Primary Care in the U.S. Measuring and Improving Primary Care in the United States ISQua Indicators Summit CMS Measures. Primary Care Measures

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Measuring and Improving

Primary Care in the

United States

ISQua Indicators Summit 2012

Cliff Fullerton, MD, MS VP Chronic Disease Baylor Health Care System

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Primary Care in the U.S.

AHRQ Primary Care Workforce Facts and Stats No. 1, 2010, http://w w w .ahrq.gov/research/pcw ork1.htm

Income, Poverty, and Health Insurance Coverage in the United States, 2010, http://w w w .census.gov/prod/2011pubs/p60-239.pdf

Number of PCPs in the U.S. = 209,000

Payer Breakdown

Any government plan 32.2% Any private plan 63.9% Uninsured 16.3%

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Primary Care Measures

Multiple sources of primary care measures in the U.S.

 Government

 Centers for Medicare & Medicaid Services  Agency for Health Care Research & Quality

 Private Sector Contracts

 BCBS  Aetna  Humana  United  Cigna  Others

Independent Organizations

 National Committee for Quality Assurance  National Quality Forum

 The Joint Commission  U.S. Preventive Services Task Force  American Diabetes Association, et. al.  BTE

 Specialty societies

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CMS Measures

 PQRS

– Physician Quality Reporting Measure: 26-29

 Accountable Care Organization: 33

 Medicare Advantage: Varied

 Meaningful Use of Health IT: 33

PQRS Overview

• Established in 2007, the Physician Quality Reporting System is a

pay-for-reporting program with incentives and payment

adjustments for groups who satisfactorily report quality data.

• PQRS reporting will be the basis for the value-based modifier.

• CMS is aligning various quality reporting programs such as the

Medicare Shared Savings program and EHR Meaningful Use

incentive program.

• CMS will post information for 2012 Group Practice Reporting

Option (GPRO) performance on the Physician Compare website

in 2013.

PQRS 2011

Physician Quality Reporting Systems (formerly PQRI)

The Affordable Care Act authorized incentive payments:

Year Provider Category # Participants

Medicare Reimbursement*

HTPN Total Incentive

2009 PCP 107 2% Incentive $280,000

Specialists and Non-EHR 25

Total 132

2010 PCP 144 2% Incentive $396,000

Specialists and Non-EHR 35

Total 179

2011 Main HTPN Tax ID (GPRO) 350 1% Incentive Est. $450,000

Non-Main Tax ID [1] 103

Total 453

2012 *Baseline year for 2013 CMS Physician Compare Website 0.5% Incentive

2013 *Baseline year for 2015 penalty 0.5% Incentive

2014 0.5% Incentive

2015 1.5% Penalty

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CMS Payment Schedule

Year PQRS Medicare Reimbursement e-Rx Medicare Incentives e-Rx Medicare

Penalties Total Impact

2009 2% Incentive 2% 0% 4% 2010 2% Incentive 2% 0% 4% 2011 1% Incentive 1% 0% 2% 2012 0.5% Incentive 1% 1% 0.5% 2013 0.5% Incentive 0.5% 1.5% 0.5% 2014 0.5% Incentive 0% 2.0% 1.5% 2015 1.5% Penalty TBD by CMS TBD by CMS 1.5% 2016 2% Penalty TBD by CMS TBD by CMS 2%

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PQRS Quality Metrics

• Quality Scores

– Registry: Measures are selected by providers –

3 individual measures or 1 measure group

– GPRO: Must report all 26 measures that apply to sampling

of patients selected by CMS

– Quality scores are not currently published by CMS. 2012

data will be reported

– ‘Not Performed’ is an option

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GPRO 2011 Measures

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GPRO 2011 Measures

2012 GPRO Measures

29 measures composed of • 6 disease modules o Diabetes Mellitus o Heart Failure o Coronary Artery Disease o Hypertension

o Chronic Obstructive Pulmonary Disease o Ischemic Vascular Disease

• 9 patient care measures (individually sampled) o 7 Preventive Care measures

o 2 Care Coordination/Patient Safety measures Narrative Specifications and Measures List posted at

https://www.cms.gov/PQRS/22_Group_Practice_Reporting_Option.a sp#TopOfPage

CMS Shared Savings Programs

 Accountable Care Organizations  Reward is shared savings

 PCP Quality Measures: patient satisfaction, readmissions, MU, Patient safety, APS, Chronic Disease (DM, HTN, CAD, HF)

 Medicare Advantage

 Rewards: quality bonus and shared savings  PCP quality measures vary by insurer

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ACO 2012 CMS Shared Savings

Program Metrics

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ACO 2012 CMS Shared Savings

Program Metrics

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ACO 2012 CMS Shared Savings

Program Metrics

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Meaningful Use Clinical Quality

Measures

15 core objectives that every eligible professional must meet in order

to receive an EHR Incentive Payment.

Computerized provider order entry (CPOE) Drug-drug and drug-allergy checks

Maintain an up-to-date problem list of current and active diagnoses E-Prescribing (eRx)

Maintain active medication list Maintain active medication allergy list Record demographics

Record and chart changes in vital signs Record smoking status for patients 13 years or older Report ambulatory clinical quality measures Implement clinical decision support

Provide patients with an electronic copy of their health information, upon request Provide clinical summaries for patients for each office visit

Capability to exchange key clinical information Protect electronic health information

Meaningful Use Clinical Quality

Measures

Through 2013, required to report on:

 3 core clinical quality measures AND

 3 clinical quality measures that you select from an additional list

Beginning in 2014, will have to report on 12 clinical quality measures.

CMS Meaningful Use of HIT

3 core clinical quality measures that everyone must report on through 2013:

Clinical Quality Measure NQF Measure Number

Hypertension: Blood Pressure Measurement NQF 0013

Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment b) Tobacco Cessation Intervention

NQF 0028

Adult Weight Screening and Follow-up

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CMS Meaningful Use of HIT

Alternate Core Clinical Quality Measures:

Clinical Quality Measure NQF Measure Number

Weight Assessment and Counseling for Children and Adolescents

NQF 0024 Preventive Care and Screening: Influenza

Immunization for Patients 50 Years Old or Older NQF 0041

Childhood Immunization Status NQF 0038

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38 Additional Meaningful Use

Clinical Quality Measures

Coronary Artery Disease (CAD): Drug Therapy for Low ering LDL-Cholesterol

Diabetic Retinopathy: Communication w ith the Physician Managing Ongoing Diabetes Care

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

Diabetes: LDL Management and Control Asthma Pharmacologic Therapy Ischemic Vascular Disease (IVD): BP Management

Blood Pressure Management Asthma Assessment Controlling High Blood Pressure

Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

Beta-Blocker Therapy for CAD Patients w ith Prior MI Cervical Cancer Screening Prenatal Care: Anti-D Immune Globulin

Pneumonia Vaccination Status for Older Adults Chemo for Stage III Colon Cancer Patients Diabetes: Hemoglobin A1c Control (<8.0%)

Breast Cancer Screening Prenatal Care: Screening for HIV Heart Failure (HF): Warfarin Therapy Afib Patients Colorectal Cancer Screening Diabetes: Eye Exam Chlamydia Screening for Women

Oral Antiplatelet Therapy Prescribed for CAD Patients

Diabetes: Urine Screening Use of Appropriate Medications for Asthma

Beta-Blocker Therapy for LVSD Diabetes: Foot Exam Low Back Pain: Use of Imaging Studies

Anti-depressant medication management Diabetes: Hemoglobin A1c Poor Control Ischemic Vascular Disease

Initiation and Engagement of Alcohol and Other Drug

Dependence Treatment: a) Initiation, b) Engagement Hormonal Therapy for Stage IC-IIIC for ER/PR Positive Breast Cancer Smoking and Tobacco Use Cessation, Advising to Quit, Discussing Cessation Medications, Discussing Cessation Strategies

ACE Inhibitor or ARB Therapy for LVSD Appropriate Testing for Children w ith Pharyngitis

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Care Coordination Measures

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Care Coordination Measures

Cont’d

Private Sector Measures

Private Sector Measures Include:

 Clinical

 Service Excellence

 Access

 Efficiency

 Productivity (Absenteeism and Presenteeism)

 Quality of Life Assessment

 Patient-Centered Medical Home (PCMH)

 BTE-diabetes, CAD

Common Private Sector

Clinical Process Measures

• Adult preventive Services

• Breast cancer screening • Colorectal cancer screening • Cervical Cancer Screening • Tobacco Use

• Influenza and pneumococcal vax • Diabetes

• Hgb A1c test • BP measurement • Lipid Measurement • Eye Exam • Coronary Artery Disease

• Drug Therapy for Lowering LDL Cholesterol

• Beta-Blocker Therapy – Post MI • Depression-Medication Management • Asthma-Use of controller medication

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Common Clinical Outcome

Measures

 HbA1c Management: Percentage of patients with diabetes with most recent A1C level greater than 9.0% (poor control).

 HbA1c Management: Percentage of patients with diabetes with most recent A1C level less than 8.0% (poor control).

 Blood Pressure Management: Percentage of patients with diabetes who had their blood pressure documented in the past year less than 140/90 mm Hg.

 LDL Cholesterol Level (<130mg/dL): Percentage of patients with diabetes with most recent LDL-C less than 100 mg/dL or less than 130 mg/dL.

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Private Sector Example

•Agree to gather and report, within thirty (30) days of an Participant’s first visit, and semi-annually thereafter, and in a manner that is compliant with HIPAA and other applicable laws, the following Quality Measures.

•Health Status

•SF-12 physical score (current version) •SF-12 mental score

•Single question: state of health today •Intermediate Clinical Outcomes

•BP (systolic and diastolic) <130/80 for DM and <140/90 for CAD •A1C <7.0

•LDL <100 for DM and CAD

•Selected additional HEDIS measures as mutually agreed to by the parties •Satisfaction and Communication

•Clinic visits •Nights and weekends •Care Coordinator communication •Physician communication •Health-related Productivity

•Missed work days •Ineffective work days

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Patient Centered Medical Home

NCQA’s 2011 Medical Home Standards

• Emphasis on patient-centeredness and patient experience of care • Reinforces incentives for meaningful use (HIT)

• Focuses attention on aspects of primary care that improve quality and

reduce cost

• Based on advances in evidence and changes in practice capability

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Patient Centered Medical Home

NCQA Bridges to Excellence

Diabetes Recognition Program

Diabetes Recognition Program (DRP)

 developed to provide clinicians with tools to support the delivery and recognition of consistent high quality care

 designed to recognize physicians and other clinicians, who use evidence-based measures and provide excellent care to their patients with diabetes

The DRP Program has 10 measures which cover areas such as:

 HbA1c control  Blood Pressure control  LDL control  Eye examinations  Nephropathy Assessment

 Smoking status and cessation advice or treatment

Eligible providers will abstract data from the charts of 25 diabetes patients and submit this information to NCQA for review.

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Baylor Health Care System

• Integrated health care system in Dallas-Fort Worth, Texas

– 30 owned, leased, ventured, and affiliated hospitals – 27 joint ventured ambulatory surgical centers – 180 HealthTexas ambulatory care

locations: 600 physicians – 4,631 physicians on staff – 72 Satellite outpatient facilities –

imaging, rehabilitation, and pain

• 3,534 beds

• 20,000 employees

• 2.6 million patient encounters/year

• 130,000 full admissions/year

• $4.1 billion net operating revenue

BHCS/HTPN

Bonus/Incentive

BCBS DM $100/pt 2012 150/pt 2013 BCBS CAD $100/pt BCBS Generic Rx, Amb Surg center Aetna DM $100/pt PQRS/MU Medicare Advantage (varied) Total Total/MD Quality bonus 2012 280,000 200,000 250,000 450,000 1,180,000 $5500 2013 420,000 52,000 200,000 250,000 225,000 360,000 1,507,000 $8300 DRAFT 1.Est. in US dollars

2. PCMH bonuses are not included. They are all mostly reinvested in new resources. 2014 expected to change.

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Baylor Health Care System

Experience/Challenges

 Aligning with disparate measures

 Private vs. CMS measures

 Standardized Measures/Thresholds vs. Patient Preferences

 Balancing focus vs. completeness

 Focus on a few key measures

 Example-Diabetes:

 Emphasize: HbA1c < 7, BP <130/80, LDL <100, ASA and tobacco use  Not retinal, microalbuminuria, foot exam

 Internal benefits of national metrics

 Bonuses and incentives. Growing from 2.5% to 10% in 2014

 Evaluate performance

 Lessens internal debate

 Cost

 Internal Staff

 Vendor support