PQRS/QCDR/VBPM/GIQuIC -- Making $ense of All the Letters

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1 Quality Measurement in GI 2015: PQRS/QCDR/VBPM/GIQuIC -- Making $ense of All the Letters January 24, 2015 Irving M. Pike, MD, FACG Who is Interested in Your Quality? You CMS An ACO? Your Patients Maybe some-- perceived or real quality? Private Insurers Just a few examples around the country 1

2 Who Pays for Quality? Commercial Insurance companies? Government Insurers? Patients? Our practices? NO! YES! It Depends Rarely Payment for Quality 2015 Scattering of models (Major Commercial Ins Co.) Quality to Play (North Carolina Blue Cross Blue Shield) PQRS No upside in 2015 but avoids a 2% additional fee cut in

3 Value Based Modifier (VBM) or Value Based Payment Modifier (VBPM) Groups of providers and groups of > 100 providers will be compared to other groups of their size with respect to their performance on reported Measures. The performance above, equal to or less than the mean will result in +2%, +1%, neutral or -2% Fee schedule adjustment for Medicare patients in 2017 based on 2015 performance(< no worse than neutral for 2017 and -2% possible in 2016 for 2018) PQRS 2014: Overview of PQRS Reporting Options and Requirements CMS now groups PQRS measures into National Quality Strategy domains and will require Medicare providers to report 9 PQRS measures across these various domains. The domains: Person and Caregiver-Centered Experience and Outcomes; Patient Safety; Communication and Care Coordination; Community/Population Health; Efficiency and Cost Reduction; and Effective Clinical Care. New Reporting Option: Clinical Quality Data Registry (QCDR) A QCDR is a CMS-approved entity that allows registries to select their own measures to satisfy PQRS reporting requirements. GIQuIC was deemed to be a QCDR for 2014 reporting and has applied for this deemed status for 2015 reporting. 3

4 PQRS 2015 Reporting Mechanism Qualified Clinical Data Registry: Measures selected by the Qualified Clinical Data Registry Medicare Claims Form: Individual PQRS Measures Only (no measure groups) PQRS Qualified Registry: Individual PQRS Measures; and GPRO (practice of 2+) PQRS Qualified Registry: PQRS Measures Groups To Avoid the 2017 Payment Cut (-2%) Report at least 9 measures, of which 2 must be outcome measures, covering at least 3 NQS domain. Report at least 9 PQRS measures covering at least 3 NQS domains. One measure must be a crosscutting measure. Report at least 9 PQRS measures covering at least 3 NQS domains. One measure must be a crosscutting measure. Report at least 1 measures group (20 patients with the majority being MFFS) Visit the ACG website for more information on 2015 PQRS reporting options and requirements Payment for Quality 2015 Value Based Payment Modifier Eligible Providers PQRS Reporting Fee Schedule Based on Quality and Cost Data Non-PQRS Reporting 100+ Eligible Providers PQRS Reporting Fee Schedule Based on Quality and Cost Data Non-PQRS Reporting +2%, +1% or Neutral or -2% in 2017 >mean (how much), mean, <mean -2% +2%, +1% or -2% or Neutral in 2017 >mean (how much), mean, <mean -2% 4

5 Payment for Quality 2015 Value Based Purchasing Measure PQRS Reporting Fee Schedule Based on Quality and Cost Data 1-9 Providers +2%, +1% or Neutral in % >mean (how much), mean, <mean Non-PQRS Reporting Value Based Modifier(VBM) or Value Based Payment Modifier (VBPM) Impact for a group of 10 physicians 25% of gross revenue of 12 million dollars from Medicare. Above the mean $3,000,000 X 0.02= 02 $60, Below the mean = -$60,000 5

6 Commercial Ins Tennessee P4P GIQuIC Baseline value (1 st 100,000 cases) Compliance with National Guidelines Normal Screen Colon AVG Risk 10 yr F/U <3 adenoma non-high risk, Screening Colon 5 yr F/U Adenoma Detection Rate GIA contract Goal Compliance with National Guidelines GIA with GIQuIC 1 st 3 mos Compliance with National Guidelines 64% 69% 77% 73% 57% 60% 57% 69% M >25% F> 15 % Combined >20% M=39% F=39% Combined=39% GIA with GIQuIC 2 nd 3 mos Compliance with National Guidelines M=35% F=25% Combined = 31% ACG Abstract 2013 A P4P program changes physician recommendations for colonoscopy follow up intervals. Overholt, Reynolds. et al. What to Measure? Colonoscopy and Colorectal Cancer Prevention EGD Measures IBD Hepatitis C Patient Experience Endo Unit Measures 6

7 Priority Quality Indicators for Colonoscopy 1. Adenoma Detection Rate 2. Use of recommended screening and surveillance intervals 3. Cecal intubation rate including photo documentation In print January 2015 AJG and GIE From Joint Task Force of the ACG and ASGE for GI Endoscopic Quality Indicators Priority Quality Indicators for EGD 1. Frequency with which (unless contraindicated) endoscopic treatment is given to ulcers with active bleeding or nonbleeding visible vessels 2. Frequency with which patients diagnosed with gastric or duodenal ulcers have documented plans to test for H. pylori infection 3. Frequency with which appropriate prophylactic antibiotics are given in patients with cirrhosis with acute upper GI bleeding who undergo EGD 4. Frequency of proton pump inhibitor use for suspected peptic ulcer bleeding In print January 2015 AJG and GIE From Joint Task Force of the ACG and ASGE for GI Endoscopic Quality Indicators 7

8 Priority Quality Indicators for EUS 1. Frequency with which all gastrointestinal cancers are staged with the AJCC/UICC TNM staging system 2. Diagnostic rates of malignancy and sensitivity in patients undergoing EUS-FNA of pancreatic masses 3. Incidence of post EUS-FNA adverse events (bleeding, perforation and acute pancreatitis) In print January 2015 AJG and GIE From Joint Task Force of the ACG and ASGE for GI Endoscopic Quality Indicators Priority Quality Indicators for ERCP 1. Appropriate Indication 2. Cannulation Rate 3. Stone Extraction Success Rate 4. Stent Placement for Biliary Obstruction Success Rate 5. Frequency of Post Procedure Pancreatitis In Print January 2015 AJG and GIE From Joint Task Force of the ACG and ASGE for GI Endoscopic Quality Indicators 8

9 Collecting Data for Quality Measurement Collecting Data for Quality Measurement 9

10 GI Quality Improvement Consortium, LTD (GIQuIC) A non-profit organization formed by the ACG and ASGE with a purpose of keeping gastroenterologists at the helm of quality activity as it relates to our specialty Allows for direct Endo Report Writer and EMR entry into a web-based registry as well as having a manual entry option Provides immediate feedback with respect to benchmarking of accepted quality measures Provides an opportunity for customized reports to provide physician or unit-based information or as a source of data for clinical research GI Quality Improvement Consortium, LTD (GIQuIC) Applications 1. Benchmarking and Quality Improvement 2. QCDR option for PQRS 3. MOC PIM 4. QA requirement for facility accreditation 5. Clinical Research 10

11 Access Login Portal Page 11

12 Irving M. Pike, MD, FACG Time Period, Measure Reports, Filters, and Display Options Time Period can be chosen with Daily, Monthly, Quarterly, and Annual intervals, or data can be aggregated Measure reports can be run for a single physician, an entire facility, and compared to the entire study GIQuIC Measure Reports Adenoma Detection Rate (male and female combined) My Site (red) compared to the entire study (blue) 12

13 ADR Correlation with Colon Cancer Protection 314,872 colonoscopies n Early Cancer > 6mos<3 yrs n Delayed Cancer > 3 yrs ADR, Quintiles (CI 95%) (CI 95%) <19.05% (reference) (reference) %-23.85% (0.63, 1.42) (.68, 1.30) 23.86%-28.04% (0.76, 1.57) (0.58, 0.96) 28.41%-33.50% (0.39, 1.14) (0.50, 0.90) >35.51% (0.23, 0.69) (0.39, 0.97) Corley DA, Marks AR, Zhao W, Lee JK, Quesenberry C, et al. Physician adenoma detection rate variability and subsequent colorectal cancer risk following a negative colonoscopy. Gastroenterology 2013;144:S2-3. GIQuIC QCDR Measures Report at least 9 individual measures, with at least 2 outcome measures, covering at least 3 National Quality Strategy (NQS) domains for 50% or more of applicable patients of each eligible provider (12 months) Choose from GIQuIC s 13 individual measures, which include 4 outcome measures, covering 4 NQS domains 13

14 Current Data Over 1,290,000 colonoscopies with ~15,000 new colonoscopies per week (From July 2010-Oct 2012: 100,000 colonoscopies added, in October 2013: 350,000 total colonoscopies in registry) Over 330 organizations, over 2,800 physicians Registration continues Significant clinical research project ACOs as Payors Quality-Affordability-Patient Experience The three priority measures with respect to colonoscopy come into play: adenoma detection rate, cecal intubation, screening and surveillance intervals Anesthesia vs moderate sedation Appropriate utilization of Colonoscopy Site of Service Open Access 14

15 Now There is a Quality Agenda? Are you ready to shine a light on your level of quality? 15