1. Understanding Your QRUR Meghan Donohue and Mary Franzen Qualis Health Dec. 9, 2015

2. 2 Qualis Health A leading national population health management organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington The QIO Program One of the largest federal programs dedicated to improving health quality at the local level

3. 3 Housekeeping Items Please chat questions to “All Participants.” We will be answering questions as we go and at the end of the presentation. If you have downloaded your QRUR, you might want to refer to it during the presentation.

4. 4 Save the Date Public Health Reporting for Meaningful Use in WA: How to Meet 2015 Requirements January 12, 2016 12 – 1 pm PT Register herehere Speakers to include: Travis Kushner, MPA Public Health Data Exchange Program Coordinator, Office of the State Health Officer Topics will include: Technical requirements to submit MU Objective 10: Public Health Reporting, including immunization registry reporting, syndromic surveillance reporting, and specialized registry reporting. Process for submitting data in WA and options available to EPs in 2015.

5. 5 Save the Date It’s not too late! Options for 2015 PQRS Reporting January 26, 2016 11:30-12:30 PT / 12:30-1:30 MT Register herehere Speakers to include: Kelley Carnwath, MPH, CPHIT Quality Improvement Principal Qualis Health Mary Franzen, MPH Quality Improvement Consultant Qualis Health Topics will include: 2015 PQRS reporting requirements The financial risks and rewards of PQRS participation Submission options for individual and group PQRS reporting The future direction of value-based Medicare payments

6. 6 PANELISTS Today’s Speakers MODERATOR Kelley Carnwath, MPH, CPHIT Quality Improvement Principal Qualis Health kelleyc@qualishealth.org Meghan Donohue Clinical Outcomes Analyst Qualis Health meghand@qualishealth.org Mary Franzen, MPH Quality Improvement Consultant Qualis Health maryf@qualishealth.org

7. 7 Objectives By the end of today’s presentation, you will be able to: Better understand the Value Modifier program Interpret data in your QRUR Identify opportunities for quality improvement

8. 8 MACRA MIPS PQRS VM MU APM ACO SHIP MACRA, MIPS, and Modifiers… Oh My!

9. 9 Who is subject to the Value Modifier?

10. 10 Say Hello to Group X

11. 11 Say Hello to Group X’s QRUR

12. 12 Why should Group X look at their QRUR? Groups can use QRURs and available drill- down reports through PQRS to: Verify EPs were correctly assigned to group’s TIN Compare their performance to others nationwide Validate the assigned beneficiaries and the basis for attribution Understand which beneficiaries are driving performance on cost and quality measures Identify beneficiaries in need of greater care coordination Explore provider-specific quality reporting to pinpoint improvement opportunities Raise awareness of cost and quality concerns

13. 13 Overall Performance

14. 14 Impact of Performance on Reimbursement AF represents an adjustment factor to ensure the program remains budget-neutral.

15. 15 Attributed Beneficiaries

16. 16 Fewer Benes Than You Were Expecting? Beneficiaries may be attributed elsewhere if: Bulk of primary care services in your TIN provided by NPs or PAs CMS does not have accurate provider/specialty information for TIN Primary care services are not accurately coded and billed Beneficiaries are not attributed to any medical group if: They were enrolled in only Part A or only Part B for any portion of the year They were enrolled in Part C for any portion of the year They resided outside the United States for any portion of the year They had no allowable Medicare charges for primary care services for the year Supplemental Exhibits list both the providers in your TIN and the patients assigned to your TIN. It is important to validate the accuracy of these lists in case CMS made a mistake.

17. 17 Overview of Quality Domain Note: Standardized score calculated as (Group Score – National Mean) _________________________ (National Standard Deviation) All measures are weighted equally within each domain and all domains are weighted equally within the average domain score Quality Domain Number of Quality Measures Included in Composite Score Standardized Performance Score (Quality Tier Designation) Quality Composite Score16-0.13 Effective Clinical Care11-0.80 Person and Caregiver-Centered Experience and Outcomes0--- Community/Population Health1-0.13 Patient Safety1-0.22 Communication and Care Coordination3-0.31 Efficiency and Cost Reduction0---

18. 18 Sample Performance Chart Measure ReferenceMeasure Name Your TIN’s Eligible Cases Your TIN’s Performance RateBenchmark Benchmark -1 Standard Deviation Benchmark +1 Standard Deviation Standardized Score Included in Domain Score? 111Preventive Care and Screening: Pneumococcal Vaccination for Older Adults 77489.78%45.42%14.41%76.42%1.43Yes -Diabetes Mellitus (DM): Composite (All or Nothing Scoring) 86755.09%25.50%12.96%37.43%2.36Yes 204Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 38958.55%70.56%46.12%95.00%-0.49Yes 236Hypertension (HTN): Controlling High Blood Pressure 43782.43%73.99%54.77%93.22%0.44Yes -Coronary Artery Disease (CAD): Composite (All or Nothing Screening) 32843.01%68.09%53.61%82.56%-1.73Yes

19. 19 Required Care Coordination Measures Performance Category Measure ReferenceMeasure Name Your TIN’s Eligible Cases Your TIN’s Performance RateBenchmark Benchmark -1 Standard Deviation Benchmark +1 Standard Deviation Standardized Score Included in Domain Score? Hospitalization Rate per 1,000 Beneficiaries for Ambulatory Care-Sensitive Conditions CMS-1 Acute Conditions Composite 8,0767.007.531.8113.240.09Yes - Bacterial Pneumonia 8,0761.0211.201.7620.63---No Urinary Tract Infection 8,0769.377.250.0015.08---No Dehydration8,07610.624.100.008.58---No CMS-2 Chronic Conditions Composite 3,49540.7350.4326.1974.660.40Yes - Diabetes (composite of 4 indicators) 2,4652.4818.070.0038.07---No Chronic Obstructive Pulmonary Disease (COPD) or Asthma 94736.8770.2325.43115.03---No Heart Failure1,206136.9499.7548.72150.77---No Hospital Readmissions CMS-3 All-Cause Hospital Readmissions 1,59716.45%15.94%14.55%17.34%-0.37Yes Supplemental Exhibits offer additional patient-level detail on these measures and can be used to identify potential quality improvement opportunities.

20. 20 Two Hospitalization Measures Hospitalizations for benes attributed through claims quality and per capita cost measures Hospitalizations for benes attributed through Medicare Spending per Beneficiary measure

21. 21 Cost Measures: All Practices All measures are risk-adjusted using beneficiary HCC scores, price standardized to remove geographic variation in labor costs, and specialty-adjusted based on group composition. MeasureDefinitionAttribution Methodology Domain One Medicare Spending per Beneficiary Total Part A and Part B Costs for 3 days before, during, and 30 days after inpatient episode TINs providing the most Part B inpatient services as measured through allowable charges Per Capita CostsAll Part A and Part B Costs 1.Primary care physicians providing the most primary care services 2.Non-primary care physicians providing the most primary care services Domain Two Per Capita Costs for Beneficiaries with Specific Conditions Same as above; only includes individuals with COPD, CAD, HF, Diabetes (Four Separate Measures) Same as above

22. 22 Overview of Cost Domain Note: Standardized score calculated as (Group Score – National Mean) _________________________ (National Standard Deviation) Cost Domain Number of Cost Measures Included in Composite Score Standardized Performance Score (Cost Tier Designation) Cost Composite Score6-0.28 (Average) Per Capita Costs for All Attributed Beneficiaries20.54 Per Capita Costs for Beneficiaries with Specific Conditions 4-0.85

23. 23 Sample Cost Table Cost Domain Cost Measures Your TIN’s Eligible Cases or Episodes Your TIN’s Per Capita or Per Episode Costs Benchmark Benchmark -1 Standard Deviation Benchmark +1 Standard Deviation Standardized Score Included in Domain Score? Per Capita Costs for All Attributed Beneficiaries 8,076$9,998$10,907$8,066$13,749-0.32Yes Medicare Spending per Beneficiary 1,597$22,712$20,475$18,877$22,0731.40Yes Per Capita Costs for Beneficiaries with Specific Conditions Diabetes 2,465 9,329$15,826$11,466$20,185-1.49Yes Chronic Obstructive Pulmonary Disease (COPD 947 $12,760$24,854$17,524$32,185-1.65Yes Coronary Artery Disease (CAD) 932 $15,020$18,234$13,132$23,336-0.63Yes Heart Failure 1,206$32,836$28,033$19,606$36,4600.57Yes

24. 24 Framework for Risk-Adjustment

25. 25 Overview of HCC Risk Adjustment

26. 26 Sample Patient HCC Determination

27. 27 Determining Patient Risk Scores

28. 28 Expected Costs for Individual Patients Multipliers are constants for each beneficiary demographic group. Note: Community risk scores are based on diagnoses from the previous calendar year as shown on the previous slide. New Enrollee Risk Scores are based solely on beneficiary demographic factors such as age, disability, income, and institutionalization status and used only when there are fewer than 12 months of Part B coverage.

29. 29 Aggregating Provider Expected Costs Dr. Smith had actual costs of approximately $16,000 per patient, but those costs translated to $4,665 when risk-adjusted

30. 30 Cost drill-down: 201 Download your Supplemental Exhibits Rank order attributed beneficiaries by cost. You will notice that about 10% of patients incur about 50% of costs and that 20% of patients incur about 80% of costs.

31. 31 Cost drill-down: 201(Continued) Most Expensive 20%Least Expensive 80% Patient Profile Many chronic conditions; likely seeing multiple specialists Over age 85 or under age 65 Significant post-acute needs One-two chronic conditions Little to no inpatient utilization Quality Improvement Opportunities Improved care coordination and chronic disease management Increased hospice referrals Decreased use of low- value services such as unnecessary scans Same-day appointment access to avoid ED use

32. What’s Next?

33. 33 Review QRUR Before December 16, 2015 If you have any questions regarding the status of your 2014 PQRS reporting or are concerned about potentially receiving the PQRS negative payment adjustment in 2016, please do not hesitate to submit an informal review request. All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) which is available now through December 16, 2015 at 11:59 p.m. Eastern Time. Quality Reporting Communication Support Page (CSP)

34. 34 Use the information in your QRUR Guide your 2015 PQRS submission Upcoming Webinar on 2015 PQRS reporting on Jan. 26, 2016 Identify areas for improvement

35. 35 Sample Performance Chart Measure ReferenceMeasure Name Your TIN’s Eligible Cases Your TIN’s Performance RateBenchmark Benchmark -1 Standard Deviation Benchmark +1 Standard Deviation Standardized Score Included in Domain Score? 111Preventive Care and Screening: Pneumococcal Vaccination for Older Adults 77489.78%45.42%14.41%76.42%1.43Yes -Diabetes Mellitus (DM): Composite (All or Nothing Scoring) 86755.09%25.50%12.96%37.43%2.36Yes 204Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 389 58.55% 70.56%46.12%95.00%-0.49Yes 236Hypertension (HTN): Controlling High Blood Pressure 43782.43%73.99%54.77%93.22%0.44Yes -Coronary Artery Disease (CAD): Composite (All or Nothing Screening) 32843.01%68.09%53.61%82.56%-1.73Yes

36. 36 Sample Performance Chart Measure ReferenceMeasure Name Your TIN’s Eligible Cases Your TIN’s Performance RateBenchmark Benchmark -1 Standard Deviation Benchmark +1 Standard Deviation Standardized Score Included in Domain Score? 111Preventive Care and Screening: Pneumococcal Vaccination for Older Adults 77489.78%45.42%14.41%76.42%1.43Yes -Diabetes Mellitus (DM): Composite (All or Nothing Scoring) 86755.09%25.50%12.96%37.43%2.36Yes 204Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 389 58.55% 70.56%46.12%95.00%-0.49Yes 236Hypertension (HTN): Controlling High Blood Pressure 43782.43%73.99%54.77%93.22%0.44Yes -Coronary Artery Disease (CAD): Composite (All or Nothing Screening) 32843.01%68.09%53.61%82.56%-1.73Yes

37. 37 Areas for Improvement Cardiac care and adult immunization CMS has identified cardiac care and adult immunization as areas of special focus Prevent more serious, more costly conditions in the future Qualis Health has specific programs for practices to improve in these areas 2015 PQRS reporting will require cross-cutting measures Includes some cardiac and adult immunization measures

38. 38 Areas for Improvement ABCS measures A – Aspirin for IVD PQRS # 204 B – Blood Pressure Control PQRS # 236 C – Cholesterol PQRS # 316 S – Smoking Cessation PQRS # 226 Adult immunization measures Preventive care and screening: influenza immunization PQRS # 110 Pneumonia vaccination status in older adults PQRS # 111 Included in cross-cutting measures for 2015 PQRS reporting

39. 39 Model for Improvement Choose one measure or one area of improvement Ask three fundamental questions What are we trying to accomplish? How will we know if that change is an improvement? What changes can we make that will result in that improvement? Develop an aim statement State the aim clearly Use numerical goals (“75% of our Medicare Part B patients”) State the timeframe and site of work (“by Feb. 29 at our downtown clinic”)

40. 40 Plan-Do-Study-Act Plan – Define your goals and decide what you will do to try to reach them. Do – Implement the change on a small scale. Study – What did you learn? Act – Change the plan as necessary, or adopt, to meet your goals.

41. 41 Helpful CMS Resources 2014 QRUR https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeedbackProgram/2014-QRUR.html How to Obtain a QRUR https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html

42. 42 Q & A

43. 43 For survey: https://www.surveymonkey.com/r/SZXRCF8 https://www.surveymonkey.com/r/SZXRCF8 For more information: www.Medicare.QualisHealth.org www.Medicare.QualisHealth.org This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, 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. ID/WA-HITC-QH-2047-12-15 Contact Kelley Carnwath Quality Improvement Principal kelleyc@qualishealth.org 206.288.2574 Meghan Donohue Clinical Outcomes Analyst meghand@qualishealth.org 206.288.2440 Mary Franzen Quality Improvement Consultant maryf@qualishealth.org 206.288.2554