The ABC’s of PQRI in the SNF/NF setting

The ABC’s of PQRI Carolinas Medical Directors Assn. conference 10/9/2009 Rod Baird – presenter –President of Geriatric Practice Management, Inc. Asheville, NC. –Mr. Baird reports no conflict of interest associated with this presentation

Origin of PQRI The 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries. CMS named this program the Physician Quality Reporting Initiative (PQRI).

PQRI CMS – Medicare incentive program Began in 2007 w/ 1.5% payment for successful participation Incentive increased to 2% in 2009 Proposed to continue in data will serve as basis for public reporting of MD ‘quality’

What is a PQRI Measure Intent – to promote individual quality improvement Measure types (process, outcome, etc.) Subject population (age, diagnosis, etc.) –Exclusions from subject population A specification (what is measured) –Frequency (annually, each encounter, etc,) Location (specified by CPT or HCPCS)

Measure Example Measure #1: Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus Reporting Description: Percentage of patients aged 18 through 75 years with diabetes and an applicable CPT Category II code reported a minimum of once during the reporting period Performance Description: Percentage of patients aged 18 through 75 years with diabetes (type 1or type 2) who had most recent hemoglobin A1c greater than 9.0%

PQRI in the Nursing Facility No measures are specific to LTC setting 24 measures apply to LTC CPT Codes A measure’s definition of ‘quality’ may not match ‘best practices’ for the LTC population. Neither AMDA or AGS have proposed PQRI measures, nor published any guidance on their use.

PQRI Participation Claims Based –Individual –Measure Group Registry –Measure Group

Claims Based -Individual Submit individual measures on claims –24 measures apply to codes You must use a minimum of 3 measures in 80% of the eligible encounters (e.g. annual or each visit). Some measures apply to nearly every patient in a nursing home –#47 Advanced Care Plan (≥ 65 y/o, and ) Others are highly restrictive –#12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation »patients aged ≥18 y/o with POAG who have an optic nerve head evaluation during one or more office visits within 12 months

LTC APPLICABLE PQRI MEASURES for not published

1 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had mostrecent hemoglobin A1c greater than 9.0% 2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg/dl) 3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg) 5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD who were prescribed ACE inhibitor or ARB therapy 6 Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy 7 Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy 8 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD and who were prescribed beta-blocker therapy 12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation Percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic nerve head evaluation during one or more office visits within 12 months

14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination Percentage of patients aged 50 years and older with a diagnosis of AMD who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months 18 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months 19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months 47 Advance Care Plan Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan 110 Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February) 113 Preventive Care and Screening: Colorectal Cancer Screening Percentage of patients aged 50 through 80 years who received the appropriate colorectal cancer screening 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam 118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LSVD) Percentage of patients aged 18 years and older with a diagnosis of CAD who also have diabetes mellitus and/or LVSD who were prescribed ACE inhibitor or ARB therapy

119 Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein screening or medical attention for nephropathy during at least one office visit within 12 months 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement Percentage of patients aged 50 years and older with a diagnosis of AMD and/or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care Percentage of patients aged 18 years and older with a diagnosis of POAG whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within 12 months 152 Coronary Artery Disease (CAD): Lipid Profile in Patients with CAD Percentage of patients aged 18 years and older with a diagnosis of CAD who received least one lipid profile within 12 months 154 Falls: Risk Assessment Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months 163 Diabetes Mellitus: Foot Exam The percentage of patients aged 18 through 75 years with diabetes who had a foot examination

MEASURE GROUPS Diabetes Mellitus Measures Group –DM is only measures group applicable to CPT Chronic Kidney Disease (CKD) Measures Group Preventive Care Measures Group Rheumatoid Arthritis Measures Group Perioperative Care Measures Group Back Pain Measures Group

Diabetes Mellitus Measures Group: #1. Hemoglobin A1c Poor Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0% #2. Low Density Lipoprotein Cholesterol (LDL-C) Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL- C level in control (less than 100 mg/dL) #3. High Blood Pressure Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg) #117. Dilated Eye Exam in Diabetic Patient Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam #119. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein screening or medical attention for nephropathy during at least one office visit within 12 months #163. Foot Exam Percentage of patients aged 18 through 75 years with diabetes mellitus who had a foot examination

Diabetes Mellitus Measures Group – required steps to successfully report: #1. Hemoglobin A1c Poor Control in Diabetes Mellitus completed lab test needed for complete reporting. A1c level <9.0% for ‘quality’ outcome. #2. Low Density Lipoprotein Cholesterol (LDL-C) Control in Diabetes Mellitus completed lab test needed for complete reporting. LDL-C level <100 for ‘quality’ outcome #3. High Blood Pressure Control in Diabetes Mellitus Can test & 1 st encounter but ‘quality’ requires b/p less than 140/80 mmHg #117. Dilated Eye Exam in Diabetic Patient usually requires consultation w/ report to complete this quality mesure. #119. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients usually requires lab test to report successfully. #163. Foot Exam requires either more complete exam (possibly w/o higher CPT), or referral and report

Reporting Measure Groups Claims Based –80% Sample of Eligible Patients 30 minimum Patients for year 15 minimum Patients after 7/1/09 (only pays 1% incentive) or –30 Consecutive Eligible Patients Registry Based – 30 Consecutive Eligible Patients

Considerations In 2010 – your data will be basis for public performance reporting. –TIP - Avoid reporting noncompliant behavior (a new admitted diabetic – no eye exam, no foot exam, missing labs?). Key Strategy Point – your sample population is based on billed ICD-9 codes. If you don’t list 250.xx on bill, they wouldn’t count for diabetic measures

Conisderations – cont. Cost benefit ratio for 80% sample – Potential Revenue –Medicare Charges(300 vsts./mnth x $80/vst) = $24K/month –PQRI Bonus $24K*12mnth*2% = $5,760 »Same $ effect as doing additional 1.8 visits/week 50% overhead = $2,880 MD income Added Costs –Clinician Time for review, documentation, coding »Added form?? –Medical Records – additional transcription and/or coding –Billing – additional codes on bills – ~33% error rate in 2007 submissions

Considerations – cont. 30 sequential patient sample –Only works for Diabetes Measures Group in LTC encounters –Ordering/reporting cycle for eye & foot exams; only established patients reflect ‘quality care’ Incorporation of foot exam in visit would not enhance ‘nature of presenting problem’ –Does your patient population qualify? 30 diabetics < 76 years age –< 10% of typical NF census meets these criteria

Recommended Strategy If you have 30+ sample of eligible diabetics – use measures group –Identify active, and newly admitted elegibles –Order any missing tests –Queue sample for sequential visits (can intersperse ineligibles w/o affecting PQRI –Use billing worksheet to select HCPCS codes –Coordinate w/ billing dept. or use registry NCMedSoc has $0 deal w/ docsite registry for members

Alternate Strategies Don’t have 30 eligible Diabetics? –Don’t participate Complexity of reporting multiple individual measures hard to justify (caveat – may be mandatory in 2011!) Higher risk for failure – too many variables Some measures not = best care in LTC setting –Lobby AGS & AMDA for ‘chronic care’ measures group. Requires new individual measures w/ identical denominator for measure

Claims Based Strategy Pick 3 Measures that you can successfully report on 1 st visit: –One measure must be reported 15 times or more ( minimum # goes into effect 2010) –Pick 1x/year measures –Pick process measures (ones you control - like ordering antiplatelet therapy for CAD) that do no harm –Develop a process, and templates for notes

Recommended Measures for Claims Based Submission #6 - Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD #47 – Advanced Care Planning #110 – Influenza Immunization

Template Example [] Quality Measures –4011F – oral antiplatelet therapy ordered for CAD –1124F – patient unable to participate in Adv. Care Planning; no family member or POA is available –G orders for seasonal flu shot is present in patient record

PQRI Preliminary Steps To access PQRI Data (not payments), providers have to register w/ CMS for an online account. This requires: –Register in PECOS – providers whose last CMS form 855 submission was 2006 or earlier may not be in PECOS and will have to reregister. –Register in IACS – this is portal for PQRI reports. Requires PECOS eligibility prior to registration. These processes will test your patience and leave you questioning the wisdom of a single payor system.