PQRS measures and the chronically ill – ships passing in the night

June 6th, 2013 by Rod Baird

There is some comfort in discovering that recognized experts share your opinions. This doesn’t necessarily prove you’re correct, but in the field of health policy, expert opinion has a good record for shaping regulations. It’s heartening to see some bona fide policy experts that support our group’s opinion that the Centers for Medicare & Medicaid Services (CMS) Quality Measuring programs suffer from design errors.

Since its inception, CMS’s PQRS (Physician Quality Reporting System) has frustrated our physicians and administrative staff. So I was delighted to read Robert Berenson’s Seven Policy Recommendations To Improve Quality Measurement on the Health Affairs Blog. The post discussed a full-length paper Berenson, along with J. Pronovost, and Harlan M. Krumholz, authored for the Robert Wood Johnson Foundation titled Achieving the Potential of Health Care Performance Measures.

The authors provide seven recommendations to guide the reworking of the various quality measurement systems. It is difficult to stress highly enough how important this is becoming. The entire healthcare reimbursement system is moving toward the use of measures to drive provider reimbursement.

Physicians working in LTC are subject to the same sets of rules for quality- and cost-related reimbursement as all other ambulatory providers. But few, if any, existing physician quality and cost measures were written with our patient population in mind. There are bewildering sets of overlapping regulations in the links provided below. Take a look and see how many of these measures you think reflect “best practices” for the typical nursing facility resident (female, 80-years-old or older, five or more chronic diseases, cognitive impairment, approximate 18-month expected life span). We think the pickings are pretty slim – a real shame since this population is the most costly to our public healthcare programs (Medicare & Medicaid). We do need a rethinking of the entire structure of the Quality Measurement – value based purchasing schema. The urgency to get this right for the LTPAC population should be CMS’s No. 1 priority.

For 2013 the current quality/performance include:

PQRS (Physician Quality Reporting System): Applies to all medical providers billing Medicare Part B. Includes 203 active individual measures and 22 measure groups. LTC physicians must report on three individual measures or one group measure.

·       List of individual measures that apply to LTC encounters

·       List of group measures that apply to LTC encounters

CQM (Clinical Quality Measures): A set of 44 quality measures embedded in the Ambulatory EHR standards. Includes three core, three alternate core and 38 menu measures. Many of the measures are analogous to PQRS measures, but have their own specifications (this complexity is reconciled in Meaningful Use Stage 2 rules).

·       List of CQMs that apply to LTC encounters.

VBP (Value Based Purchasing): An additional Medicare (excluding beneficiaries covered by Part C plans) pay-for-performance program that uses a combination of cost and quality measures.

·          Quality Measures: Either existing PQRS measures or an Administrative Claims option that extracts 26 measures from processed Medicare Claims (A, B and D). To our knowledge ALL of the 26 Administrative Claims measures apply to LTC physicians subject to the VBP program.

·          Cost: Attributes patients to provider groups and compares risk adjusted costs to the average of a national peer group (same specialty practices with more than 25 providers and 20 Medicare patients).  The actual costs for all groups are risk adjusted based patient acuity, which ignores the established risk differences based on being institutionalized.

ACO (Accountable Care Organizations): Program requires the tracking of 33 total quality measures by CMS. The measures apply at the ACO level, and 22 of these measures are produced by clinicians treating the patient. They are reported to CMS via the ACO GPRO website. Based on our current experience with one of our LTC practices which is an ACO participant, nearly all of those 22 measures are assigned to the LTC physician and/or facility for reporting. CMS policy states that physicians whose practice is participating in an ACO must satisfy their PQRS reporting via the ACO GPRO interface. The current regulations appear to be moot about the threshold for avoiding the penalty for non-reporting PQRS during 2013 (-1.5% that applies to 2015 payments).

Fortunately for both LTC physicians, and the public treasury, the American Medical Directors Association (AMDA) is undertaking a project to identify and develop a set of measures that capture quality for both short term (SNF) and long term (NF) patients.

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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