Healthcare providers and systems that not only survive but flourish while in the transition from the fee-for-service world to the world of value-based purchasing need much more than a robust electronic health record (EHR) and an expanded schedule. It takes more than access to drive outcomes; it takes capacity, compliance, and strong care teams, with every member working to the fullest level of their license. It takes careful use of risk stratification with appropriate and timely registry outreach. It takes care coordination and transitions of care by highly trained and dedicated professionals. It takes robust population health management and care coordination across the continuum. And it takes a supporting network of managed care contracts that encourages quality above all else. 

Bon Secours Medical Group realized early on that physicians working outside the team structure could not provide the comprehensive, coordinated care required in the value-based purchasing world. Providing for acute and chronic patient needs, ensuring appropriate preventive services, providing patient education, offering enhanced access, and coordinating care with other providers and specialties has been estimated to require 21.7 hours per day for a primary care provider with a typical 2,500-patient panel. By enlisting the support of other healthcare team members, however, this same provider can oversee this patient panel within a workday of reasonable length. A registered nurse (RN) care manager can handle medication refills, monitor chronic diseases, and review test results. A medical assistant can provide point-of-care testing. Additional professionals, including behavioral health phycologists and social workers, registered dieticians, diabetes educators, and pharmDs can address acute mental health complaints and chronic disease compliance barriers. 

Having the appropriate team members on staff is foundational to providing patients appropriate access and care. Expanded office hours, electronic portals, video conferencing, and electronic messaging are just a few of the modern patient’s expectations for 21st-century medicine. 

Bon Secours provides numerous tools and points of access for its patient population.  Patients are encouraged to utilize MyChart, an electronic medical record portal, to seek non-urgent medical advice, review labs and other tests, request appointments and medication refills, and access their health summaries. Over 175,000 patients are currently enrolled in MyChart. Bon Secours 24/7 is a mobile application offering immediate access through teleconference to a primary care provider, any day of the week, at any time. FastCare clinics are conveniently located in area grocery stores and provide acute care 12 hours per day, 7 days per week for a $40 fee or the patient’s co-pay, whichever costs less. iTriage provides patients with a symptom checker, general medical information, and access to doctors by location and specialty through an easy-to-use application. The ZocDoc application provides new and existing patients with another avenue to access primary and specialty care providers and easily make appointments via smartphone or website.

While access is a very important element of the equation, it is by no means the only one as it pertains to comprehensive capacity. Care is available through appropriate access, but coordinated in a way that reduces waste. The cornerstone of this coordinated care at Bon Secours is the RN nurse navigator, a specially trained case manager charged with overseeing the health of specific patient populations. 

Nurse navigators are either embedded in medical practices or work virtually, depending on panel size. Navigators focus on the patients transitioning from hospital to home, long-term care, or hospice. They focus on the patients with complex conditions or multiple co-morbidities. They focus on patients at high risk of hospital readmission using risk stratification tools. These nurse navigators help patients coordinate needed care, manage symptoms, provide education, and promote self-management, when possible. 

In a typical day a nurse navigator will provide case management for 120-150 patients. At Bon Secours, the use of navigators to manage post-hospitalizations and post-ED visits has resulted in a readmission rate of 2 percent or less for those patients at a medical home practice.  When compared to the Virginia state average, which is greater than 8 percent for all-cause readmissions, it is obvious that this type of intervention makes a tremendous difference in the quality of patient care. 

This type of care begins at the primary care practice level. To ensure that patients and potential patients can obtain the care they need, Bon Secours continually evaluates provider capacity. When establishing and reviewing access standards, Bon Secours looks at several parameters. The time to the next available appointment within any given practice must be 30 days or less for a physical and 48 hours or less for a 15-minute visit. Anything outside this standard triggers one of several actions: add staff, such as an NP or PA; close the panel to new patients; or expand the existing provider hours. In fact, expanded hours is one of the 12 quality measures embedded into the Bon Secours Primary Care Quality Incentive Program (PCQIP), a voluntary bonus offered to all eligible providers, physicians, NPs, and PAs. The program provides a lucrative financial incentive for providers who meet meaningful use, patient satisfaction, citizenship goals, and quality measures deemed most important by the health system’s leadership and managed care contractors. While the access measure calls for providers to open schedules for patient appointment slots outside the normal business hours of Monday-Friday, 8 a.m. to 5 p.m., other measures are tied directly to clinical outcomes. Not surprisingly, given the escalation of diabetes in the United States, four of the PCQIP quality measures are designed to address and assure appropriate treatment of patients in this population. 


 

Other efforts in progress at Bon Secours to ensure appropriate management of all patient populations include proper resource allocation as it pertains to transitions of care, complex and chronic care management, disease management, and health promotion and risk reduction. By careful stratification that includes a health risk assessment, a readmission risk assessment, and predictive modeling, populations in greatest need of more extensive care management are targeted despite limited resources. This stratification and the use of evidence-based interventions involves lofty but obtainable goals to reduce overall hospital admissions, reduce the number of high-ED utilizers, reduce readmissions, and reduce skilled nursing facility (SNF) expenditures. 

None of this is possible without delivery system redesign, championed at the highest level of leadership within the organization. The Bon Secours Medical Group began implementing patient-centered medical homes using NCQA standards over five years ago, and today, the majority of all primary care ambulatory providers are NCQA Level 3-certified, focused on the key elements of quality, performance improvement, care coordination, care team development, access, and appropriate referral management.  

While the transition from fee-for-service to value-based purchasing is challenging on many levels, Bon Secours has established a supporting infrastructure early in the game that positioned the organization for the current climate and the many new payment models to come. 

About the Authors

Robert Fortini, PNP, is the VP and chief clinical officer for Bon Secours Virginia Medical Group, Home Health and Hospice. In this role he is responsible for facilitating provider adoption of electronic medical records (EMRs), coordinating clinical transformation, and facilitating advances in population health initiatives. Robert has extensive experience in operations and clinical policy development, plus experience in workflow re-engineering and CQI in ambulatory care. He has recently advanced Bon Secours’ efforts in “Good Help for Life” by leading efforts in advance care planning and behavioral health integration into primary care, promoting access by the expansion into the retail clinic and telehealth arenas, and develoing a workforce equal to the task.

Patti Lipes is a senior clinical operations project administrator for Bon Secours Virginia Medical Group, and is responsible for coordinating and facilitating project plans within the knowledge areas of analytics, patient-centered medical home, population health, and quality. Patti is Lean Six Sigma Green Belt-trained and is an active member of the Virginia chapter of the Project Management Institute. She is certified in mass care, disaster services, and shelter management through the Red Cross and worked in Mississippi and Louisiana with City Impact following Hurricane Katrina.   

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During a U.S. Senate Committee on Finance hearing yesterday on the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS), indicated that there could be some revisions to the proposed rule, including a possible delay in the January 1, 2017 proposed start date.

The hearing, which Committee Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) led, was an opportunity for Slavitt to report on the number and types of comments that CMS received to the proposed rule. (CMS accepted comments until 5 p.m. on June 27, 2016.)  It is now up to CMS to process all the comments and determine how to best revise and respond to them.

It has been well-publicized that CMS has received many comments from healthcare entities such as providers, vendors, and health plans. One of the biggest concerns from the point of the eligible provider (EP) is the timeline of MACRA for implementation, which is currently scheduled to begin in 2017 with bonuses being paid out to EPs in 2019.

Chairman Hatch states that the MACRA law gives CMS the flexibility to move the start date of the reporting period back. The current timeline it only gives EPs about two months to prepare for this major revision—a key concern especially for single EPs and smaller physician practices.

A definite decision on the implementation date will not be available until CMS publishes the final rule, which is expected in late October or early November.

Key Components of Proposed MACRA Rule

Merit-Based Incentive Payment System (MIPS)

  • The renaming of “EPs” to MIPS eligible clinicians, which will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians. The rule proposes definitions and requirements for groups. The rule also proposes excluding specific Medicare-enrolled practitioners, including newly Medicare-enrolled eligible clinicians, qualifying APM participants (QPs), certain partial qualifying APM participants (Partial QPs), and clinicians that fall under the proposed low-volume threshold.
  • MIPS performance standards and a MIPS performance period of one calendar year (Jan. 1 through Dec. 31) for all measures and activities applicable to the four performance categories.
  • Using 2017 as the performance period for the 2019 payment adjustment. Therefore, the first performance period would start in 2017 for payments adjusted in 2019.
  • Four performance categories: quality, resource use, clinical practice improvement activities (CPIAs), and meaningful use of certified EHR technology (referred to in this proposed rule as “advancing care information”).
  • Quality measures selected annually through a call for a quality measures process. Selection of these measures is proposed to be based on certain criteria that align with CMS priorities, and a final list of quality measures will be published in the Federal Register by Nov. 1 of each year.
  • Quality measures: For most MIPS-eligible clinicians, a minimum of six measures with at least one cross-cutting measure (for patient-facing MIPS-eligible clinicians) and an outcome measure will be used, if available; if an outcome measure is not available, then the eligible clinician would report one other high-priority measure (appropriate use, patient safety, efficiency, patient experience, or care coordination measures) in lieu of an outcome measure.
  • Resource use: Continuation of two measures from the VM: total per costs capita for all attributed beneficiaries and Medicare spending per beneficiary (MSPB), with minor technical adjustments. In addition, episode-based measures, as applicable to the MIPS eligible clinician, will be applied.
  • Clinical practice improvement activity (CPIA): a minimum number of CPIAs will be encouraged but not required.
  • Advancing care information (meaningful use): an assessment based on advancing care information measures and objectives will be performed.
  • A process for providing performance feedback to MIPS-eligible clinicians. Beginning July 1, 2017, it is proposed to include information on the quality and resource use performance categories in the performance feedback.

Alternative Payment Models (APMs)

  • Definitions of APMs, including other payor APMs, APM entities, and advanced APMs
  • Requirements for participation and incentive payments
  • A process for eligible clinicians to choose whether to be subject to the MIPS payment adjustment in the event that they are determined to be partial QPs
  • A definition for physician-focused payment models (PFPMs), criteria that would be used by the PFPM Technical Advisory Committee (PTAC), the HHS secretary, and CMS to evaluate proposals for PFPMs, and the process by which PFPMs would be considered for testing and implementation by CMS after review by the PTAC.

Data-Sharing Requirement

This would require MIPS-eligible clinicians as well as EPs, eligible hospitals, and critical access hospitals (CAHs) under the existing EHR incentive programs to make a demonstration related to the provisions concerning blocking the sharing of information under section 106(b)(2) of the Medicare Access and CHIP Reauthorization Act of 2015(MACRA) and, separately, to demonstrate cooperation with authorized ONC surveillance of certified EHR technology.

About the Author

Kim Charland is the editor of VBPmonitor.com and the senior vice president of clinical innovation with Panacea Healthcare Solutions. Kim has 30 years of experience in health information and reimbursement management for hospitals and physician offices. Kim’s primary role with Panacea is publisher of VBPmonitor.com, which is the company’s newest online monitor and is focused on value-based purchasing and quality. She is also co-host of ICD10monitor.com’s Internet news broadcast Talk Ten Tuesdays. In addition, she assists with product development for Panacea’s consulting and software divisions, as well as the MedLearn Publishing division. Kim is also recognized as a national speaker and has spoken for numerous organizations.

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This is the seventh article in a series addressing the value proposition of long-term, post-acute care (LTPAC) providers and health IT vendors. The articles focus on five major valued quality of care coordination (VQCC) differentials between LTPAC providers and acute/ambulatory care providers. This series is based on the LTPAC health IT collaborative ONC brief written in May 2015 for Karen B. DeSalvo, national coordinator for health informationtechnology and acting assistant secretary for health with the U.S. Department of Health and Human Services (HHS), titled Health Information Technology Use & Value Delivered by The Long-Term and Post-Acute Care (LTPAC) Sector. Readers can find the ONC Brief on the LTPAC Health IT Collaborative website.

Technology is a broad subject, and it includes much more than health information technology (IT). First we must expand on the word “technology.” Specifically, we must begin to talk about “clinical technology.” In today’s world and in the future, the two functions cannot exist separately. Clinical initiatives such as  quality measures, clinical outcomes, new pay and care models, and clinical partnerships are all in the mix. I have tried to get providers to understand that they have to be partners with their health IT vendor, and in the case of small, independent skilled nursing facilities (SNFs) and home health agencies (HHAs), I have suggested that the vendor sit in on strategic clinical meetings. The IT vendors have to think clinical technology, but the providers continually separate the two functions.

This is a slide I have used for years to illustrate that the past and current thinking is not the future. 

Since the release of the 2009 HITECH Act and the development of the meaningful use incentive program, when the LTPAC as well as behavorial health segments were left out, LTPAC health IT has been under secunity. I feel that it is the adoption of Health IT that is lagging behind; after all, the applications are available. If LTPAC were provided with financial assistance, the adoption rate would be much higher. ONC has done its very best to provide grant fundng, and the new Medicaid financing helps with interoperability, but it does not the assist the SNFs or HHAs in upgrading their electronic medical records (EMRs).

The important point in the  technology VQCC is that the technology in LTPAC is different than that of hospitals and physician offices. As we move to transitions of care, some technologies like telehealth and telemedicine, as well as interoperability technology, will bring the clinical technology of the three segments of care closer.

Hospital instrumentation includes areas such as computerized axial tomogaphy (CAT), magnetic resonance imaging (MRI), positron emission tomagraphy (PET), surgical, cardiac monitoring, etc. Health IT is an aggregation of departments to central billing by a person. There is not really enough time in a person’s LOS to develop a longitudinal record. Physician office technology has a person-centric focus to cover what the person is seeing the physician to fix. Health IT is being upgraded to develop a person-centric longitudinal care plan, but it’s going to be made up of personal input and long periods of time between visits – and a number of specialists becoming involved that are not part of the office practice (i.e. therapists).

The ONC brief states that the technology VQCC:

  • Provides a “person-centric electronic care EMR that covers a long duration of care;”
  • Aggregates all personal medical data functions over a long duration, allowing for trending and alerts to prevent incidents;
  • Uses devices to track activities of daily living; and
  • Provides a controlled clinical environment where advanced clinical technology can be tested and utilized by hundreds of persons to assist in public health technology.

The following is a quote from the ONC brief’s Appendix L:

“As previously stated, there are VQCC differentials between the care given in LTPAC and acute care. These VQCC differentials cannot be realized without state-of-the-art technology.


 

Various new technologies have been used in LTPAC and are being expanded by LTPAC providers, as this healthcare segment invests millions of dollars in the future healthcare system. The LTPAC provider has to aggregate clinical data from many sources of clinical services that are provided in longitudinal chronic care. These different clinical data sources are important over long periods of time, as they are interrelated to each other in longitudinal chronic care. Social and therapy care are interrelated to adjustments to daily living; comprehensive medication management are interrelated with diet and therapy; and the interrelationship between changes in condition, quality measure, and continuous eAssessments.”

As reported earlier in this series, persons with chronic conditions have to receive holistic longitudinal care during their stay in LTPAC, especially in SNFs and long-term acute-care hospitals (LTACHs). This requires clinical technology to be in harmony with the diagnosis, treatment, care plan, and discharge plan when going through the transition of care to another provider setting or to the home. This is longitudinal care and planning, not static episodic care. As an example, dieticians and social workers are very important to chronic care patients, as well as those in LTPAC who are in rehabilitation. As reported on a o-Net OnLine 2016 summary report, dieticians and nutritionists use various electronic devices to measure body weight and other metrics, including metabolic carts, glucose monitors, bioelectric impedance machines, and wearable fitness monitors for physiological as well as various analytical or scientific purposes. Numerous new device applications are being released to aid monitoring persons in LTPAC.

The leading LTPAC health IT vendors have spent millions of dollars on upgrading their EMRs to include longitudinal plans, clinical decision software, interoperability applications, integration of assisted living/home care/hospice software, activities of daily life monitoring, and integration of therapy/medication/social/diet needs.

At the April meeting of the Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association, or AMDA), one of the leading health IT vendors presented a roadmap of their current capabilities in the support of the new LTPAC EMR.

            


 

 

The other leading health IT vendors also have similar capability. So the answer to health IT in the LTPAC sector is the have all the providers on the most current EMR software technology.

SNFs, LTACHs, independent rehabilitation facilities (IRF), and other providers have sophisticated therapy technology, and it is being improved daily with new API applications that monitor therapy outcomes. ALFs are also starting to incorporate therapy instrumentation so the residents can maintain their rehabilitation plans and prevent re-hospitalization. With the increase in sensors and wearables, therapy is going to be a more sophisticated clinical technology.

One of the least known technologies in SNFs is their mockup home environment facilities. Most SNFs have an area set aside that is a mockup of a person’s home. The nurses and therapists teach patients on rehabilitation, plus how they can live with their disability. Examples are toilet training, cooking, and just getting around the home while rehabilitating or living their new life with a disability. Home care nurses then can build on this training when they visit persons in their home. SNFs also involve family members, loved ones, and caregivers so they can assist the patient when they return home.

 

In another area, first, there is some confusion as to the difference between telehealth and telemedicine. This confusion has continued as Congress and other agencies have begun to comprehend the advantage of these two clinical technologies in the new care models. For the purposes of this article, telehealth is the monitoring of a patient’s health and environment, usually in their home. It is used to acquire vital signs and to provide an early warning to the HHA nurse or the caregiver should issues arise. The accountable care organizations (ACOs) are looking to adopt telehealth monitoring to give alerts between visits of a caregiver or warning of an impending re-hospitalization. Telemedicine on the other hand is real-time electronic visual and audio communication between two or more healthcare professionals concerning a person’s medical condition. New technology such as the iPhone and iPad has replaced large costly video instrumentation that was mostly unaffordable.

Home health agencies and the VA have been using telehealth monitoring devices for years. It has been reported by the VA that they have over 5,000 veterans using a telehealth monitoring device report their daily activities and other measurements to a care coordinator so the VA can take action to prevent an incident causing a hospitalization.


 

This next form of clinical technology is going to cause the biggest changes in longitudinal care. The ability to clinically and wirelessly monitor a person as they and their caregiver team take them through rehabilitation and maintenance of their chronic conditions will lead us into the preventative stage of healthcare. In SNFs you can visualize patients with an iWatch to measure vital signs integrated into the longitudinal EMR. Or sensors measuring rehabilitation outcome improvements integrated with clinical decision software to monitor changes and provide alerts when the plan is not going in the right direction as programed for the best clinical outcome.

Clinical technology will continue to advance and be available to LTPAC to use in their capability of initiating the person-centric electronic longitudinal care record while the patient is in the care of a LTPAC provider.

The major barriers to success are:

  • Widespread recognition of the VQCC differentials and their value to the spectrum of care providers;
  • Recognition of the need and value by non-LTPAC providers;
  • Reimbursement of the costs of clinical technology in payment risk models; and
  • Understanding of the value to long-range clinical outcomes of a comprehensive longitudinal record with analytic integration of all clinical elements, trending, and preventative alerts.

About the Author

John F. Derr, RPh is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has over 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan and EVP of AHCA. He was SVP, CIO and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical Health IT and medication management. He represents LTPAC and pharmacy as a member of the HHS HITECH Committee on Standards. Derr is a graduate of Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

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Introduction

As the healthcare industry continues to evolve in its transition to a value-based system, the pressure is mounting for providers to participate. The Centers for Medicare & Medicaid Services’ (CMS’s) quality initiatives are mandated to streamline this process, making it increasingly critical for clinicians to not only understand exactly how quality reporting systems pertain to their practice’s future payments, but to ensure that they are aligned to satisfactorily participate now. In the wake of the utilization of the Qualified Clinical Data Registry (QCDR) reporting mechanism, providers should seek to gain a greater knowledge of how the consolidation of quality and outcomes can aid in achieving full participation.

What is a QCDR?

Evolutionary Role of Clinical Data Registries

By now, providers are familiar with CMS’s introduction of the QCDR in 2014 as a new mechanism of reporting, but they may still be questioning how it offers a new standard to satisfy the Physician Quality Reporting System (PQRS) program requirements. The concept of a clinical data registry (CDR) developed from efforts to measure the most effective treatment options and recognize leading trends in the outcomes of unifying diseases at the patient level; further expanding to include defining roles within healthcare research and education; and advancements in evidence-based quality and safety improvements. The shift from the fee-for-service to the pay-for-performance payment method brought forward the provisions of several innovative healthcare programs that place increasing national focus on linking costs to the satisfactory reporting of improved patient outcomes.

As the PQRS program gradually mandated eligible professionals (EPs) to report on a common set of quality measures to avoid a negative payment adjustment to their Medicare Part B physician fee schedule, many specialists found a lack of relevant measures available to their specific area of practice. In recognition of this inadequacy, specialist societies pleaded their case for CMS to allow them to create additional measures that were the most appropriate for their field of interest. Though reluctant to introduce new measures without National Quality Forum (NQF) endorsement, satisfactory PQRS participation through a QCDR was drafted within the American Taxpayer Relief Act. The introduction of the QCDR represents a way to meaningfully contribute to the initial values of healthcare improvement while additionally encouraging the opportunity to comply with value-based initiatives. Figure 1 visually outlines the QCDR’s central foundations to developing in an expanded role.


How Does it Differ from a Traditional Registry?

Functions and Requirements

Providers still may feel slightly overwhelmed by being asked not only to fully understand how to meet the PQRS quality reporting requirements, but also to differentiate between the QCDR and traditional registry reporting options. As defined by CMS, a QCDR is an “approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.” For the 2016 reporting year, much like a traditional registry, a QCDR can collect, analyze, and submit PQRS quality measure performance data on behalf of individual EPs and group practices seeking to achieve satisfactory participation. In contrast to other reporting mechanisms, QCDRs can offer more flexibility for PQRS participation. Many QCDRs are headed by medical specialty societies concentrating on a specific area of interest in order to accommodate the reporting needs of their physician members.

In differentiation, QCDRs must have the ability to track outcomes, possess benchmarking capabilities, afford timely feedback reports a minimum of four times a year, appropriately adjust for risk, and submit applicable measures across multiple payors beyond Medicare beneficiaries. Alongside these requirements, QCDRs are called upon to publicly report providers’ performance results, exclusive of measures in their first year of reporting. Perhaps the most unique function that sets QCDRs apart from traditional PQRS registries is that they are not limited to measures within PQRS. Medicare authorizes QCDRs to develop and customize non-PQRS measures that, with approval, can provide reporting compliance. A QCDR is entitled to submit a maximum of 30 non-PQRS measures from one or more of the domains listed in Figure 2, with exceptions to their elected reporting option criteria. Despite the appeal of a QCDR’s vast capabilities, it is important for providers to first ensure that a qualified registry is the appropriate reporting mechanism for their practice. 

071116_johnston_02.png


Reporting Quality Data through a QCDR

The 2016 QCDR reporting requirements are applicable to the individual or group reporting options. Individual EPs are obligated to report at least nine measures, a combination of PQRS and/or non-PQRS available under a QCDR, that cover at least three National Quality Strategy (NQS) domains for 50 percent of the EP’s patients, inclusive of case data for all payors. Of these measures reported, an EP would report on at least two outcome measures, or if insignificant outcome measures exist, report on at least one outcome measure and at least one of the following types of measures – resources use, patient experience of care, efficiency/appropriate use, or patient safety.

Participation in a QCDR as a Group Practice Reporting Option (GPRO) is new to PQRS 2016, and providers should be aware that they must register via the Physician Value-Physician Quality Reporting System (PV-PQRS) registration system, of which not all QCDRs have applied to support. Nonetheless, group practices of 2-99 EPs must meet the same reporting requirements as that of individual EPs. Group practices of 99 or more EPs that intend to report via QCDR GPRO must include all Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS survey measures reported on its behalf via a CMS-certified survey vendor, and report at least six additional measures covering at least two NQS domains using the QCDR. Of the additional measures that must be reported in conjunction with reporting the CAHPS for PQRS survey measures, at least one measure must be an outcome measure. One important feature to note is that individual EPs and GPROs alike would not be subject to MAV or the cross-cutting measure criteria under a QCDR. A graphic overview of the QCDR reporting requirements is outlined in Figure 3 seen below.

071116_johnston_03.png

Advantages

There are several distinguishable characteristics that set a QCDR apart from other reporting options for PQRS participation. The recognition of and concern regarding the limited number of specialty-focused measures have brought forth an answer to limit these inequalities. The development of customized measures allows for more meaningful quality reporting without being restricted to existing PQRS measures. The QCDR reporting option is intended to reflect specialty-specific priorities involving instances of care that offer stronger performance capabilities in meeting reporting requirements.

Participation in a QCDR also holds the potential to greatly improve physicians’ opportunities to foster requirements or needs simultaneously to PQRS, including the maintenance of certification (MOC), meaningful use (MU), and practice improvement in performance and outcomes in care. This streamlined reporting option is ultimately dependent upon PQRS and clinical quality measure (CQM) relevance and applicability, overlap with distinct initiative requirements, value and level of appropriateness to each practice, and capability of reporting. Additionally, a QCDR can offer support now through the available GPRO option to achieve better outcomes under the Value Based Modifier (VBM) program by using physicians’ overall performance rates for the quality portion of the VBM calculation. The continual monitoring and feedback available under a QCDR allows providers to adjust performance metrics much more frequently. A practice that provides exceptional quality and efficient care could anticipate quality scores to be much higher, which may translate into payment incentives. Analyzing these benefits alongside the overall comprehensive structure of a QCDR outlines an ideal path for compliance.


 

Disadvantages

In recognition of the advancements of establishing the QCDR reporting option, there are still obstacles to overcome in order to leverage the important benefit they may offer as it pertains to the future of quality improvement initiatives. For the 2016 reporting year, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has required that all individual and group-level QCDR performance data be available for public reporting. As CMS continues to identify and resolve efficient approaches to publicly report to Physician Compare, QCDRs’ public reporting efforts are in premature stages. Despite the exception for QCDRs to report this data during their first year of use, many QCDRs have little to no experience doing so. The volume of data that will encompass the production of these reports for CMS will be extremely burdensome, especially with the addition of the QCDR GPRO option this year. The inexperience leaves QCDRs and providers’ performance reputations susceptible to the distribution of inaccurate and unreliable data.

In order to avoid these discrepancies, the QCDR self-nomination process has become increasingly extensive in order to ensure that acceptable validation strategies, accuracy of data content, completeness of reporting, and adherence to the required sampling methodology are in place. The presence of inaccurate data gives CMS the right to audit as well as the ability to disqualify a QCDR. A disqualified QDCR may not resubmit quality measures data on behalf of its EPs for the following year, in turn discounting their satisfactory participation in a QCDR. Further limitation lies within the potential for QCDR specific measures’ subjection to full NQF endorsement. In the event of this, QCDRs could anticipate deepened administrative complexities, increased costs, and deferral for measures developers. Therein lies the likelihood to further delay the availability of new measures and solidify a focus on quantity over quality. Figure 4 comparatively displays the potential significances of a QCDR, and like any investment, the physician community must weigh these options in their respective values. 

071116_johnston_04.pngQCDR Outlook

How a QCDR and Quality Reporting Are Increasingly Linked in the Future of Reimbursement

It should come as no surprise that the healthcare industry is on the fast track to being driven by greater accountability. The accelerated efforts to transition to a value-based payment system have created a slight sense of urgency alongside overwhelming opportunity. The foundational provisions for measuring quality-of-care improvements have given rise to a multitude of reporting programs capturing clinical performance across hundreds of unique performance measurements. The proliferation of varying reporting programs, despite sharing the goals of improving care outcomes and cost savings, has placed an exorbitant burden on providers to adhere to complex requirements while monitoring annual changes in programs.

In recognition of this, CMS has focused attention on the alignment of its major quality programs in an effort to reach the programs’ maximum potential. The recent development of MACRA legislates the consolidation of PQRS, the electronic health record (EHR) incentive programs, and value-based nodifier into a single streamlined program known as the Merit-Based Incentive Payment System (MIPS) program. The advent of MIPS will bring forward an exciting opportunity to increase measure selection, and with the consideration of including QCDR measures, there is no doubt that QCDRs possess a powerful ability to meet the best representation of quality measurement based on specialists’ varying care criteria.

The QCDR reporting option holds the potential to leverage fulfilling the future healthcare payment requirements while simultaneously offering tools to maximize outcome improvement efforts. Value-based care is a reality, and QCDRs’ collaborative solutions to reporting supports improving providers’ quality of care delivery to payors, peers, and above all, patients.

About the Authors

Gloria Johnston is an accomplished healthcare executive with extensive experience leading people, improving and expanding healthcare operations, and providing consultative services to healthcare systems. Gloria has held leadership positions at several prestigious academic medical centers. She holds MBA, BSN, and AS degrees and is a credentialed health information professional.

Stephanie Doran is a health information management (HIM) consultant and project manager for HealthAdvanta, a health information and technology company. She is a graduate of Temple University, where she earned a bachelor’s degree in health information management and was honored with the Health Information Management Professional Excellence Award for her distinguished development and achievement.

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A recent announcement by the Centers for Medicare & Medicaid Services (CMS) has set the stage for big changes expected to affect home health agencies nationwide.  

In late June, the agency announced proposed changes to the Medicare Home Health Prospective Payment System (HHPPS), a move it said in a press release “would foster greater efficiency, flexibility, payment accuracy, and improved quality.”

In its new rule, scheduled to take effect for the 2017 fiscal year, CMS projected that Medicare payments to home health agencies would be reduced by 1 percent, or $180 million, based on the proposed policies.

The proposed decrease reflects the cumulative effects of the following funding moves, the agency noted:

  • A 2.3-percent home health payment update, marking a $420 million increase;
  • Rebasing adjustments to the national, standardized, 60-day episode payment rate, the national per-visit payment rates, and the non-routine medical supplies (NRS) conversion factor, marking a $420 million decrease;
  • A -0.97 percent adjustment to the national, standardized, 60-day episode payment rate to account for nominal case-mix growth for an impact of -0.9 percent, marking a $160 million decrease; and
  • The proposed increase to the fixed-dollar loss (FDL) ratio used in determining outlier payments from 0.45 to 0.56 for an estimate impact of -0.1 percent, marking a $20 million decrease.

Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home health agencies last year, costing Medicare approximately $17.8 billion, according to federal statistics. To be eligible for the home health benefit, CMS noted, beneficiaries must need intermittent skilled nursing or therapy services and must be homebound and under the care of a physician. Covered home health services include skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, medical social services, and medical supplies.

Home health agencies (HHAs) are paid a national, standardized, 60-day episode payment for all covered home health services, adjusted for case mix and area wage differences.

A recently published Modern Healthcare article about the changes noted that they were part and parcel of the Patient Protection and Affordable Care Act (PPACA), which mandated funding reductions to address Medicare overpayments for home health services dating back to 2000.

CMS cut payments by $260 million for 2016, $60 million for 2015, and $200 million for 2014 prior to the latest cut, the article noted, while also adding that these moves appear to have contributed to some agencies closing their doors for good.

“In 2014 … CMS estimated there were 11,781 home health agencies caring for Medicare beneficiaries. That figure dropped to 11,400 in the estimate issued Monday,” the article read. “The difference may also reflect moratoria Medicare placed on new providers in several areas identified as hot spots for fraud.”

In addition to spelling out the details behind the latest round of funding cuts, the new CMS rule also revealed additional details regarding a mandatory value-based purchasing pilot designed to encourage greater quality in home health services, Modern Healthcare reported. All Medicare-certified home health agencies in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington will participate in the pilot, the article noted, meaning that home health agencies in these states will see their rates adjusted annually up or down depending on whether they meet certain performance metrics.

The move will mean a 3-percent annual payment reduction or increase to home health agencies in those nine states starting in 2018, with that figure jumping to 8 percent in 2022.

CMS also noted in its aforementioned press release that the new move marked only “one of several rules for … 2017 that reflect a broader administration-wide strategy to create a healthcare system that results in better care, smarter spending, and healthier people.”

“Provisions in these rules are helping to move our healthcare system to one that values quality over quantity and focuses on reforms such as achieving better health outcomes, preventing disease, helping patients return home, helping manage and improve chronic diseases, and fostering a more-efficient and coordinated health care system,” the release said.


 

Such other pending changes include the following, CMS said:

Negative Pressure Wound Therapy (NPWT)

The Consolidated Appropriations Act of 2016 requires a separate payment to be made to HHAs for disposable NPWT devices when furnished on or after Jan. 1, 2017 to any individual who receives home health services for which payment is made under the Medicare home health benefit, the agency noted. As described in the Act, the separate payment amount for an applicable disposable device will be set equal to the amount of the payment that would otherwise be made under the Medicare Hospital Outpatient Prospective Payment System (OPPS).

Home Health Quality Reporting Program (HHQRP) Update

The Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) requires HHAs, skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs) to “submit standardized patient assessment data, data on quality measures, and data on resource use and other measures,” CMS noted.

“The data must be standardized and interoperable so as to allow for the exchange of such data among PAC providers,” the press release read. “It also modifies PAC assessment instruments to provide for the submission and comparison of such standardized patient assessment data. These requirements are intended to enable interoperability as well as improve quality and discharge planning, among other purposes.”

Home Health Value-Based Purchasing Model

Regarding the aforementioned Home Health Value-Based Purchasing (HHVBP) pilot going on in nine states, CMS announced that it would:

  • Calculate benchmarks and achievement thresholds at the state level rather than the level of the size cohort and revise the definition for “benchmark” to state that this term refers to the mean of the top decile of Medicare-certified HHA performance on the specified quality measure during the baseline period calculated for each state;
  • Enforce a minimum requirement of eight HHAs in a size cohort;
  • Increase the timeframe for submitting data from seven calendar days to 15 calendar days following the end of each reporting period to account for weekends and holidays;
  • Remove four measures (Care Management: Types and Sources of Assistance; Prior Functioning ADL/IADL; Influenza Vaccine Data Collection Period; and Reason Pneumococcal Vaccine Not Received) from the set of applicable measures;
  • Adjust the reporting period and submission date for the Influenza Vaccination Coverage for Home Health Personnel measure from a quarterly submission to an annual submission; and
  • Add an appeals process that includes the existing recalculation process and adds a reconsideration process.

For additional information about the Home Health Prospective Payment System, go online to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index.html.

For additional information about the Home Health Value-Based Purchasing Model, go online to https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model

The proposed rule can be viewed online at https://www.federalregister.gov/public-inspection.

Mark Spivey is a national correspondent for VBPmonitor.com, ICD10monitor.com, and RACmonitor.com. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

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