Where compliance meets opportunity

June 25, 2015
Greg Fulton,
Industry & Government
Affairs Team Member,
Greenway Health

Implementing and meeting quality reporting program demands can feel like assembling a 1,000-piece puzzle – the pieces of which have been scattered and mixed into the mismatched pieces of dozens of other puzzles along the way. Even worse, the puzzle keeps expanding.

Currently, you may be juggling requirements for the Physician Quality Reporting System (PQRS), patient-centered medical home (PCMH), and accountable care organization (ACO) while preparing your practice for the transition to ICD-10, but there are additional pieces on the horizon – such as the White House precision medicine initiative, Meaningful Use (MU) Stage 3, changes to Medicare patient volume, and yet-to-be-decided interoperability demands.

Altogether, you have a jigsaw nightmare.Fortunately, recent healthcare legislation and alignment across quality reporting and payment requirements have made it easier to sort out the many jumbled pieces. Slowly, the final picture is coming into view and, with it, hope of relief for practices.

Good news within Meaningful Use

While Meaningful Use can be a complicated brainteaser on its own, there’s simplification ahead. The Centers for Medicare & Medicaid Services (CMS) recently released a proposal shortening the 2015 MU reporting period to 90 days, and still to come this year is a 50 percent cut in overall MU objectives and a reduction in the threshold measures within them. The anticipated changes would apply to eligible professionals (EPs) and eligible hospitals (EHs) through 2017 and then merge with the mandatory advent of Stage 3 in 2018 (2017 for now is an optional year to begin Stage 3).

For EPs in Stage 2, the 17 core objectives and six menu options will be reduced to nine objectives, including one public health reporting objective with two measure options.

For EHs in Stage 2, the proposal reduces 16 objectives to eight, including the public health objective with three measure options.

CMS has not yet passed the final rule; however, it’s expected to pass without many changes in late summer and would allow the reporting data to come from any continuous 90-day span from within the 2015 calendar year for EPs, and even earlier for EHs.

Medicare Access and CHIP Reauthorization Act

More commonly known as the permanent “doc fix” or sustainable growth rate (SGR) reform, this new law establishes a 0.5 percent annual increase in Medicare fee-for-service reimbursements beginning this year, which will be replaced by a 100-point scoring system that determines reimbursement in 2019.

Meaningful Use represents 25 percent of that scoring, with remaining factors including PQRS and the Value-Based Modifier, patient engagement, and other still-to-be-identified quality reporting measures.

But there is a way out: Providers who are already in or join an “alternative payment model” (APM) and receive certain percentages of income from them can be excluded from the scoring system.

Alignment to the rescue: A true story

Increasing alignment of payment and quality measures across programs is already simplifying the puzzle for some providers. Nancy Brown, administrator at the 18-provider multispecialty practice The Veranda in Albany, GA, reports that electronic health record (EHR) functionality and adaptable workflows enable them to meet the requirements of multiple quality reporting programs and their internal care delivery standards.

“We know how providers can get very frustrated with regulation,” she says. She notes that nurturing the provider mindset remains key. “If you can really look at the model and the proactive management of the patient, you can find what works on all levels,” she says.

For The Veranda, taking advantage of the alignment of Meaningful Use objectives and PCMH standards has contributed to success. The practice has achieved Level III recognition from the National Committee for Quality Assurance’s (NCQA) PCMH program and works with private payers on monthly per-patient and annual-bonus incentive structures.

For Meaningful Use, the practice has successfully attested since 2011 and even survived a post-payment audit. (A tip from Brown: Archive printouts of your MU reporting to avoid having to pull it from your system.)

The practice administrator is well aware of how Stage 1 and PCMH 2011 – and subsequently Stage 2 and PCMH 2014 – objectives and standards line up.

“Much of it is linked, and within our practice we developed a care coordination department to focus on improvement goals and communication … how we’re managing CCD [continuity of care] documents and data exchange, for example, and aspects such as management referral,” Brown says.

EHR referral management capabilities enable the practice to “track if you refer the patient out and whether or not we received something back,” says Brown. “You have to close that loop.”

The EHR also offers clinical decision support and alerts that populate the next day’s patient roster and flag items that should be addressed during the visit. To ensure everyone is on the same page, facesheets list the members of a patient’s entire care team.

Additional functionality enables efficient, proactive communication based on the patient’s chosen method –
phone, text, or secure messaging – that also sends a reminder when they are overdue for a scheduled or recommended visit. Brown’s IT vendor also provides education materials and a cloud-based solution that streamlines the process of distributing patient satisfaction surveys linked to quality measures.

“We really try to practice proactive patient management,” she says. “When a patient chooses our practice, they may be sometimes out of sight but can never be out of mind. Especially with meeting the quality measures, that’s only possible with the right tools in place to do so.”

Alignment 2.0

Other areas of alignment are also expected to expand within SGR payment reform. Federal agencies know they’re adding to the complexities of patient care as they carry out the mandates of the HITECH Act and the Affordable Care Act. And since CMS has a hand in so many incentive programs, and private payers have taken quality program cues from the agency, expect an increase of quality reporting alignment opportunities among the various programs. Seeking out the opportunities that fit your organization is a major strategy for streamlining your data capture and liquidity.

If you’re a member of or are considering joining a CMS ACO (also known as a Medicare Shared Savings Program, or MSSP), the seven patient experience measures are expected to align with what will become patient engagement measures within the SGR reform scoring system. Patient surveys affix one or two possible points for each measure, with a high score of 14 points. Those measures are:

  1. Timely care, appointments, and information;
  2. Provider communication skills;
  3. Patient overall rating of provider;
  4. Access to specialists;
  5. Health promotion and education;
  6. Shared decision-making; and
  7. Rating of your health/functional status.

Still to be seen is whether membership within a CMS ACO will count as an alternative payment model within the SGR reform payment structure options from 2019 onward.

Alignment also exists within the CMS Comprehensive Primary Care Initiative (CPCI). This is another quality reporting program that should be an APM option in SGR reform, and it’s noteworthy because, like many PCMH programs, it’s supported by commercial payers.

Four hundred sites in seven states are participating in the CPCI pilot, which will close at the end of 2015. Results to date have been favorable enough that the program is expected to expand. The alignment point is that within the scoring domains – patient engagement (again), care management, access and continuity, chronic/preventive care, and care coordination – the specific quality measures within patient engagement mirror those of CMS ACOs.

Further contributing to alignment momentum, in early May 2015, CMS released the list of clinical quality measures for 2016 reporting and made a point to note that the number of CQMs in Meaningful Use is not increasing. This is another signal that CMS is seeking as much programmatic stability as it can within congressional legislation.

Pick your spots, and lean on your vendor

Whether it’s the complex chronic care incentive within the 2015 CMS Physician Fee Schedule, Meaningful Use, PCMH, or ACO programs, continue to seek out where quality reporting and payment alignment match your patient population, volumes, and the level of care-plan adherence your patients are achieving.

Following alignment trends, savvy vendors will build documentation and reporting tools into their systems to simplify your tasks. Be wary of vendors who didn’t keep up with regulatory changes in the past, such as those who struggled to supply a 2014 edition ONC-certified solution in time for a successful MU attestation.

The 2015 certification so far proposes 63 criteria to meet Meaningful Use and other program requirements as early as 2017. Certification is no longer just an EHR functionality test for MU requirements, but is currently expanding to ensure that EHRs can comply with new programs on the horizon.

An unprecedented spotlight on HIT

There’s been an unprecedented congressional spotlight on EHRs and health information technology this year, brought by the billions of dollars paid out for MU incentives and a general unhappiness with the state of interoperability. For example, in Congress this session the 21st Century Cures bill may finalize several years of debate on the role of EHRs in patient safety, whether providers will be asked to report any incidents tied to health IT, and whether the Food & Drug Administration should have regulatory oversight of EHRs.

Given all of this, your relationship with your IT solutions partner is paramount. As the quality program puzzle aligns and futures are increasingly tied to compliance, access to tools and solutions designed with current and emerging needs in mind will be your solution for success.

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