Primary Care in the U.S. Measuring and Improving Primary Care in the United States ISQua Indicators Summit CMS Measures. Primary Care Measures

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1 Primary Care in the U.S. Measuring and Improving Primary Care in the United States ISQua Indicators Summit 2012 Cliff Fullerton, MD, MS VP Chronic Disease Baylor Health Care System Number of PCPs in the U.S. = 209,000 Payer Breakdown Any government plan 32.2% Any private plan 63.9% Uninsured 16.3% AHRQ Primary Care Workforce Facts and Stats No. 1, 2010, w w.ahrq.gov/research/pcwork1.htm Income, Poverty, and Health Insurance Coverage in the United States, 2010, w w.census.gov/prod/2011pubs/p pdf 2 Primary Care Measures Multiple sources of primary care measures in the U.S. Government Centers for Medicare & Medicaid Services Agency for Health Care Research & Quality Private Sector Contracts BCBS Aetna Humana United Cigna Others Independent Organizations National Committee for Quality Assurance National Quality Forum The Joint Commission U.S. Preventive Services Task Force American Diabetes Association, et. al. BTE Specialty societies 3 CMS Measures PQRS Physician Quality Reporting Measure: Accountable Care Organization: 33 Medicare Advantage: Varied Meaningful Use of Health IT: 33 4 PQRS Overview PQRS 2011 Established in 2007, the Physician Quality Reporting System is a pay-for-reporting program with incentives and payment adjustments for groups who satisfactorily report quality data. PQRS reporting will be the basis for the value-based modifier. CMS is aligning various quality reporting programs such as the Medicare Shared Savings program and EHR Meaningful Use incentive program. CMS will post information for 2012 Group Practice Reporting Option (GPRO) performance on the Physician Compare website in Physician Quality Reporting Systems (formerly PQRI) The Affordable Care Act authorized incentive payments: Year Provider Category # Participants Medicare Reimbursement* HTPN Total Incentive 2009 PCP 107 2% Incentive $280,000 Specialists and Non-EHR 25 Total PCP 144 2% Incentive $396,000 Specialists and Non-EHR 35 Total Main HTPN Tax ID (GPRO) 350 1% Incentive Est. $450,000 Non-Main Tax ID [1] 103 Total *Baseline year for 2013 CMS Physician Compare Website 0.5% Incentive 2013 *Baseline year for 2015 penalty 0.5% Incentive % Incentive % Penalty % Penalty 5 6 1

2 CMS Payment Schedule PQRS Quality Metrics Year PQRS Medicare Reimbursement e-rx Medicare Incentives e-rx Medicare Penalties Total Impact % Incentive 2% 0% 4% % Incentive 2% 0% 4% % Incentive 1% 0% 2% % Incentive 1% 1% 0.5% % Incentive 0.5% 1.5% 0.5% % Incentive 0% 2.0% 1.5% % Penalty TBD by CMS TBD by CMS 1.5% % Penalty TBD by CMS TBD by CMS 2% Quality Scores Registry: Measures are selected by providers 3 individual measures or 1 measure group GPRO: Must report all 26 measures that apply to sampling of patients selected by CMS Quality scores are not currently published by CMS data will be reported Not Performed is an option 7 8 GPRO 2011 Measures GPRO 2011 Measures measures composed of 2012 GPRO Measures 6 disease modules o Diabetes Mellitus o Heart Failure o Coronary Artery Disease o Hypertension o Chronic Obstructive Pulmonary Disease o Ischemic Vascular Disease 9 patient care measures (individually sampled) o 7 Preventive Care measures o 2 Care Coordination/Patient Safety measures CMS Shared Savings Programs Accountable Care Organizations Reward is shared savings PCP Quality Measures: patient satisfaction, readmissions, MU, Patient safety, APS, Chronic Disease (DM, HTN, CAD, HF) Medicare Advantage Rewards: quality bonus and shared savings PCP quality measures vary by insurer Narrative Specifications and Measures List posted at https://www.cms.gov/pqrs/22_group_practice_reporting_option.a sp#topofpage

3 ACO 2012 CMS Shared Savings Program Metrics ACO 2012 CMS Shared Savings Program Metrics ACO 2012 CMS Shared Savings Program Metrics Meaningful Use Clinical Quality Measures 15 core objectives that every eligible professional must meet in order to receive an EHR Incentive Payment. Computerized provider order entry (CPOE) Drug-drug and drug-allergy checks Maintain an up-to-date problem list of current and active diagnoses E-Prescribing (erx) Maintain active medication list Maintain active medication allergy list Record demographics Record and chart changes in vital signs Record smoking status for patients 13 years or older Report ambulatory clinical quality measures Implement clinical decision support Provide patients with an electronic copy of their health information, upon request Provide clinical summaries for patients for each office visit Capability to exchange key clinical information Protect electronic health information Meaningful Use Clinical Quality Measures Through 2013, required to report on: 3 core clinical quality measures AND 3 clinical quality measures that you select from an additional list Beginning in 2014, will have to report on 12 clinical quality measures. CMS Meaningful Use of HIT 3 core clinical quality measures that everyone must report on through 2013: Clinical Quality Measure Hypertension: Blood Pressure Measurement NQF 0013 Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment b) Tobacco Cessation Intervention NQF Measure Number NQF 0028 Adult Weight Screening and Follow-up NQF

4 CMS Meaningful Use of HIT Alternate Core Clinical Quality Measures: Clinical Quality Measure Weight Assessment and Counseling for Children and Adolescents Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older NQF Measure Number NQF 0024 NQF 0041 Childhood Immunization Status NQF 0038 Coronary Artery Disease (CAD): Drug Therapy for Low ering LDL-Cholesterol 38 Additional Meaningful Use Clinical Quality Measures Diabetic Retinopathy: Communication w ith the Physician Managing Ongoing Diabetes Care Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Diabetes: LDL Management and Control Asthma Pharmacologic Therapy Ischemic Vascular Disease (IVD): BP Management Blood Pressure Management Asthma Assessment Controlling High Blood Pressure Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Beta-Blocker Therapy for CAD Patients w ith Prior MI Cervical Cancer Screening Prenatal Care: Anti-D Immune Globulin Pneumonia Vaccination Status for Older Adults Chemo for Stage III Colon Cancer Patients Diabetes: Hemoglobin A1c Control (<8.0%) Breast Cancer Screening Prenatal Care: Screening for HIV Heart Failure (HF): Warfarin Therapy Afib Patients Colorectal Cancer Screening Diabetes: Eye Exam Chlamydia Screening for Women Oral Antiplatelet Therapy Prescribed for CAD Patients Diabetes: Urine Screening Use of Appropriate Medications for Asthma Beta-Blocker Therapy for LVSD Diabetes: Foot Exam Low Back Pain: Use of Imaging Studies Anti-depressant medication management Diabetes: Hemoglobin A1c Poor Control Ischemic Vascular Disease Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement Hormonal Therapy for Stage IC-IIIC for ER/PR Positive Breast Cancer Smoking and Tobacco Use Cessation, Advising to Quit, Discussing Cessation Medications, Discussing Cessation Strategies 19 ACE Inhibitor or ARB Therapy for LVSD Appropriate Testing for Children w ith Pharyngitis 20 Care Coordination Measures Care Coordination Measures Cont d Private Sector Measures Private Sector Measures Include: Clinical Service Excellence Access Efficiency Productivity (Absenteeism and Presenteeism) Quality of Life Assessment Patient-Centered Medical Home (PCMH) BTE-diabetes, CAD Common Private Sector Clinical Process Measures Adult preventive Services Breast cancer screening Colorectal cancer screening Cervical Cancer Screening Tobacco Use Influenza and pneumococcal vax Diabetes Hgb A1c test BP measurement Lipid Measurement Eye Exam Coronary Artery Disease Drug Therapy for Lowering LDL Cholesterol Beta-Blocker Therapy Post MI Depression-Medication Management Asthma-Use of controller medication

5 Common Clinical Outcome Measures HbA1c Management: Percentage of patients with diabetes with most recent A1C level greater than 9.0% (poor control). HbA1c Management: Percentage of patients with diabetes with most recent A1C level less than 8.0% (poor control). Blood Pressure Management: Percentage of patients with diabetes who had their blood pressure documented in the past year less than 140/90 mm Hg. LDL Cholesterol Level (<130mg/dL): Percentage of patients with diabetes with most recent LDL-C less than 100 mg/dl or less than 130 mg/dl. 25 Private Sector Example Agree to gather and report, within thirty (30) days of an Participant s first visit, and semiannually thereafter, and in a manner that is compliant with HIPAA and other applicable laws, the following Quality Measures. Health Status SF-12 physical score (current version) SF-12 mental score Single question: state of health today Intermediate Clinical Outcomes BP (systolic and diastolic) <130/80 for DM and <140/90 for CAD A1C <7.0 LDL <100 for DM and CAD Selected additional HEDIS measures as mutually agreed to by the parties Satisfaction and Communication Clinic visits Nights and weekends Care Coordinator communication Physician communication Health-related Productivity Missed work days 26 Ineffective work days Patient Centered Medical Home Patient Centered Medical Home NCQA s 2011 Medical Home Standards Emphasis on patient-centeredness and patient experience of care Reinforces incentives for meaningful use (HIT) Focuses attention on aspects of primary care that improve quality and reduce cost Based on advances in evidence and changes in practice capability Patient Centered Medical Home NCQA Bridges to Excellence Diabetes Recognition Program Diabetes Recognition Program (DRP) developed to provide clinicians with tools to support the delivery and recognition of consistent high quality care designed to recognize physicians and other clinicians, who use evidence-based measures and provide excellent care to their patients with diabetes The DRP Program has 10 measures which cover areas such as: HbA1c control Blood Pressure control LDL control Eye examinations Nephropathy Assessment Smoking status and cessation advice or treatment Eligible providers will abstract data from the charts of 25 diabetes patients and submit this information to NCQA for review

6 Baylor Health Care System Integrated health care system in Dallas-Fort Worth, Texas 30 owned, leased, ventured, and affiliated hospitals 27 joint ventured ambulatory surgical centers 180 HealthTexas ambulatory care locations: 600 physicians 4,631 physicians on staff 72 Satellite outpatient facilities imaging, rehabilitation, and pain 3,534 beds 20,000 employees 2.6 million patient encounters/year 130,000 full admissions/year $4.1 billion net operating revenue BCBS DM $100/pt /pt 2013 BCBS CAD $100/pt BHCS/HTPN Bonus/Incentive BCBS Generic Rx, Amb Surg center Aetna DM $100/pt PQRS/MU Medicare Advantage (varied) , , , ,000 1,180,000 $ ,000 52, , , , ,000 1,507,000 $ Est. in US dollars 2. PCMH bonuses are not included. They are all mostly reinvested in new resources expected to change. Total Total/MD Quality bonus 31 DRAFT Baylor Health Care System Experience/Challenges Aligning with disparate measures Private vs. CMS measures Standardized Measures/Thresholds vs. Patient Preferences Balancing focus vs. completeness Focus on a few key measures Example-Diabetes: Emphasize: HbA1c < 7, BP <130/80, LDL <100, ASA and tobacco use Not retinal, microalbuminuria, foot exam Internal benefits of national metrics Bonuses and incentives. Growing from 2.5% to 10% in 2014 Evaluate performance Lessens internal debate Cost Internal Staff Vendor support Working with non-ehr community medical staff 33 6

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