By Morris W. Stemp, CPA, MBA, CPHIMS, June 03, 2013
The Centers for Medicare and Medicaid Services (CMS) use quality measures for quality improvement, public reporting, and pay-for-reporting programs. CMS defines “quality measures” as:
tools that help us measure or quantify health care processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.
A brief history of quality measures
How did we get to a place where we’re reporting quality measures to CMS via registries and electronic claims? The history of quality measures in the United States dates back to 1917 when the American College of Surgeons established its Hospital Standardization Program (HSP). This program included a set of five standards known simply as “minimum standards,” which included some of today’s most common and accepted medical practices, such as keeping records that include history, physical exam, and lab results. The HSP eventually led to the formation of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), which was tasked with reviewing medical records to assess quality of care and developing statistics on readmissions and screening procedures as a measure of performance. [pagebreak]
State oversight of physicians has been in effect ever since states started licensing physicians around the late 1800s. Federal oversight started in 1935 when the Social Security Act set minimum standards for maternal and children’s services. This oversight was expanded with the passage of the Social Security Act of 1965, which created the Medicare program, granting Americans over age 65 medical and hospital insurance. In order to participate in the program, providers had to meet certain “Conditions of Participation” — essentially a set of basic quality measures.
Quality reporting initiatives continued to evolve and be refined until, in short order, three new laws created the three Medicare-related programs I will discuss in the rest of this column:
- In 2006, the Tax Relief and Health Care Act established the voluntary Physician Quality Reporting System (PQRS), which provided for incentive payments to eligible professionals who satisfactorily report data on quality measures for covered professional services provided to Medicare beneficiaries.
- In 2008, the Medicare Improvements for Patients and Providers Act (MIPPA) authorized a combination of incentives and payment adjustments (deductions) to encourage eligible professionals to use electronic prescribing (eRx).
- Finally, in 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed. It provided for financial incentive for the meaningful use (MU) of electronic health records (EHR). Core Measure 10 of MU Stage 1 requires that providers seeking the incentives report on six clinical quality measures (CQMs). [pagebreak]
All of these federal programs only apply if the eligible professional (EP) serves a specified level of Medicare or Medicaid patients. Thus, these programs are not applicable to dermatologists who only accept private insurance or who provide services not covered by insurance.
What has to be done to meet the requirements?
For meaningful use Stage 1, effective through the end of 2013, in addition to reporting on 15 Core Objectives and five Menu Objectives, EPs need to report on a total of six CQMs. There are no minimum thresholds to meet for CQMs. EPs simply report the data exactly as it is calculated by their certified EHR.
At least three CQMs must be chosen from a group of core/required measures or alternate measures. Fortunately it is acceptable to have a zero in the denominator if the EP does not have an applicable population. Since none of these measures specifically relate to dermatology, an EP may enter zero for the denominator of these measures, effectively not reporting any of the core CQMs.
EPs are also required to select three CQMs from the list of 38 additional quality measures for Stage 1 that are relevant to the practice. These CQMs are related to diseases such as diabetes, heart failure, coronary artery disease, pneumonia, and cancer. Once again, it is acceptable to enter a zero in the denominator if these conditions are not related to a provider’s services. [pagebreak]
There are new CQMs for 2014 that might apply to dermatologists such as:
- NQF 0022: Use of High-Risk Medications in the Elderly
- NQF 0419: Documentation of Current Medications in the Medical Record
- CMS50v1: Closing the referral loop: receipt of specialist report
It is necessary for each dermatologist to review the full list of CQMs when reporting each year. Beginning in 2014, EPs will need to report on nine of 64 CQMs covering at least three of the six National Quality Strategy domains. A list of 2014 CQMs and their domains is available at www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf.
How do you submit quality measures?
In order to submit CQMs, an EP must be using an EHR certified for meaningful use. The EHR system calculates the numerator, denominator, and exclusion for each of the CQMs. In general, the numerator represents the number of patients/items from the measured population who qualify for that measure. The denominator represents the entire number of unique patients in the measured population, and the exclusions indicate the number of the measured population which does not apply to that CQM.
Data on CQM performance is reported through attestation of relevant numerators and denominators on the CMS EHR incentives site. Beginning in 2014, all Medicare EPs beyond their first year of MU participation must submit aggregate CQMs to CMS electronically while Medicaid EPs must submit CQMs electronically to their state. [pagebreak]
Eligible Professionals who meet MU may qualify for up to $44,000 (over five years) for the Medicare program run by CMS or $63,750 (over six years) for Medicaid program run by each state. Those who do not comply with MU by 2015 are subject to penalties of a 1 percent reduction in 2015 and a 2 percent reduction in 2016, increasing by 1 percent each year up to a 3 percent reduction in 2017, and up to minus 5 percent in 2019 if at least 75 percent of the total number of physicians nationwide does not attain MU. For each year, the EHR reporting period for the penalty is the calendar year two years prior to the payment adjustment period. So the penalty for not achieving MU in 2013 will be assessed in 2015, however CMS has allowed a one-time extension for those physicians beginning meaningful use in 2014. They will have until Oct. 1, 2014 to submit their attestation to avoid the 2015 penalty.
What has to be done to meet the requirements?
There are four dermatology-appropriate measures for the 2013 PQRS program, none of which are related to the CQMs required for MU. These include:
- PQRS Measure #137/NQF 0650 — Melanoma: Continuity of Care Recall System
- PQRS Measure #138 — Melanoma: Coordination of Care
- PQRS Measure #224/NQF o562 — Melanoma: Overutilization of Imaging Studies in Melanoma
- PQRS Measure #265 — Biopsy Follow-Up
Descriptions of these four measures appear online at www.aad.org/qrs. Dermatologists can also file PQRS Measure #46/NQF 0097 Medication Reconciliation and PQRS Measure #130/NQF 0419 Documentation of Current Medications in the Medical Record. [pagebreak]
How do you submit quality measures?
There are several methods by which to submit quality data to CMS. While eligible professionals may report to PQRS (1) on their Medicare Part B claims, or (2) through a qualified PQRS registry, or (3) via a qualified EHR product, or (4) through the Group Practice Reporting Option (GPRO), the four dermatology-appropriate measures can only be reported via registry. A registry is an electronic system built by an outside vendor that allows the provider to enter the information online. For example, the cost to report through the AAD Quality Reporting System is $249 per physician; this registry can be found on the AAD website.
Providers must report a minimum of three quality measures to earn an incentive; there is no payment advantage to reporting more than three. Although not eligible for any incentive, providers who report at least one measure for one patient in 2013 will avoid a 1.5 percent payment reduction in 2015. The penalty increases to 2 percent in 2016 and beyond. While with MU, EPs may report a 0 percent performance, for PQRS, the percent performance rate must be greater than zero for all reported measures.
EPs who report on PQRS can receive a 0.5 percent incentive in both 2013 and 2014. The PQRS incentives are phased out after 2014. [pagebreak]
What has to be done to meet the requirements?
Electronic prescribing is the electronic transmission of prescription or prescription-related information directly or through an intermediary such as an eRx network. To earn an incentive, a solo EP must report at least 25 prescribing events for which the denominator is eligible during 2013. In other words, prescribe electronically for 25 unique patient visits and report the G-code G8553. To avoid a penalty, the EP must submit at least 10 electronic prescriptions and report the G-code via claims during the first six months of 2013, or apply for an exemption. Group practices have higher thresholds based on group size. To be eligible to participate, office visit codes (E/M) need to represent at least 10 percent of the EP’s total Medicare Part B Physician Fee Schedule charges.
There are several hardship exemptions that prevent providers from being penalized for non-participation in eRx. However, it is already past the January 2013 deadline to request a hardship exemption to avoid the 2013 eRx payment adjustment. The deadline to apply for an exemption for 2014 is June 30, 2013. Exemptions include:
- Inability to electronically prescribe due to state or federal law, or local law or regulation;
- The eligible professional prescribes fewer than 100 prescriptions during a six-month payment adjustment reporting period;
- The eligible professional practices in a rural area without sufficient high-speed Internet access; and/or
- The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing.
Requests for exemption are made on the CMS Quality Reporting Communication Support Page. [pagebreak]
How do you submit the eRx measure?
To participate in the eRx incentive program, an EP must have and routinely use an eRx system, and report on its adoption and use. No sign-up or registration is required. The eRx system may be either a “stand-alone” system (a system designed for eRx only) or a qualified EHR system. To report on the adoption and use of eRx, the EP either (1) submits G8553 on Medicare part B claims, or (2) attests to a qualified registry, or (3) attests to CMS via a qualified EHR system, or (4) attests to a qualified data submission vendor. (G8553 indicates that at least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system.)
The 2013 eRx incentive payment is .5 percent, payable in 2014; this is the last year for which there is an incentive payment. If an EP does not report their use of eRx, Medicare will impose a penalty of 1.5 percent in 2013, and 2.0 percent in 2014 and 2015. The eRx incentive program ends after 2014. EPs who file for (or demonstrate intent to participate by registering in) the meaningful use incentive under the Medicare program are not eligible for the eRx incentive but are exempt from the penalty automatically (as e-prescribing is a core measure of MU). EPs earning the Medicaid MU incentive are eligible to also receive the eRx incentive. If you apply for both the eRx and meaningful use incentive, CMS will automatically give you the meaningful use incentive as that is paid out first. It is also most likely in your best interest to receive the meaningful use incentive as opposed to the eRx incentive since the eRx incentive dropped to 0.5 percent in 2013. You should calculate these figures out based on your Medicare Part B allowed charges to determine which incentive is greater for your practice. [pagebreak]
I think the medical community all agree that providing the highest quality health care in a safe, efficient, patient-centered, timely manner is a worthwhile goal. As Ed Koch, former mayor of New York, used to say, “How am I doing?” Using quality measures allows providers to see where they are now and to implement strategies and workflows for improvement over time. Providers should also benefit from reduced prescription errors, increased patient satisfaction, and avoidance of unnecessary phone calls for prescription clarifications through the use of eRx. And as the incentives to implement quality measures are phased out, providers will be penalized at increasing rates on top of other reimbursement reductions. It makes sense to study the quality measures relevant to dermatologists and consider how you could change your workflow to be able to comply with and report on these measures.