective Measures using 2015 Edition CEHRT
• Reporting period: minimum any continuous 90 days within 2018

Medicare/Dual-Eligible Hospitals Promoting Interoperability: Objective Measures
Modified Stage 2 Objectives & Measures – CY 2018
Objective Measure Name
Threshold
Requirement
Protect Patient
Health Information
Security Risk Analysis Yes/No Attestation
Electronic
Prescribing
e-Prescribing >10%
Health Information
Exchange
Health Information Exchange >10%
Patient Specific
Education
Patient-Specific Education >10%
Medication
Reconciliation
Medication Reconciliation >50%
Patient Electronic
Access
Provide Patient Access >50%
View, Download or Transmit
(VDT)
At least 1 Patient
Public Health
Reporting
Immunization Registry
reporting
Attest to 3 Registries or
claim exclusions
Syndromic Surveillance
Reporting
Specialized Registry Reporting
Electronic Reportable
Laboratory Result Reporting
Stage 3 Objectives & Measures – CY 2018
Objective Measure Name Threshold Requirement
Protect Patient Health
Information
Electronic Prescribing e-Prescribing >25%
Patient Electronic Access
to Health Information
Patient Specific Education >10%
Coordination of Care
through Patient
Engagement
(DVT)
At least 1 patient
Secure Messaging >5%
Patient Generated Health
Data
>5%
Health Information
Exchange
Send a Summary of Care >10%
Request/Accept Summary of
Care
>10%
Clinical Information
Reconciliation
>50%
Public Health and Clinical
Data Registry Reporting
Reporting
Attest to 3 Registries or claim
exclusions
Reporting
Electronic Case Reporting
Public Health Registry
Reporting
Clinical Data Registry
Reporting
For CY 2018 reporting, hospitals have the option to report Modified Stage 2 or Stage 3.
• Medicare Modified Stage 2 Specifications
• Medicare Stage 3 Specifications
must attest to all 3, but
meet the thresholds for at
least 2
least 2

Medicaid Promoting Interoperability: Objective Measures
Modified Stage 2 Objectives & Measures – CY 2018
Information
Clinical Decision Support
(CDS)
Interventions
Five CDS
Drug Interaction and Drug-
Allergy Checks
Yes/No
Computerized Provider
Order Entry (CPOE)
Medication Orders >60%
Laboratory Orders >30%
Radiology Orders >30%
Health Information
Exchange
Health Information Exchange >10%
Patient Specific Education Patient-Specific Education >10%
Medication Reconciliation Medication Reconciliation >50%
Patient Electronic Access
(VDT)
>5%
Public Health Reporting
reporting
exclusions
Reporting
Specialized Registry Reporting
Stage 3 Objectives & Measures – CY 2018
Information
(CDS)
Interventions
Five CDS
Drug Interaction and Drug-
Allergy Checks
Yes/No
Computerized Provider
Order Entry (CPOE)
Medication Orders >60%
Laboratory Orders >60%
Diagnostic Imaging Orders >60%
Patient Electronic Access to
Health Information
Patient Specific Education >35%
Coordination of Care through
Patient Engagement
(DVT)
>5%
Secure Messaging >5%
Patient Generated Health Data >5%
Health Information Exchange
Send a Summary of Care >50%
Request/Accept Summary of
Care
>40%
Clinical Information
Reconciliation
>80%
Public Health and Clinical
Data Registry Reporting
Reporting
exclusions
Reporting
Electronic Case Reporting
Public Health Registry Reporting
Clinical Data Registry Reporting
For CY 2018 reporting, hospitals have the option to report Modified Stage 2 or Stage 3.
• Medicaid Modified Stage 2 Specifications
• Medicaid Stage 3 Specifications
least 2
least 2

2019 IPPS Proposal – eCQM Trend

EHR Incentive Program Penalties

EHR Incentive Program Resources
National Library of Medicine
http://www.nlm.nih.gov/healthit/meaningful_use.html
eCQM Library
http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html
eCQI Resource Center
https://ecqi.healthit.gov

ORYX
THE JOINT COMMISSION
PERFORMANCE MEASURES PROGRAM

ORYX Program Purpose
o The Joint Commission’s ORYX® initiative integrates outcomes and other
performance measurement data into the accreditation process.
o ORYX measurement requirements are intended to support Joint Commission
accredited organizations in their quality improvement efforts.
o ORYX measures are publicly reported on The Joint Commission website at
www.qualitycheck.org.

ORYX Program Background
o Hospitals began reporting core measures nearly 15 years ago as part of hospital
accreditation by the Joint Commission.
o In 1999, the first ORYX data transmitted to the Joint Commission from hospitals
and long term care organizations.
o In 2007, added seven hospital outpatient measures to core measure sets to
satisfy ORYX performance measurement requirements.
o New in 2015, offered Hospitals greater flexibility in meeting ORYX performance
measures with eCQM reporting.

ORYX Program Requirements
o As of 2015, Core measures have been aligned with CMS eCQM Specifications.
o Perinatal care will remain mandatory in 2018 for hospitals with at least 300 live
births per year.
o Approved ORYX Vendor for Chart Abstraction or eCQM.

ORYX Program Resources
The Joint Commission
http://www.jointcommission.org
ORYX Program
http://www.jointcommission.org/facts_about_oryx_for_hospitals/
default.aspx
Pioneers in Quality
https://www.jointcommission.org/topics/pioneers_in_quality.aspx
https://www.jointcommission.org/assets/1/6/Presenter_slides_PI
Q_ORYX_reporting_webinar_Oct_20171.PDF

VBP Program Purpose
o Required by the Affordable Care Act for IPPS hospitals; quality payment
program
o Moving toward rewarding better value, outcomes, and innovations, instead of
volume
o Promote better clinical outcomes for hospital patients
o Improve patient experience of care during hospital stays

VBP Program Background
o Funded by reductions from Diagnosis-Related Group (DRG) payments; Budget
Neutral
o Built on the Hospital Inpatient Quality Reporting (IQR) measure reporting
infrastructure
o Measures collected through the Hospital IQR Program infrastructure
o Reimbursements based on either national benchmarks or internal
improvements

VBP Program Domains and Measures

MORT-30-AMI:
Acute Myocardial Infarction (AMI)
30-Day Mortality Rate
MORT-30-HF:
Heart Failure (HF)
MORT-30-PN:
Pneumonia (PN)
THA/TKA:
Elective Primary Total Hip
Arthroplasty (THA) and/or Total
Knee Arthroplasty (TKA)
Complication Rate

HCAHPS Dimensions:
• Communication with Nurses
• Communication with Doctors
• Responsiveness of Hospital Staff
• Communication about
Medicines
• Cleanliness and Quietness of
Hospital Environment
• Discharge Information
• Overall Rating of Hospital
• Care Transition

PSI-90: Complication/patient safety
for selected indicators (composite)
CLABSI: Central line-associated blood
stream infections
CAUTI: Catheter-associated urinary
tract
infections
SSI: Surgical site infections specific to
abdominal hysterectomy and colon
surgery
MRSA: Methicillin-Resistant
Staphylococcus
aureus Bacteremia
CDI: Clostridium difficile Infection
PC-01: Elective Delivery prior to 39
Completed Weeks of Gestation

MSPB: Medicare
Spending by Beneficiary:
• Claims-Based Measure
• Includes risk-adjusted and
price-standardized
payments for Part A and
Part B services provided
three days prior to hospital
admission through 30 days
after hospital discharge

VBP Scoring Terminology: Benchmark

Value Based Purchasing Scoring
◦ Achievement points: Compared to all hospitals
o Above National Benchmark: 10 Points
o Below National Threshold: 0 Points
o In Between: 1-9 Points
◦ Improvement points: Compared to same hospital baseline
o 0-9; similar methodology to above
◦ Consistency points: HCAHPS
o 0-20 based on hospital’s HCAHPS scores compared to the benchmark and threshold of all
hospitals’ scores
o Scores for all measures generate total performance score
◦ Use greater score, multiple by weight, add totals

Financial Impact
o Total amount of value-based incentive payments must equal the total amount
withheld across all hospitals in the program.
o For FY19 payment (2017 performance): 2% withhold
o Value-based incentive payments = Sum of all hospital’s base-operating
DRG*0.02 (withhold)
o Total amount of incentive payment available in FY 19 = 1.9 Billion

VBP Program Penalties
Reimbursement = Achievement + Improvement

VBP Program Resources
http://www.qualityreportingcenter.com/inpatient/vbp-archived-events
https://www.qualityreportingcenter.com/wp-
content/uploads/2018/04/Inpatient_FY2019_IPPSProposedRule_Slides_vFINAL508.1pdf.pdf
https://www.qualityreportingcenter.com/wp-content/uploads/2018/05/IQR-FY-2020-New-
Facility-Guide_vFinal_5.4.2018.508.pdf
CMS VBP
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-
value-based-purchasing/index.html
QualityNet
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQne
tTier2&cid=1228772039937

HAC
HOSPITAL ACQUIRED CONDITIONS

HAC Program Purpose
o The Affordable Care Act (ACA) established the HAC Reduction Program to
incentivize hospitals to reduce hospital-acquired conditions (HACs)
o Payment adjustments to discharges started in FY 2015
o Payment adjustments for lowest performing quartile
o Improve patient outcomes with quality measurements

HAC Program Background
o Applies to hospitals paid under the Medicare Inpatient Prospective Payment
System (IPPS)
o Program does not affect:
◦ Long-term acute care hospitals
◦ Cancer hospitals
◦ Children’s hospitals
◦ Inpatient rehab facilities
◦ Inpatient psychiatric facilities
◦ Critical access hospitals

IPPS Proposed Rule: IQR/VBP/HAC
o HAC measures included in random audits

HAC Program Penalties
o Reduce hospital payments by 1 percent for hospitals that rank among the
lowest-performing 25 percent.
o All hospitals receive between 1 and 10 points per measure - Higher Score =
Worse Performance
o 1% penalty to any hospital that falls into the bottom 25%

HAC Program Resources
o Quality Reporting Programs
o https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions.html
o https://www.qualityreportingcenter.com/wp-
content/uploads/2018/04/Inpatient_FY2019_IPPSProposedRule_Slides_vFINAL508.1p
df.pdf
o Hospital Compare
o www.medicare.gov/hospitalcompare/HAC-reduction-program.html
o QualityNet HAC Reduction Program
o www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2F
QnetTier2&cid=1228774189166

HRRP
HOSPITAL READMISSIONS
REDUCUTION PROGRAM

HRRP Program Purpose
o The Affordable Care Act (ACA) established the Hospital Readmissions Reduction
Program (HRRP).
o Requires the CMS to adjust payments to hospitals with excess unplanned
readmissions for certain conditions.
o Aims to improve the quality of care by improving communication and care
coordination, while reducing the costs.

HRRP Program Background
o According to CMS, historically about one in five Medicare patients discharged
from a hospital are readmitted within 30 days.
o In 2005, the Medicare Payment Advisory Commission (MedPAC) concluded that
about three-quarters of readmissions within 30 days were preventable.
◦ Estimated at $12 billion in Medicare spending.

HRRP Program Penalties
o Hospitals below national average for any one of the conditions
are subject to a payment adjustment.
o Payment adjustment applies to all Medicare discharges for that
year, not just a hospital’s readmissions.

HRRP Program Resources
QualityNet Program
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic
%2FPage%2FQnetTier2&cid=1228772412458
CMS Acute IPPS
https://www.cms.gov/medicare/medicare-fee-for-service-
payment/acuteinpatientpps/readmissions-reduction-program.html
Quality Reporting Programs
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-
Program.html

OQR
OUTPATIENT QUALITY REPORTING

OQR Program Purpose
o The Hospital Outpatient Quality Reporting (OQR) Program is a quality measure
reporting program implemented by the CMS for outpatient hospital services
o Starting CY 2009, Hospitals report data using standardized measures of care to
receive the full annual update to their Outpatient Prospective Payment System
(OPPS) rate
o Pay for quality data reporting program

OQR Program Background
o CMS publicly reports Hospital OQR data
o OQR Program is modeled after the IQR Program
o OQR Program is a voluntary for outpatient hospital services
o OQR focuses on quality measures that have a high impact and improved quality
and efficiency.
◦ process of care, imaging efficiency patterns, care transitions, ED throughput efficiency, use of
Health Information Technology (HIT) care coordination, patient safety and volume.

OQR Program Requirements
o Measures submitted on QualityNet
o Clinical data submission is accomplished in one of two ways:
◦ CMS Abstraction & Reporting Tool (CART)
◦ Third party vendor
o Hospitals measurements published to Hospital Compare
o CMS is considering a proposal for eCQM submissions

OQR Program Penalties
o Hospitals that meet measure reporting requirements during a calendar year to
receive their full OPPS reimbursements
o Fail to meet these requirements receive a 2% reduction of their APU

OQR Program Resources
Hospital OQR Program
www.qualityreportingcenter.com
http://www.qualityreportingcenter.com/hospitaloqr
OQR Measures
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPag
e%2FQnetTier3&cid=1192804531207
Hospital OQR ListServe
www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic/ListServe/Register

MACRA/MIPS
MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT
MERIT-BASED INCENTIVE PAYMENT SYSTEM

MACRA Background
o Bipartisan legislation signed into law on April 16, 2015
o Repealed Sustainable Growth Rate Formula
o Rewards providers for quality versus quantity
o Combines existing quality programs into one
o Participants: Part B Eligible Professionals

MIPS Background
o Combines components of PQRS, Value Modifier, and MU into one program
o One composite performance score, 0-100 points, determined through 3
weighted categories
o Budget neutral program rewarding quality performance
o 2018 performance impacts 2020 payment

50%
25%
15%
10%
Quality
Replaced the Physician Quality
Reporting System (PQRS)
Promoting Interoperability
Replaces
Advancing Care
Information
Replaced the Medicare
EHR Incentive Program
also known as
Meaningful Use.
Improvement Activities
MIPS Categories: 2018 Weights
Cost

Merit-based Incentive Payment System (MIPS)
Quality
50%
ACI
25%
IA
15%
Cost
10%
Quality:
• Report 6 measures (including one outcome measure) for full year
• 3 point floor for measures scored against a benchmark
• 3 points for measures scored that don’t have a benchmark or don’t meet case minimum
• 1 point for measures that don’t meet data completeness; except if submitted by small practice which will earn
3 points
• Bonus points available for end-to-end reporting and high priority measures
• New policy/scoring for topped out measures
• New improvement scoring measured at the performance category level
Advancing Care Information (ACI):
• Report either 2018 ACI Trans Measures or ACI Measures depending on Edition of CEHRT for minimum 90 days
• Base measures required to receive any points in ACI
• 10% bonus available if you only use 2015 Edition CEHRT
Improvement Activities (IA):
• Finalized more activities and changes to existing activities
• No changes to requirements for small practices, practices in rural areas, HPSAs, and non-patient facing MIPS
eligible clinicians
• Minimum 90 days reporting
Cost:
• 2 measures: Medicare Spend Per Beneficiary (MSPB) and total per capita cost measure
• Administrative claims – no additional reporting
• Performance is compared to other MIPS Eligible Clinicians and groups during the performance period
• Improvement scoring measured at the specific measure level
MIPS Eligibility
• MIPS Eligible Clinician Types – same as 2017
• Low volume threshold – excluded from MIPS
if you or your group has ≤ $90,000 in Part B
allowed charges or ≤ 200 Part B beneficiaries
Additional Bonus
• Complex patients bonus
• Small practice bonus
Performance Threshold: 15 points
Payment Adjustment: +/- 5%; budget neutral
Submission Deadline: March 31, 2019

2018 Eligibility
Billed Medicare over 90K and provided care for over 200
patients
Up from 30k/100 patients in 2017
• QPP MIPS Eligibility Tool
• New APM Tool
• MIPS APMS – What are they? Resource attached
• APM Scoring standard – Different category weights by APM type
• Resource link provided
• Highly recommended that you use these tools!

MIPS Eligibility Across Settings
EC EC EC EC EC
Hospitalist ED Provider Ortho Practice Family Practice
EC
Private Practice
Acute Ambulatory

Eligibility Tool Query Results
o MIPS Eligibility Tool:
o APM Eligibility Tool (same provider):

Other 2018 Changes
o Virtual Groups
o Election by 12/31/17 was required
o Quality Category weight decreased to 50%
o New Quality Measures added including specialty sets
o Quality data completeness criteria increased from 50 to 60%
◦ Asking that quality action is performed 60% of the time
◦ If do not meet data completion criteria, will receive 1 point unless small group in which case
3 points are received.

MIPS Participation Options
Pick Your Pace
Option 1 (Crawl)
Test the System by submitting partial data
(1 Quality Measure OR 1 IA OR Base ACI Measures)
Avoid negative payment adjustment in
2019
Option 2 (Walk)
Participate for Part of the Year (minimum 90 days)
Neutral or small positive payment
adjustment in 2019
Option 3 (Run)
Participate Full Calendar Year
Modest payment adjustment
in 2019

2018 Concessions to Reduce Burden
o Increased low volume threshold
◦ More exempt providers
o Low Performance Threshold
◦ Total Performance Score (0-100)
◦ > 15 Positive Adjustment
◦ At 15 Neutral Adjustment
◦ < 15 Negative Adjustment

Submission
Category
Scoring
Composite
Performance
Score
Calculation
Comparison
to
Performance
Benchmark
Payment
Adjustment
Calculation
and
Application
Total Performance Score

Advanced Payment Models (APMs)
o Regional commitment
◦ High Quality Care
◦ Efficiency without duplication
◦ Unified evidenced based pathways
o MSSPs/Bundled Payments/Capitated Payment Models

ACO Quality Metrics: A VT Example
o OneCareVT.org

MACRA/MIPS Program Resources
o QualityNet PQRS
o https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQ
netTier2&cid=1187820137434
o eCQM Reporting
o http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/PQRS/Electronic-Health-Record-Reporting.html
o CMS Website
o http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/
o QPP:
o https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/MIPS-APMs-in-
the-Quality-Payment-Program.pdf

The Future of Quality Reporting
o 2019 IPPS Proposed Rule
o Addressing social determinants
o Codification
◦ Leverage data
◦ Share data
◦ Analyze and use data
◦ Improve outcomes

FY 19 IPPS Proposed Rule: April 2018 Release
o Goal: To create a parsimonious measure set that focuses on the most critical
quality issues with the least burden for clinicians and providers.
◦ Measure Removals
◦ Proposed to remove 39 measures from the Hospital IQR Program over four fiscal years
◦ Proposed to remove 10 measures from the Hospital VBP Program beginning with the FY
2021 program
◦ No proposals to remove measures from the HAC Reduction Program or HRRP
o Proposed new measure removal factor: The costs associated with a measure
outweigh the benefit of its continued use in the program.

Proposed New IQR Quality Measures
o Claims-Only Hospital-Wide Mortality Measure
o Hybrid Hospital-Wide Mortality Measures with Electronic Health Record Data
o Hospital Harm – Opioid-Related Adverse Events eCQM

Codifying Food Insecurity
“More than 41 million Americans live in food-insecure households, negatively affecting the
health, productivity, and well-being of our nation. According to one estimate, the direct and
indirect health related costs of hunger and food insecurity in the US are more than $160 billion
a year.”
http://childrenshealthwatch.org/wp-content/uploads/An-Overview-of-Coding_2.15.18_final.pdf

Enhanced Oversight and Accountability
o ONC expands role of oversight
o Clinicians required to give access to their EHR for “field inspection”
o Clinicians must attest to cooperating with ONC surveillance and oversight
activities
o No restriction of data sharing and interoperability

Meeting Requirements
of Multiple Programs
IQR, PI, ORYX

2018 Hospital Quality Reporting - Overview
o Inpatient Quality Reporting (IQR)
o Promoting Interoperability for Eligible Hospitals and Critical Access Hospitals
o The Joint Commission ORYX

IQR
o CY 2018 eCQM Reporting Requirements
• Same as CY 2017 eCQM Reporting Requirements
• Report 4 eCQMs for 1 self-selected quarter (Q1, 2, 3 or 4)
• Submission Deadline: February 28, 2019
AMI-8a CAC-3 ED-1 ED-2
EHDI-1a PC-01 PC-05 STK-02
STK-03 STK-05 STK-06 STK-08
STK-10 VTE-1 VTE-2

Promoting Interoperability for Hospitals
o CY 2018 eCQM Reporting Requirements (Medicare/Dual-Eligible)
• Submission Deadline: February 28, 2019
STK-03 STK-05 STK-06 STK-08
STK-10 VTE-1 VTE-2 ED-3*
*ED-3 cannot be submitted for dual IQR/MU submission because it is an outpatient measure

The Joint Commission ORYX
o CY 2018 eCQM Reporting Requirements
• Submission deadline: March 15, 2019
STK-03 STK-05 STK-06
VTE-1 VTE-2

eCQM Reporting Submission
PI EH
Electronic Clinical Quality Measures (eCQM)
MIPS IQR
Joint
Commission
QPP QualityNet PET
QRDA I or III Reports

MEDITECH
Data
Repository
eCQM
Calculation Engine
QualityNet
CEHRT
Web QRDA Files
{VTE, ED, STK, AMI,
SCIP,..}
Quality Measure Data Flow
eCQM Reporting Diagram

eCQM Reporting Standards
o Introduction of universal identifier
• Example: Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
• NQF# = 0373 (VTE-3)
• eMeasure ID = CMS-73
o How do standardized nomenclature based code system work?
• Using Quality Data Model (QDM) with HL7 QRDA (Quality Reporting Document
Architecture)
o eCQM Library Specifications Published Annually
◦ VTE-3 Example

Description:
This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral
(intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five
days of overlap therapy, they should be discharged on both medications or have a reason for discontinuation of overlap
therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater
than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or
have a reason for discontinuation of overlap therapy.
Data criteria (QDM Data Elements):
"Medication, Administered: Warfarin" using "Warfarin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"
"Medication, Discharge: Parenteral Anticoagulant" using "Parenteral Anticoagulant RXNORM Value Set
(2.16.840.1.113883.3.117.1.7.1.266)"
"Medication, Discharge: Parenteral anticoagulant ingredient specific" using "Parenteral anticoagulant ingredient specific
RXNORM Value Set (2.16.840.1.113762.1.4.1021.4)"
"Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"
eMeasure Identifier: CMS-73
Reconcile and Validate eCQMs
VTE-3 Reporting Example

This shows a value set for a class of medications (Warfarin)
"Medication, Administered: Warfarin" using "Warfarin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.232)“
Value Set Table:
eMeasure Identifier: CMS108

"Medication, Administered: Warfarin" using "Warfarin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.232)“
Value Set Table:

"Medication, Administered: Warfarin" using "Warfarin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"
"Medication, Discharge: Parenteral Anticoagulant" using "Parenteral Anticoagulant RXNORM Value Set
(2.16.840.1.113883.3.117.1.7.1.266)"
"Medication, Discharge: Parenteral anticoagulant ingredient specific" using "Parenteral anticoagulant ingredient specific
RXNORM Value Set (2.16.840.1.113762.1.4.1021.4)"
"Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"

HL7 QRDA (XML File) Snippet for Patient Visit that meets NQF#: 0371

Challenges
o Disparate Systems, Integration
o Difficult to assess performance across settings
o Creation of Clinical Alerts
o Coding occurs post discharge
o Understanding workflow required by eCQMs
o Transition from free text and customized reporting

Concluding Thoughts: Tom Brady
o Knowledge
◦ The Game
◦ Strategy
◦ Teamwork
◦ When to pass and when to plow forward
o Set backs
◦ Did he know the ball was deflated?
◦ Injuries
o Success
◦ Only quarterback to win 5 Super Bowls for the same team
◦ “Possibly the best quarterback the game has ever seen”
o Retirement
◦ Announces 2021 retirement
◦ On his own terms
◦ Seeks challenge till the bitter end – show me what you’ve got!

References
Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html
Instruments/QualityInitiativesGenInfo/Downloads/CMS-Meaningful-
Measures_Overview-Fact-Sheet_508_2018-02-28.pdf
o https://www.qualityreportingcenter.com/wp-
content/uploads/2018/04/Inpatient_FY2019_IPPSProposedRule_Slides_vFINAL
508.1pdf.pdf
o http://www.acmeware.com/posts/2018/may/2019-ipps-proposed-rule

Look for our MUSE sessions
o Tuesday, May 29
• 702 - Custom BCA Dashboards with Visual Insight
• 703 - The Alphabet Soup of Clinical Quality Measures
Reporting and Reimbursement: 2018 Updates
• 704 - Soup to Nuts - Data Repository 101
• 802 - Report Designer Fundamentals
• 804 - Soup to Nuts – Data Repository 102
o 1010 - Revenue Cycle Optimization: Tools and Strategies for Success
Wednesday May 30 at 2:30 pm
o 1087 - HIE: Effective Integration and Interoperability
Thursday May 31 at 1:45 pm
o 1104 - The DR Overnight DBA
Thursday May 31 at 2:45 pm
o 1091 - Electronic Reporting: Quality Management Cycle Concepts that Achieve
Reliable Results
Friday June 1 at 9:00 am
o 1103 - The Report Request Lifecycle
Friday June 1 at 10:00 am
130

The alphabet soup of clinical quality measures reporting and reimbursement 2018 updates

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Ähnlich wie The alphabet soup of clinical quality measures reporting and reimbursement 2018 updates

Ähnlich wie The alphabet soup of clinical quality measures reporting and reimbursement 2018 updates (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

The alphabet soup of clinical quality measures reporting and reimbursement 2018 updates