CMS CROWNWeb Application Understanding the PY 2015 ESRD QIP With the Centers for Medicare & Medicaid Services December 19, 2013
Today s Hosts Janis Grady, RHIT, CPHQ Contract Officer s Representative (COR) CROWNWeb Outreach, Communication, and Training (OCT) Contract Centers for Medicare & Medicaid Services Oniel Delva, BA, CTT Communications and Training Manager CROWNWeb Outreach, Communication, and Training (OCT) Contract 2 O
Today s Presenter The Centers for Medicare & Medicaid Services Anita Segar, MBA, MSHCA, MA Program Lead & Policy Lead ESRD Quality Incentive Program Anita Segar is the Program Lead and Policy Lead for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) at the Centers for Medicare & Medicaid Services (CMS). Anita is responsible for providing leadership and oversight of the program, as well as writing federal regulations and other policies that impact more than 5,000 dialysis facilities nationwide. Anita works closely with components within CMS, other federal agencies, industry stakeholders, and the public in identifying quality gaps and developing policy to improve the care provided to Medicare beneficiaries. 3 O
HMS Data Submission Requirements
HMS Data Submission 5 CMS has contracted with Healthcare Management Solutions, LLC (HMS) to conduct a data reliability and validity check on various aspects of CROWNWeb data reporting by facilities. Participating facilities will be contacted and asked to submit source documentation from each patient s medical record. Participating facilities can submit requested documents to HMS via one of three options: Protected PDF file on CD/DVD/Flash Drive (preferred method) Secure fax submission Paper submission Submission options are included as part of a request letter submitted to participating facilities. O
HMS Data Submission HMS provides each participating facility a password to use when submitting password-protected PDFs. Facilities can convert Word documents to PDF or scan a document and save it as a PDF file. Facilities may need to work with their IT departments when scanning and converting files to PDFs, as scanners and PDF creator software vary. 6 O
Password Protecting PDF How to password protect and securely submit data to HMS for its CROWNWeb data validation project: 1. Ensure that you have Adobe Acrobat or another PDF creator software on the computer to be used. (NOTE: To confirm if that computer has a PDF creator software, check under All Programs from the Start menu for an Adobe or other PDF creator folder.) 2. Open your document and click on the file menu, then click on Save As. 7 O
Password Protecting PDF 3. Choose a location to save the document. 4. Click the Save as type drop-down menu, and select PDF. The Options button now displays. 8 O
Password Protecting PDF 5. Click the Options button. An Options dialog box displays. 6. Click the Encrypt the document with a password checkbox, and click the OK button. 9 O
Password Protecting PDF 7. Enter the HMS-provided password located under Option 1: PDF Submission in the Submission Requirements section, and click the OK button. 8. Click the Save button to save the document as a password-protected PDF. 10 O
Saving to CD or DVD Example of how to burn files to a CD or DVD: 11 Source: http://windows.microsoft.com/en-us/windows-vista/burn-a-cd-or-dvd O
ESRD QIP: An Overview
Value-Based Purchasing Value-Based Purchasing (VBP) is an important driver in changing how care and services are reimbursed It represents a shift from payment based solely on number of patients treated to one that factors in quality of treatment The End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) was CMS s first VBP initiative 13 C
ESRD QIP and Other Quality Improvement Efforts The ESRD QIP works in concert with other CMS quality improvement (QI) initiatives: ESRD Conditions for Coverage specify health and safety standards, which serve as the foundation of QI Survey and Certification Program conducts on-site inspections to ensure compliance with Medicare regulations National programs and campaigns, such as the Fistula First initiative, target specific areas for improving dialysis treatment Demonstrations that study the impact of new methods to deliver care, as well as new payment approaches ESRD Networks address local needs and provide technical assistance to facilities in their geographic regions 14 C
Impact on Facilities and Patients CMS introduces a financial incentive to facilities that meets quality standards established by CMS Patients and their families can use publicly available data to make the best decisions for their own care Information on facility performance is made available online Performance Score Certificates (PSCs) that show facility performance are displayed (in both English and Spanish) in a prominent location within each facility 15 C
Law Creating the ESRD QIP ESRD QIP was established in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) by adding Section 1881(h) to the Social Security Act Program intent: Promote patient health by giving renal dialysis facilities an incentive to deliver high-quality patient care Facilities that do not meet certain performance standards can have their payments from CMS reduced by up to 2% 16 C
Program Structure The ESRD QIP is governed by rules for each Payment Year (PY) that: Identifies measures Establishes performance standards that apply to each measure Identifies the performance period (usually two years before the PY) Outlines a methodology for calculating a Total Performance Score (TPS) for each facility Explains how a facility s TPS may result in a payment reduction o Payment reductions apply to services that the facility will render during the PY 17 C
The Rulemaking Process 1. CMS publishes a Proposed Rule via Notice of Proposed Rulemaking (NPRM) in the Federal Register Presents proposed measures and evidence-based justifications for why the measures will encourage high-quality clinical practices Reflects various what-if considerations to determine financial impacts on facilities 2. Public has a 60-day period to comment Online via www.regulations.gov Mail (US Postal Service, commercial express service, hand delivery/courier) 3. CMS takes public comment into consideration and publishes a Final Rule in the Federal Register 18 C
Measures The ESRD QIP currently is made up of two categories of measures: Clinical measures score facilities based on the quality of clinical services provided to patients with ESRD Reporting measures score facilities based on whether they collect and/or report particular data during the performance period (this data is used to establish baselines for clinical measures in future PYs) The ESRD QIP measures several elements of care provided to patients, including: Anemia management Vascular access Dialysis adequacy Bone mineral metabolism Patient experience of care 19 C
Scoring Clinical measures are scored by comparing a facility s performance during the performance period to: 1) The same facility s performance in the previous year ( improvement score ) 2) National performance two years prior to the performance period ( achievement score ) o The facility s score on the measure is the higher of the improvement or achievement score o Clinical measures make up a higher percentage of the facility s TPS Reporting measures are scored based on whether a facility collects and/or reports predetermined information about its patients This gives facilities an incentive to closely monitor important patient attributes and share information about dialysis treatment Reporting measures make up a smaller percentage of the facility s TPS 20 C
Payment Reductions CMS combines scores on all of these measures to create the TPS, which grades a facility s accomplishments overall If the facility s TPS is lower than the minimum TPS determined by CMS for that year, then the facility will get less money for the services they provide during that payment year Payment reductions are capped by statute at 2% 21 C
The PY 2015 ESRD QIP Six clinical measures make up 75% of TPS: Anemia Management Vascular Access Type (VAT) (2 measures) Kt/V Dialysis Adequacy (3 measures) Four reporting measures make up 25% of TPS: Dialysis Events (infections) via the Centers for Disease Control and Prevention s (CDC) National Healthcare Safety Network (NSHN) Patient satisfaction via the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey Mineral Metabolism Anemia Management 22 Technical Specifications for every measure available on www.dialysisreports.org/esrdmeasures.aspx C
PY 2015 ESRD QIP Clinical Measures
PY 2015 Clinical Measures Six clinical measures Anemia Management VAT Measure Topic o Arteriovenous Fistula o Catheter Kt/V Dialysis Adequacy Measure Topic o Adult Hemodialysis o Adult Peritoneal Dialysis o Pediatric Hemodialysis PY 2015 clinical measures data comes entirely from Medicare claims Additional data sources for clinical measures (including CROWNWeb) will be used in PY 2016 24 C
Clinical Measure Directionality A high rate is not always better for every clinical measure: 25 C
Earning Points on Clinical Measures Facility gets the BETTER score from the two methods Achievement Score: Points awarded by comparing the facility s rate during the performance period (CY 2013) with the performance of all facilities nationally during CY 2011 Improvement Score: Points awarded by comparing the facility s rate during the performance period (CY 2013) with its own previous performance during CY 2012 26 C
PY 2015 ESRD QIP Reporting Measures (CROWNWeb Data Submission Requirements)
PY 2015 Reporting Measures Four reporting measures NHSN Dialysis Event (data source: NHSN System) ICH CAHPS Survey (data source: CROWNWeb attestation) Mineral Metabolism (data source: CROWNWeb reporting) Anemia Management (data source: Medicare claims) Ratio for calculating Anemia Management and Mineral Metabolism reporting measure scores: [(# months reporting data # eligible months) 12] 2 Ratio for calculating NHSN reporting measure score: (# months reporting data 12) 10 (NOTE: Zero points awarded for delivering less than six months of data on this measure) 28 C
PY 2015 Reporting Measures Facilities receiving their CMS Certification Number (CCN) after June 30, 2013, are excluded from all reporting measures and will not receive a TPS Facilities receiving their CCN after January 1, 2013, are excluded from the NHSN measure 11-case minimum applies (for all of 2013, not monthly) 29 C
Measure Specifications Technical Specifications of every measure available on www.dialysisreports.org/esrdmeasures.aspx Description Exclusions Data Sources More Details 30 C
Earning Points on Reporting Measures Score full points on each measure by: NHSN reporting 12 months of data ICH CAHPS Survey attesting that the facility conducted the survey (facilities that are not in-center hemodialysis facilities are exempt from this measure) Anemia Management reporting hemoglobin/ hematocrit and erythopoiesis-stimulating agent (ESA) dosage (as applicable) on Medicare claims on a monthly basis Mineral Metabolism reporting serum calcium and serum phosphorus levels of Medicare patients to CROWNWeb on a monthly basis 31 C
Example: Mineral Metabolism Facts and Circumstances: Acme Dialysis Facility, Inc. 100 in-center Medicare patients treated 7+ times on a normal month Received its CCN on April 4, 2013 Analysis: 8 eligible months (April is not a whole month ) Reporting requirements met in 5 months (did not meet 97% reporting threshold in May, July, or December) Formula: Month April Number of Patients Reported Not Applicable May 57 of 60 June 89 of 90 July 92 of 100 August 97 of 100 September 98 of 100 October 100 of 100 November 99 of 100 December 95 of 100 5 8 12 2 = 5.5, rounded to 6 32 C
Making Attestations for PY 2015 For the ICH CAHPS Survey attestation: ALL facilities should select a response in the field Yes the measure applies AND we performed the survey per the measure requirements No the measure applies BUT we did not perform the survey N/A the measure does not apply to our facility For the others: ONLY select N/A if the measure does not apply to your facility; otherwise, do not make ANY selection NHSN data is recorded on the NHSN system, which creates the report Anemia Management data is recorded on Medicare claims Mineral Metabolism data is recorded elsewhere on CROWNWeb 33 C
PY 2015 Scoring Methodology 34 C
Facility Attestation Demo
CROWNWeb Attestation Demo How do I complete Facility Attestation requirements in CROWNWeb? CROWNWeb Online Tutorial: Facility Information, Default Preferences, and Attestations CROWNWeb Online Help: Submit a Facility Attestation 36 O
CMS Comments and Wrap-Up
Final Comments 38 C
Questions 39 O
Our Next Session CMS Community Town Hall: Topic: TBD Date: January 30, 2014 Time: 2pm - 3pm ET 40 O
ESRD QIP Resources MIPPA: www.gpo.gov/fdsys/pkg/plaw-110publ275/pdf/plaw-110publ275.pdf PY 2015 Final Rule: www.gpo.gov/fdsys/pkg/fr-2012-11-09/pdf/2012-26903.pdf ESRD Center on CMS website: www.cms.gov/center/special-topic/end-stage-renal- Disease-ESRD-Center.html?redirect= /center/esrd.asp ESRD QIP section of CMS website: www.cms.gov/medicare/quality-initiatives-patient- Assessment-Instruments/ESRDQIP/index.html Dialysis Facility Compare (DFC): www.medicare.gov/dialysisfacilitycompare Dialysis Facility Reports (DFR): www.dialysisreports.org ESRD QIP measure specifications: ww.dialysisreports.org/esrdmeasures.aspx United States Renal Data Service (USRDS): www.usrds.org ESRD Network Coordinating Center (NCC): www.esrdncc.org Dialysis Outcomes and Practice Patterns Study (DOPPS): www.dopps.org National Quality Forum: www.qualityforum.org 41 O
Thank You For Further Information Help Me Form: http://help.projectcrownweb.org/ QualityNet Help Desk: 1-866-288-8912 Website: http://www.projectcrownweb.org 42 This material was prepared by FMQAI, the CROWNWeb Outreach, Communication, and Training contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. OCT contract # HHSM-500-2011-00157G. Publication Number: FL-OCT-2013OCTT2-12-1556 O