1 Data Reporting In The CMS Physician Quality Reporting Initiative National P4P Summit February 15, 2007 Ron Bangasser, M.D.

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Presentation transcript:

1 Data Reporting In The CMS Physician Quality Reporting Initiative National P4P Summit February 15, 2007 Ron Bangasser, M.D.

2 IHA, CMS, and PVRP IHA tried to work with CMS to integrate as many PVRP Measures as possible in IHA chose 7 measures to test in IHA agreed to work on implementing 4 other measures and leave 5 for later. Issues of implementation were mainly attribution and ability to gather data from administrative data only. 7 measures tested, not only for reporting, but also for results.

IHA Rating of PVRP Measures PVRP MeasureCommentsRating Aspirin at arrive for AMI Depends on action of ER doc; not attributable to PCP or managing doc No Beta blocker at arrive for AMI See aboveNo HbA1c control for DMGoodA LCL control for DMGoodA BP control for DMGoodA ACE/ARB for left ventricular systolic dysfunctionGoodA Beta blocker for prior MIGoodA Assessment for fallsPotentially good but needs work; NCQA working on it; difficult B Dialysis dose in ESRDNot sure of potential impact because involves so few docs C Hematocrit level in ESRDSee aboveC Autogenous arteriovenous fistula in ESRDSee aboveC Antidepressant medsIssue with carve-outs / contractingB Antibiotic prophylaxis in surg ptCurrently in NQF process; not ready now but good measure for future B Thromboembolism prophylaxis in surg ptSee aboveB Internal mammary artery in CABGAffects small number of docs, but valid measure C Pre-operative beta blocker in isolated CABGDenominator problem?B/C A = good measure; could test now B = potential measure, but needs work before could be tested C = questionable measure; not sure of impact; but could be tested No = not feasible

4 IHA Medicare Test Measures Actual 2005 test data results HgbA1c Testing 85% HgbA1c control68% LDL Testing in Diabetics93% LDL control in Diabetics73% Other than PVRP measures Breast CA screening 76% Colorectal CA screening47% Nephropathy Monitoring 54% LDL Testing in CV dx 80% LDL control in CV dx65%

5 Changes To PQRI For 2007 More measures (current count = 74) Measures may be submitted to CMS until the end of February Measures are NQF or AQA vetted Pay for reporting feature starts July 1, 2007 Physicians must report on at least three measures to qualify (80% level) A 1.5% bonus will be paid for all Medicare billings There will be caps on some payments – high dollar, low volume – more claims will reduce chances to avoid cap

6 More Details and Issues The 1.5% bonus will apply to six months of all allowed claims starting July 1, 2007 The exact nature of the caps related to some services or procedures still need to be worked out The final set of measures could change up to July 1, 2007 If no measures are available for a specialty, no money will be paid

7 PQRI-Implications Of Pay For Reporting in 2007 This is clearly Pay for Reporting and not Pay for Performance at this time The bonus amount may not be enough to cause some physicians to make the needed changes to comply Quality data must be reported using G-codes or CPT category II codes Reporting any G-code or CPT II code triggers the denominator calculation

8 How to Report By Claim Form (electronic UB 1500) ICD-9 CPT CPT II or G code CPT becomes denominator, CPT II or G code is numerator May report on paper claim form also Worksheet is helpful Data will be reported by individual Physician’s NPI, payment will be made in one check to billing entity 2008 – Registry-based will be available and data can be used by some specialties for maintenance of certification

9 PQRI In 2008 And Beyond? Further Medicare conversion factor updates are likely to be tied to reporting At some point, performance targets will be part of the program formula (P4P) There may be bonuses attached to improvement as well as targets The set of measures and the number that must be reported will expand as the capability of electronic health records is enhanced to do this work

10 No one has all the answers yet Questions?

11 Still Seeking The Ideal Payment Environment Salary- problems with productivity Fee for service- problems with overuse Capitation- problems with under use Pay for performance- problems with ignoring the things not attached to pay Some blend of all four is probably the answer!

12 Misconceptions About Clinical Performance Measurement My patients are sicker! All my patients are like my most difficult patient “Non-compliant patients” The “right answer” for every measure is 100% There should be exclusions for every unique situation

13 CMS Physician Quality Reporting Initiative AAFP Resources FPM Article Work flow suggestions Data collection sheets Coding help CMS PQRI web site Latest list of 2007 measures

14 Resources Integrated Healthcare Association Family Practice Management ions/journals/fpm.html ions/journals/fpm.html Academy Practice Support Division