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1 "2015 ACO quality measures- What's new? How can we be successful?"

2 ACO Announcements Reminders: ACO Notifications, Requests for Tax ID information from PECOS, Upcoming Boardline Upcoming Specialty Initiative Meetings Creekside Banquet Hall 2669 Union Road Cheektowaga, NY May 20 th /June 11 5:00-7:00 For RSVP information, please contact me.

3 Agenda How quality is measured for the ACO by CMS 2015 ACO Quality Measures CMP data collection Alignment with other CMS initiatives Q&A section

4 Quality Measurement: Domains 33 quality measures are separated into the following four key domains that will serve as the basis for assessing, benchmarking, rewarding, and improving ACO quality performance: 1. Patient/Caregiver Experience 2. Care Coordination/Patient Safety 3. Preventive Health 4. Clinical Care for At Risk Population

5 Quality Performance Pay for Performance vs Reporting The standard for quality performance is based on: Performance Year Pay-for-Reporting or Pay-for-Performance 1 Pay-for-Reporting 2 and 3 Pay-for-Performance To be eligible to share in savings, if earned, the ACO must: Completely and accurately report all quality measures. This qualifies the ACO to share in the maximum available sharing rate for payment. Completely and accurately report all quality measures and meet minimum attainment on at least one pay-forperformance measure in each domain.

6 Quality Performance Pay for Performance vs Reporting 2012 /2013 starters ACO GPRO Measures Pay-for-Performance in ACO GPRO Measures that are Pay-for-Reporting in Total ACO GPRO Measures in of the 33 measures are reported through the GPRO Web Interface 2012 /2013 starters GPRO WI Measures that are Pay-for-Performance in GPRO WI Measures that are Pay-for-Reporting in Total GPRO WI Measures in

7 2015 ACO QUALITY MEASURES

8 2015 GPRO Web Interface measures " Quality Measure and Performance Standards". Available online at

9 2015 GPRO Web Interface measures cont

10 2015 ACO QUALITY MEASURES DOMAIN: CARE COORDINATION

11 CARE 2: Screening for Future Fall Risk Description: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period. What is the Quality Action? Completion of a fall risk screening. The screening may be done with a formal screening tool as long as it fulfills the fall history documentation requirements (see below). Where may the Quality Action take place? Must take place in a healthcare setting.

12 CARE 2: Screening for Future Fall Risk Who may perform the Quality Action? cont. Any healthcare professional may perform a fall risk screening. When must the Quality Action be performed? The screening may take place at any time within the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: Documentation of any of the following regarding the patient s past history of falls: No falls; or One fall without major injury; or Two or more falls; or Any fall with major injury.

13 CARE 3: Documentation of Current Medications in the Medical Record (NEW) Description: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration. What is the Quality Action? Documenting, updating or reviewing the patient s current medications using all immediate resources available on the date of the encounter. Current medications is defined as medications the patient is presently taking including all prescriptions, overthe-counter (OTC) medications, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication s name, dosage, frequency and route of administration

14 CARE 3: Documentation of Current Medications in the Medical Record (NEW) Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Eligible professionals reporting this measure may document measure information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. When must the Quality Action be performed? This measure is to be reported for every pre-filled (in the GPRO Web Interface) encounter during the measurement period.

15 CARE 3: Documentation of Current Medications in the Medical Record (NEW) What are the documentation requirements relative to the Quality Action? The patient s medical record must contain for each pre-filled office visit: A list of all prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medication s name, dosage, frequency and route of administration OR if the patient is not currently taking any medications. Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical reason exceptions).

16 2015 ACO QUALITY MEASURES DOMAIN: PREVENTIVE MEASURES

17 PREV-5: Breast Cancer Screening Description Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient s medical record must contain: Date the mammogram was performed; and Results of the mammogram; Guidance Screening includes breast imaging, breast x-ray, diagnostic mammography, digital mammography, mammogram, screening mammography

18 PREV-6: Colorectal Cancer Screening Description Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient s medical record must contain: Indication of a current colorectal cancer screening, as evidenced by the completion of one of the previously mentioned tests or procedures within its corresponding timeframe; or A patient report stating the type of colorectal cancer screening, when it was performed and the result; " Quality Measure and Performance Standards".Available online at Fee-for-Service- Payment/sharedsavingsprogram/Quality_M

19 PREV-6: Colorectal Cancer Screening Guidance FOBT includes ColoCARE, Coloscreen, EZ Detect, Fecal occult blood test, flushable reagent pads, flushable reagent stool blood test, guaiac smear test, Hemoccult, Seracult, stool occult blood test, FIT Colorectal screening does not include: virtual colonoscopy, Barium enema, or Colovantage Patient refusal is not a reason to exclude

20 Description: PREV-7: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31, who received an influenza immunization OR who reported previous receipt of an influenza immunization. WHAT is the Quality Action? Receipt of an influenza immunization between August 1, 2014, and March 31, What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient s medical record must contain: Indication the patient received an influenza immunization between August 1, 2014 and March 31, 2015

21 PREV-8: Pneumonia Vaccination Status Description: for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. Quality Action: Receipt of a pneumonia vaccination. Documentation Requirements: The patient's medical record must contain documentation of receipt of a pneumonia vaccination or PCV13 and the PPSV23 series

22 PREV-9: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Description Percentage of patients aged 18 years and older with a documented BMI during the encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter Normal Parameters: Age 65 years and older BMI 23 and < 30 Age years BMI 18.5 and < 25 What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient s medical record must contain: BMI screening date and results; and If a follow-up plan is required, documentation of discussion of the plan. The follow-up plan must be specified as an intervention that pertains to the BMI outside of normal parameters " Quality Measure and Performance Standards". Available online at

23 PREV-9: BMI Assessment and Follow-Up WHEN must the Quality Action be performed? The BMI screening may take place during the most recent visit within the measurement period or within the 6 months prior to that visit. If a follow-up plan is needed, it must be documented during the visit in which the abnormal BMI is documented. Guidance Follow-up may include, but is not limited to: documentation of education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), pharmacological interventions or dietary supplements, exercise counseling or nutrition counseling Follow-up plan is not required for normal BMI

24 PREV-10: Tobacco Use: Screening and Measure Description: Cessation Intervention Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. WHAT is the Quality Action? Screening for tobacco use at least once within 24 months. For any patient identified as a tobacco user, tobacco cessation counseling must also be provided. Tobacco use includes any type of tobacco. WHEN must the Quality Action be performed? The screening for tobacco use must occur within the 24 months prior to the end of the measurement period. The same time frame also applies for cessation intervention for those patients identified as tobacco users. If there is more than one tobacco screening, use the most recent.

25 PREV-10: Tobacco Use: Screening and Cessation Intervention What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient's medical record must contain: The date and results of a query of the patient's use of tobacco; and If identified as a tobacco user, documentation of a related cessation counseling intervention

26 PREV-11: Screening for High Blood Pressure and Follow-Up Documented Description Percentage of patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient s medical record must contain: Date and values of the most recent systolic and diastolic blood pressure measurements. If more there are multiple blood pressure measurements on the same date of service, use the lowest systolic and diastolic blood pressure on that date. Reported systolic and diastolic values should be from a single blood pressure reading; and If a follow-up plan is required, documentation of discussion of the plan. The follow-up plan must be specified as an intervention that pertains to the blood pressure measurement;

27 PREV-11: Screening for High Blood Pressure and Follow-Up Documented Guidance Patients with a Medicare claim indicating a history of hypertension prior to the first day of the measurement period (1/1/2014) will not be included in your sample for this measure A normal blood pressure reading (<120 systolic and < 80 diastolic) requires no documentation of follow-up Recommended follow-up based on BP classification includes: recommending screening interval follow-up, lifestyle modifications, referrals to alternative/primary care provider, anti-hypertensive pharmacological therapy, laboratory tests, or an electrocardiogram Need to link the recommended follow-up to the elevated blood pressure using guidance provided

28 PREV-12: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Description Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen WHAT is the Quality Action? Screening includes completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition even in the absence of symptoms This measure requires the screening to be completed in the office of the provider filing the code Follow-up plan may include a proposed outline of treatment to be conducted as a result of positive clinical depression screening Use a normalized and validated depression screening tool developed for the patient population where it is being utilized. Examples of depression screening tools include but are not limited to: Adolescent Screening Tools (12-17 years) Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire, Center for Epidemiologic Studies Depression Scale (CES-D) and PRIME MD-PHQ-2

29 PREV-12: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient s medical record must contain: The date and results of an age appropriate standardized depression screening tool; and If a follow-up plan is required, documentation of discussion and implementation of the plan. The follow-up plan must be specified as an intervention that pertains to depression; or If the quality action is not performed due to an exception (medical or patient reasons), documentation of these reasons ;

30 2015 ACO QUALITY MEASURES DOMAIN: AT RISK POPULATION

31 CAD-7: ACE Inhibitor or ARB Therapy Description: Diabetes or LVEF <40% Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy. What is the Quality Action? Prescription of either an ACE inhibitor or ARB therapy. Where may the Quality Action take place? Must take place in a healthcare setting. Who may perform the Quality Action? Any prescribing healthcare professional may prescribe ACE inhibitor or ARB therapy.

32 CAD-7: ACE Inhibitor or ARB Therapy Diabetes or LVEF <40% When must the Quality Action be performed? The prescription of an ACE inhibitor or ARB therapy must be documented as either initiated or continuing during the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: A diagnosis of coronary artery disease or history of cardiac surgery; and A diagnosis of diabetes and/or LVEF < 40% (or documentation of moderate or severe) at anytime in their history, up through the last day of the measurement period; and An active prescription for an ACE inhibitor or ARB therapy anytime during the measurement period

33 HTN 2: Controlling High Blood Pressure Description: Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmhg) during the measurement period. What is the Quality Action? Performance of a blood pressure reading and documentation of its result. A result of < 140/90 mmhg is required for numerator inclusion. Where may the Quality Action take place? Must take place in a healthcare setting.

34 HTN 2: Controlling High Blood Pressure Who may perform the Quality Action? Any qualified healthcare professional may take the patient s blood pressure. Patient reported blood pressure readings, including readings directly from home monitoring devices, are not acceptable. When must the Quality Action be performed? The blood pressure must be taken and the value recorded during the measurement period. If there is more than one blood pressure reading, use the most recent. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: A diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period but does not end before the start of the measurement period; and The date and value of the most recent systolic and diastolic blood pressure readings. If there are multiple blood pressure readings on the same date of service, use the lowest systolic and lowest diastolic pressures on that date

35 Description: IVD 2: Use of Aspirin or Another Antithrombotic Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period. What is the Quality Action? Prescription of aspirin or another antithrombotic. Where may the Quality Action take place? Must take place in a healthcare setting.

36 IVD 2: Use of Aspirin or Another Who may perform the Quality Action? Antithrombotic Any prescribing healthcare professional may prescribe the use of aspirin or another antithrombotic. In addition to aspirin, antithrombotic medications may include: clopidogrel, a combination of aspirin and extended release dipyridamole, Prasugrel, Ticagrelor, or Ticlopidine. When must the Quality Action be performed? The prescription for aspirin or another antithrombotic must be either initiated or continued during the measurement period. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: An active diagnosis of ischemic vascular disease or discharged alive for AMI, CABG or PCI; and An active prescription for aspirin or another antithrombotic anytime during the measurement period.

37 MH-1: Depression Remission at 12 Description: Months (NEW) Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. What is the Quality Action? Remission attained at 12 months (+/- 30 days) from the index date. Remission is defined as a PHQ-9 score less than five. The index date is defined as the first PHQ-9 score greater than 9 between 12/1/2013 to 11/30/2014.

38 MH-1: Depression Remission at 12 Months (NEW) Where may the Quality Action take place? The patient needs to be seen by an eligible professional to have the diagnosis of depression, but the actual tool does not have to be administered by an eligible provider. Multiple modes of administration are allowed: office visit/in-person, telephone encounter, e-visit, mail (post), electronic administration ( , patient portal, ipad/tablet, patient kiosk) Who may perform the Quality Action? Any healthcare professional may administer the screening tool.

39 MH-1: Depression Remission at 12 Months (NEW) When must the Quality Action be performed? An initial PHQ-9 score greater than 9 between 12/1/2013 and 11/30/2014. A follow-up PHQ-9 score less than 5 at 12 months (+/- 30 days) from the index date. What are the documentation requirements relative to the Quality Action? The patient s medical record must contain: A diagnosis of major depression or dysthymia; and A PHQ-9 score greater than 9 during an outpatient encounter between 12/1/2013 and 11/30/2014; and A follow-up PHQ-9 score less than 5 at 12 months (+/- 30 days) of the initial PHQ- 9 score greater than 9; or Documentation of exclusion criteria.

40 MH-1: Depression Remission at 12 Months (NEW)

41 HF-6: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction Description (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge WHAT is the Quality Action? Prescription of beta-blocker therapy. Beta-blocker therapy is limited to the prescription of Bisoprolol, Carvedilol, or Sustained Release Metoprolol Succinate. What are the DOCUMENTATION REQUIREMENTS relative to the Quality Action? The patient s medical record must contain: A diagnosis of heart failure; and LVEF of < 40% (or documented as moderate or severe) at anytime in the patient s history, up through the last day of the measurement period; and An active prescription for beta-blocker therapy,

42 HF-6: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction Guidance (LVSD) If the patient has ever had an LVEF < 40% or a documented LVEF as moderate or severe answer Yes to the presence of LVSD Bisoprolol, carvedilol, or sustained release metoprolol succinate are the ONLY beta-blockers allowed for this measure

43 DM-2: Composite (All or Nothing Scoring): Diabetes Hemoglobin A1c Poor Control Measure Description: (>9%) Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Denominator Exclusions: A diagnosis of gestational diabetes during the measurement period Quality Action: Performance of an HbA1c test and documentation of its result. A result of > 9.0%, or is missing a result, or an HbA1c test was not done, is required for numerator inclusion. Documentation requirements: A diagnosis of diabetes mellitus; and The date and value of the HbA1c test;

44 DM-7 Composite (All or Nothing Scoring): DESCRIPTION: Diabetes: Eye Exam Percentage of patients years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period DENOMINATOR: Equals Initial Patient Population (patients years of age with diabetes) NUMERATOR: Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: A retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period The eye exam must be performed by an ophthalmologist or optometrist.

45 WHY IMPORTANT?

46 Why is reporting important? As an ACO, we must report all measures within each domain. Performance year 3, ACOs must meet the minimum attainment level ( 30thpercentile) Incomplete reporting, failure to meet minimum attainment, and poor performance on the audit may result in a a Corrective Action Plan (CAP) or termination

47 PQRS Alignment ACO participants may only participate in PQRS via the Shared Savings Program. No separate PQRS registration is required. If the ACO satisfactorily reports measures, then all ACO participants with PQRS eligible professionals will not be subject to the 2017 PQRS payment adjustment. EPs working for more than one organization need to meet the PQRS reporting criteria for each TIN under which (s)he works during the 2015 PQRS program year to avoid the 2017 PQRS payment adjustment for each TIN.

48 Value-Based Payment Modifier alignment 2015 ACO participants will be subject to the 2017 Value based Modifier (VM) based on their performance in calendar year For ACO participants, the cost composite will be classified as Average, but the quality composite will be calculated using the data reported by the ACO. If the ACO fails to successfully report on quality measures, then all ACO participants (who have providers subject to the VM) will be subject to an automatic downward adjustment. -4.0% for physicians in groups with 10 or more EPs and -2.0% for physicians in groups with between 2 to 9 EPs and physician solo practitioners.

49 Announcements Next Lunch & Learn: 6/17/2015 Topic: "Screening for Future Risk of Falls-When & Why Important Patty Podkulski, Director of ACO Facilitation and Educational Transformation Reminders: ACO Notifications, Requests for Tax ID information from PECOS, Boardline Upcoming Specialty Initiative Meetings Creekside Banquet Hall May 20 th /June 11 5:00pm-7:00pm. Sheree M Arnold ACO Clinical Transformation Specialist (716)

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