Centers for Medicare & Medicaid Services Quality Measurement and Program Alignment

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Centers for Medicare & Medicaid Services Quality Measurement and

Program Alignment

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Conflict of Interest Disclosure

Deborah Krauss, MS, BSN, RN Maria Michaels, MBA, CCRP, PMP

Maria Harr, MBA, RHIA

Have no real or apparent

conflicts of interest to report.

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Learning Objectives

This presentation will focus on alignment efforts across the Centers for Medicare & Medicaid

Services (CMS) for Clinical Quality Measures (CQMs), highlighting the incorporation of

meaningful use of EHRs in:

 CQM Selection

 Hospital Quality Reporting

 Eligible Professional (EP) Quality Reporting

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CQM Selection

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HHS, CMS, and National Quality Strategy

BETTER HEALTH

BETTER CARE LOWER COSTS

Care Coordination

Safety Clinical

Care

Population &

Community

Health Efficiency

& Cost Reduction

Person / Caregiver

Centered

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 Three levels of

measurement critical to achieving three aims of National Quality Strategy

 Measure concepts should

“roll up” to align quality improvement objectives at all levels

 Patient-centric, outcomes- oriented measures preferred at all three levels

 The “six domains” can be measured at each of the three levels

Community

Practice setting

Individual physician

• Population-based denominator

• Multiple ways to define

denominator, e.g., county, HRR

• Applicable to all providers

• Denominator based on practice

setting, e.g., hospital, group practice

• Denominator bound by patients cared for

• Applies to all physicians

• Greatest component of a physician’s total performance

Quality:

Multi-level Measurement & Improvement

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CMS CQM Alignment Objectives

 Align with the National Quality Strategy and Six Measure Domains

 Implement CQMs that fill critical gaps within the six domains

 Align across programs whenever appropriate

 Leverage opportunities to align with private sector (e.g., NQF MAP), and focus on patient-centered CQMs (patient outcomes and patient experience).

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CMS CQM Alignment Objectives (continued)

 Create parsimonious sets of CQMs — core sets and measure concepts

 Maintain optional menu to apply to broad range of

specialties and clinical practice of medicine in programs seeking broad, diverse participation

 Remove CQMs that are no longer appropriate (e.g., topped out)

 Maximize improvement in quality and minimize

provider burden

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NQS Interagency Work Group HHS Measurement

Policy Council

HHS Measure

Coordination Group CMS Quality Measures Task Force

CMS Measures Forum Work Groups

CMS Grand Rounds

CMS Quality Improvement

Council

CMS Grand Rounds

CMS and HHS

Measurement Policy Work Groups

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CMS Quality and Performance Programs

Medicare and Medicaid EHR Incentive Program

PPS-Exempt Cancer Hospitals

Inpatient Psychiatric Facilities

Inpatient Quality Reporting

HAC Payment Reduction Program

Readmission reduction program

Outpatient Quality Reporting

Ambulatory Surgical Centers

 Medicare and Medicaid EHR Incentive Program

 PQRS

 eRx quality reporting

 Inpatient Rehabilitation Facility

 Nursing Home Compare Measures

 LTCH Quality Reporting

 Hospice Quality Reporting

 Home Health Quality Reporting

 Medicare Shared Savings Program

 Hospital Value- based Purchasing

 Physician Feedback

 Physician Value- based Modifier

 ESRD QIP

 Innovations Pilots

 Medicaid Adult Quality Reporting

 CHIPRA Quality Reporting

 Health Insurance Exchange Quality Reporting

 Medicare Part C

 Medicare Part D Hospital Quality Physician Quality

Reporting

PAC and OTHER Setting Quality

Reporting

Payment Model

Reporting “Population”

Quality Reporting

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 Measures should be patient-

centered and

outcome-oriented whenever possible

 Form a core set of measures from measure concepts in each of the six domains that are common across providers and settings

Person- and Caregiver-centered

Experience and Outcomes

 Experience of care

 Patient-reported outcomes

Efficiency and Cost Reduction

 Annual spend measures (e.g., per capita spend)

 Episode cost measures

Care

Coordination

 Care transitions

 Admission and readmission

 Provider

communication

Clinical Care

 Acute care

 Chronic care

 Prevention

 Clinical

effectiveness

Population / Community Health

 Health behaviors

 Access to care

 Disparities in care (could also apply across domains)

Safety

 Patient safety

 Healthcare- acquired

infections and conditions

 Provider safety

Greatest commonality of measure concepts across domains

CMS Measure Domains and Sub-domains

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CMS Measure Selection Criteria

Core Criteria:

 Measure addresses an important condition/topic with a

performance gap and has a strong scientific evidence base to demonstrate that the measure when implemented can lead to the desired outcomes and/or more appropriate costs (i.e., NQF’s

Importance criteria).

 Measure addresses one or more of the six National Quality Strategy Priorities (safety, care coordination, clinical care,

population health, person- and family-centered care, making care more affordable).

 Measure promotes alignment with specific program attributes and across CMS and HHS programs

 Program measure set includes consideration for healthcare disparities

 Measure reporting is feasible.

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CMS Measure Selection Criteria (concluded)

Optional Criteria:

 Measure enables measurement using measure type not already measured well (e.g., outcome, cost, etc.).

 Measure enables measurement across the person-centered episode of care, demonstrated by assessment of the person’s trajectory across providers and settings

 Program measure set promotes parsimony

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CMS Measure Selection Process

QMTF rulemaking Pre-

CQM List,

Dec 1st Pre-

rulemaking Feedback MAP

Feb 1st

NPRM for each applicable

program

Public comment on

CQMs implements CMS

CQMs in Final Rules Performance CQM

Review and Maintenance rulemaking Pre-

Assessment of Impact of

CQMs

Program staff and Stakeholders

suggest CQMs

QMTF

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Electronic Clinical Quality Measures (eCQMs)

Retooled De Novo

Start with manual chart- abstracted, paper-based specifications and translate as closely as possible to Health Quality Measures Format (HQMF) for EHR automated abstraction.

Developed from newly created measure concept into HQMF for EHR

automated abstraction.

CQM Specifications

Paper Electronic

CQM Specifications

Electronic

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eCQMs: Improvements in Development

 Standardization efforts in eCQM specifications

 Health Quality Measures Format (HQMF)

 Quality Reporting Document Architecture (QRDA)

 Q/A Review Goals in Creation of e-specifications

 National Library of Medicine: appropriate terminologies, value sets, testing, etc.

 Logic Review: frequent

 Stewards are involved throughout development processes

 Stakeholder input: early in process

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CMS Examples of Program and Measurement

Alignment

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Vision for CMS Quality Reporting Programs

Implement a unified set of

electronic clinical quality measures (eCQMs) and e-reporting requirements to synchronize

and integrate CMS quality programs and

reduce provider reporting burden.

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Goals for CMS Quality Reporting Programs

 Improve quality of care using robust CQMs, timely

feedback to hospitals and physicians, and meaningful use of EHRs.

 Minimize burden by:

 Synchronizing performance and submission periods.

 Allowing participating providers to make one submission of eCQM data for multiple programs.

 Using the same CQMs and electronic specifications across programs.

 Maximize efficiency by using eCQM data submitted by providers for multiple quality programs.

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 Quality Improvement Goals: HHS, CMS, and National Quality Strategies

 CQM Harmonization

 Populations Measured / Sample Size

 Program Performance / Reporting Periods

 Program Submission Periods

 Payment Adjustment Timelines

 Appeals

 Rulemaking Vehicles and Timelines

 Outreach, Communication, and Public Engagement

 Program Ownership

 Privacy and Security

 Type and Format

 Source

 Measure e-Specifications

 Level (aggregate, patient, or hybrid)

 Submission Pathway

 Storage

 Validation

Program Design Data and Systems

* Many of the elements are governed by statutory requirements

Alignment Elements*

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Hospital Quality Programs

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Transition to EHR Reporting for Hospitals

Transition to EHR Reporting

2011 2017

Other Hospital Quality Reporting Programs (HVBP, OQR, etc.):

Transition to eCQMs

IQR: Transition to eCQMs EHR Incentive Program

(Stage 1, 2, 3)

eCQM – Electronic Clinical Quality Measure

IQR – Inpatient Quality Reporting HVBP – Hospital Value-Based Purchasing OQR – Outpatient Quality Reporting

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 Over 99% of hospitals participate in the IQR/HVBP programs.

 Statutory requirement: CQMs must be included in IQR and displayed on Hospital Compare for one year before an HVBP performance period starts.

 CMS obtains feedback from hospitals and associations to build on current IQR/HVBP approach when aligning with EHR

Incentive Program.

 CMS will continue to electronically specify CQMs, introduce them through the EHR Incentive Program, and then transition sets of measures over time to electronic reporting in IQR,

HVBP, and other hospital reporting programs.

Hospital Program Alignment:

Key Considerations

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Hospital Program Alignment Using eCQMs

CEHRT

¹

Hospitals

1. Meaningful Use 2. IQR

3. HVBP

4. Other CMS Quality Reporting Programs eCQMs

QRDA

²

I

1

Certified EHR Technology

2

Quality Reporting Data Architecture

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Hospital Program Alignment: Timeline

 By 2013:

 Complete alignment of HVBP and IQR CQMs reported on Hospital Compare.

 Implementation of the Medicare EHR Incentive Program Electronic Reporting Pilot for Eligible Hospitals and Critical Access Hospitals.

(Note: This electronic reporting pilot will be the basis for electronic reporting in other reporting programs.)

 By 2014:

 IQR will introduce EHR-based reporting. Additional details will be included in the FY2014 Inpatient Prospective Payment Schedule proposed rule that is targeted for publication in Spring 2013.

 Beyond 2014:

 CQMs will be transitioned to EHR-based reporting in the EHR Incentive Program and then to IQR and other hospital reporting

programs.

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Eligible Professional (EP)*

Quality Programs

* NOTE: EP is a term used in the EHR Incentive

Program. Other programs may have other terms for

participants (e.g., ACOs).

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Transition to EHR Reporting

2011 2017

Other EP Quality Reporting Programs (VBM, ACOs, etc.):

Transition to eCQMs PQRS: Transition to eCQMs

EHR Incentive Program (Stage 1, 2, 3)

eCQM – Electronic Clinical Quality Measure PQRS – Physician Quality Reporting System EP – Eligible Professionals

Transition to EHR Reporting for EPs

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EP Program Alignment:

Key Considerations

 Quality Measures Reported

 PQRS and EHR Programs are aligned on the same set of eCQMs (64 total) and the same electronic specifications beginning in 2014.

 Data Origination

 If submitted electronically, the data submitted for both programs must originate from CEHRT.

 Submission Methods

 Participating EPs have the option to submit patient-level data

(via QRDA I) or aggregate data (via QRDA III) using the same

reporting mechanism for electronic reporting.

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EP Program Alignment Using eCQMs

CEHRT

¹

Individual EPs/Groups

1. Meaningful Use

2. PQRS (including PROs) 3. ACOs

4. Value-Based Modifier 5. Other CMS Quality

Reporting Programs eCQMs

QRDA

²

I or QRDA III

1

Certified EHR Technology

2

Quality Reporting Data Architecture

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EP Program Alignment: Timeline

 By 2013:

 Individual EPs

 Implementation of the PQRS-EHR Incentive Program Pilot (Note: Can fulfill the CQM component of meaningful use as well as PQRS if

reported using QRDA I).

 Group Practices

 PQRS Group Practice Reporting Option (GPRO) web interface CQMs aligned with those in the ACO GPRO measure set and the VBM GPRO measure set.

 PQRS aligned with the Physician Value-Based Modifier (VBM), whereby

the quality component of the 2015 VBM for group practices with 100 or

more eligible professionals that elect quality tiering will be based on

the groups’ performance on PQRS measures.

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EP Program Alignment: Timeline (concluded)

 By 2014:

 Individual EPs

 CMS previously finalized full alignment of PQRS EHR reporting options, including CQMs, reporting criteria, and reporting mechanism in the CY 2013 Physician Fee Schedule (PFS) and the Stage 2 rules.

 Group Practices

 CMS also previously finalized in the CY 2013 PFS and Stage 2 rules that group practices participating in the PQRS GPRO or ACOs using CEHRT and reporting via the GPRO web interface fulfill the

Centers for Medicare & Medicaid Services Quality Measurement and Program Alignment

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