PQRI Special Open Door Forum in Collaboration with the American Gastroenterological Association (AGA) Institute

1. PQRI Special Open Door Forum in Collaboration with the American Gastroenterological Association (AGA) Institute Tuesday, September 23, 2008 2-3:30 p.m. EDT

2. Doing Well by Doing Good Simple Steps Collect and Report Quality Data Earn a Medicare Bonus Payment

3. Conference Leaders Daniel Green, MD (CMS) Mary Igo, RN, MBA (AGA Institute) Joel Brill, MD, AGAF (AGA Institute)

4. Topics Basic concepts Preparing for 2009 PQRI participation GI measures development for PQRI GI measures details and specifications Question and Answer Session

5. Basic Concept Select quality measures that are important to your practice and patients Establish processes to systematically report the quality measures for each eligible patient Reporting mainly done by including a quality code on claim or through registries Receive feedback on extent to which patient got the recommended care described in the quality measure Receive modest payment for effort Use process to facilitate practice and patient care improvements

6. PQRI Background - 2007 Program Federal law enacted in December 2006 established PQRI PQRI 2007 pays physicians 1.5% bonus for reporting quality measures July 1 – December 31, 2007 Select up to three measures applicable to practice from a list of 74 and report on 80% of eligible encounters for each measure selected Report against measures on standard CMS claim form CMS determines who reported successfully CMS pays bonus and provides reporting/performance score feedback in mid-2008

7. Update on PQRI 2007 Status Incentive payments for successful 2007 reporting issued mid-late July 2008 Payments issued to Tax ID Number (TIN) for all associated physicians who earned bonus Feedback reports available in July that provided reporting/performance score for each individual, for group, and national averages for comparison Feedback reports are generated for all providers that reported a quality data code regardless of whether or not he/she received a bonus Individual physician or designated staff person needs to register with secure system to access confidential reports CMS has mechanisms to help physicians with registration and receipt of reports

8. PQRI 2008 Program Congress passed December 2007 law continuing PQRI for 2008 Includes many features of the 2007 PQRI program Report codes for individual quality measures Report on up to three individual measures for at least 80% of eligible encounters Earn a 1.5% bonus Additional changes/enhancements for 2008 PQRI Expansion from 74 to 119 measures Addition of two “structural measures” Additional reporting options No cap on the bonus incentive

9. Why Participate in PQRI 2008 Increase your ability to track patients with common conditions through practice management systems Promote team care and identify team member roles and responsibilities Collect clinical information at the point of care, as opposed to retrospective chart review Reporting quality codes on claims involves minimal burden when systems in place Measures can act as reminders for certain care actions

10. Why Participate in PQRI 2008 Learn about ability to routinely provide evidence-based care relevant to your patients Receive modest payment Gain experience in reporting and measuring against quality measures Programs likely to continue, and even grow, for Medicare and private payers PQRI experience to inform and be a component of broader quality improvement strategy

11. Why participate in PQRI in 2009 Increase to 2% from 1.5% bonus incentive The bonus incentive is contingent on achieving 80 percent success for patients that have a disease/diagnosis that a quality measure you selected is being reported for; and achieving that success rate for three quality measures (or fewer measures if less apply to your practice). 

12. PQRI Update Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) - Passed in July 2008 - Makes PQRI permanent; however only 2009 and 2010 incentives are funded - Increased 2009 PQRI incentive to 2% - Added new E-Prescribing incentive for 2009, an additional 2% subject to qualifying for the measure - Additional provisions for PQRI 2010 and beyond

13. 2008 PQRI GI Measures Hepatitis C Measures in 2008 PQRI based on AQA Alliance adoption GERD One measure on GERD medication management in 2008 Four measures in 2007 PQRI were not carried over into 2008 as not endorsed by NQF Weight Screening One measure on BMI screening in 2008

14. 2008 Measures Measure 77 – GERD medication management Measures 83-90 - Treatment and Management of Hepatitis C Measure 113 – Colorectal cancer screening Measure 124 - Health Information Technology (HIT) – Adoption/Use of Health Information Technology (Electronic Health Records) Measure 125 - Health Information Technology (HIT) Adoption/Use of e-Prescribing Measure 128 – BMI Screening

15. GERD - Measure 77 • Assessment of GERD Symptoms in Patients Receiving Chronic Medication for GERD • Percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed continuous PPI or H2RA therapy who received an annual assessment of their GERD symptoms after 12 months of therapy

16. Hepatitis C - Measure 83 • Testing of Patients with Chronic Hepatitis C (HCV) for Hepatitis C Viremia • Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed

17. Hepatitis C - Measure 84 • Initial Hepatitis C RNA Testing • Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of treatment

18. Hepatitis C - Measure 85 • HCV Genotype Testing Prior to Therapy • Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of treatment

19. Hepatitis C - Measure 86 • Consideration for Antiviral Therapy in HCV Patients • Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were considered for peginterferon and ribavirin therapy within the 12-month reporting period

20. Hepatitis C - Measure 87 • HCV RNA Testing at Week 12 of Therapy • Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 12 weeks from the initiation of antiviral treatment

21. Hepatitis C - Measure 88 • Hepatitis A and B Vaccination in Patients with HCV • Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were recommended to receive or who have received hepatitis A vaccination or who have documented immunity to hepatitis A AND who were recommended to receive or have received hepatitis B vaccination or who have documented immunity to hepatitis B

22. Hepatitis C - Measure 89 • Counseling Patients with HCV Regarding Use of Alcohol • Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received education regarding the risk of alcohol consumption at least once within the 12-month reporting period

23. Hepatitis C - Measure 90 • Counseling of Patients Regarding Use of Contraception Prior to Starting Antiviral Therapy • Percentage of female patients aged 18 through 44 years and all men aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled regarding contraception prior to the initiation of treatment

24. CRC Screening - Measure 113 • Colorectal Cancer Screening • Percentage of patients aged 50 through 80 years who received the appropriate colorectal cancer screening

25. EHR Adoption - Measure 124 • HIT- Adoption/Use of Health Information Technology (Electronic Health Records) • Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted a qualified electronic medical record (EMR) that is either CCHIT certified or capable of all of the following: • Generating a medication list • Generating a problem list • Entering laboratory tests as discrete searchable data elements

26. E-Prescribing - Measure 125 • HIT- Adoption/Use of e-Prescribing • Documents whether provider has adopted a qualified e-Prescribing system and the extent of use in the ambulatory setting. To qualify this system must be capable of ALL of the following: • Generating a complete active medication list • Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checks • Providing information related to the availability of lower cost, therapeutically appropriate alternatives (if any) • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements from the patient’s drug plan

27. BMI Screening - Measure 128 • Universal Weight Screening and Follow-Up • Percentage of patients aged 65 years and older with a calculated Body Mass Index (BMI) within the past six months or during the current visit that is documented in the medical record and if the most recent BMI is ≥ 30 or < 22, a follow-up plan is documented

28. Proposed 2009 PQRI GI Measures Hepatitis C Proposed / modified for 2009 based on NQF endorsement GERD GERD medication management in 2009 Proposed Rule measure set Weight Screening One measure on BMI screening in 2009 proposed measure set Endoscopy Surveillance Colonoscopy Interval for Patients with a History of Colonic Polyps- Avoidance of Inappropriate Use Developed via PCPI process Adopted by AQA Alliance In 2009 proposed rule measure set

29. Potential Changes in 2009 Measures • Hepatitis C • Hepatitis A and B vaccinations proposed as two separate measures (NQF endorsed as paired measures) • Measures # 84 (Hepatitis C RNA Testing before Initiating Treatment) and #85 (HCV Genotype Testing Prior to Treatment) NQF endorsed as paired measures • Health Information Technology (HIT) Adoption/Use of e-Prescribing • Could be eliminated as e-Prescribing requirements are implemented • Endoscopy & Polyp Surveillance: Surveillance Colonoscopy Interval in Patients with History of Adenomatous Polyps • Watch for measure specifications

30. Endoscopy and Polyp Surveillance • Surveillance Colonoscopy Interval for Patients with a History of Colonic Polyps- Avoidance of Inappropriate Use • Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp in previous colonoscopy findings who had a follow-up interval of 3 or more years since their last colonoscopy documented in the colonoscopy report

31. PQRI and Fee Schedule Update The 2009 Physician Fee Schedule (PFS) proposed rule: - Includes the measures proposed for 2009 PQRI - Measures for 2009 PQRI will be published in Final PFS rule in November

32. 2008 Reporting Options Overview Alternate reporting periods and criteria significantly increases participation/reporting options January 1 - December 31, 2008 (12 months) July 1 - December 31, 2008 (6 months) Total of 9 PQRI reporting methods 3 claims-based 6 registry-based

33. Claims-Based Options Reporting period: January 1 – December 31, 2008 Option 1 – Report individual quality measures; report on three quality measures for 80% of eligible patients Reporting period: July 1 – December 31, 2008 Option 2 – Report a measure group for 15 consecutive eligible patients Option 3 – Report a measure group for 80% of eligible patients over the six month period

34. Reporting Individual Quality Measures If you have reported on three individual quality measures through claims for the first half of 2008, continue to do so If reported in 2007, use CMS reporting/performance feedback from that year to assess whether to adjust 2008 participation CMS/AMA measure-specific “PQRI Data Collection Worksheets” are available at: http://www.ama-assn.org/ama/pub/category/17493.html Bonus payment for full-year successful reporting is 1.5% of Medicare allowed charges over the 12 month reporting period

35. Reporting Individual Quality Measures It’s not too late to start reporting individual quality measures and hit the 80% threshold of eligible cases Requires a systematic way to identify those patients when they come in to the office Assess whether patients eligible for selected measures have been seen in the office in the first six months of year/are likely to be seen in second half of the year May report a measures group or 15 consecutive patients (i.e., Preventive Care)

36. Measure Group Reporting A measure group is a group of individual measures covering patients with a particular condition or preventive services Report applicable measures in a measure group for 15 consecutive eligible beneficiaries; OR Report applicable measures in a measure group for 80% of eligible beneficiaries during six-month reporting period Can earn bonus even if failed to report on 15 consecutive beneficiaries Provides a potentially more straightforward reporting method Bonus payment for successful reporting is 1.5% of Medicare allowed charges over the six month reporting period No measure group specifically geared to GI, but can report Preventive Care measure group

37. Registry-Based Options CMS will accept quality information reported from a clinical registry on behalf of physicians Registries collect physician-submitted data, typically related to a clinical condition or specialty but general registries are available (see CMS website) Registry data can be used a number of ways to earn a PQRI bonus payment Registry data for up to three individual measures for 80% of eligible encounters over the full year or last six months It can be used for a measure group for 30 or 15 consecutive patient or 80% of measure group eligible cases Nature and duration of reporting determines if bonus payment is equal to allowed charges for 12 or 6 months No GI specific registry at this time but there are registries collecting GI related PQRI measure’s data

38. If You Submit Quality Data to a Registry Check the CMS website at www.cms.hhs.gov/PQRI and click the reporting tab for a list of “qualified” registries. Contact a registry to see if they will report the measures you want to report and for the reporting period you want to report. Express your interest in having your data submitted for purpose of PQRI

39. How to Submit Claims To participate in PQRI, you must have a NPI number. You can submit claims for PQRI measures electronically or on a paper CMS-1500 form. You will need to provide your NPI number in the “Rendering Provider” field on the claim. Quality-data code line items must be submitted with a charge of $0.00 or $0.01.

40. Steps in Reporting Process Select the measures/measure option you will use Enlist team and assign roles and responsibilities Put systems in place to facilitate reporting/quality improvement, e.g. registries, reminders, standing orders Use a coding tool/worksheet Attach a copy of the coding tool/worksheet to the super-bill to alert coder to enter appropriate quality codes Coder verify patient eligibility, pertinent encounter, and correct quality codes

41. Steps in Reporting Process Include the NPI for each physician on claim Keep a log of information for QI Analyze your own data to improve Use experience to establish/refine systems aimed at improvement Look for other opportunities and bonus payments in your market Cultivate a positive environment for quality improvement

42. Minnesota GastroenterologyPQRI Experience 2007-2008 Providers 56 Physicians 21 NP/PA’s 2006 Quality Measure for Compensation Clinical Business 30% - 100%

43. Implementation2007 Identified Measures EMR Implementation Communication Email Fair Process Pop-up Screen With Questions Not Mandatory

44. 2007 Measures GERD 60 61 62 Encounters Lots 231 369 Compliance <4.3% 61.6% 4.3%

45. Implementation 2008 Mandatory Fields GERD Measure 77 98.8% Hep A & B Measure 88 91.7% Adoption of EMR Measure 124 100%

46. Minnesota Gastroenterology Data Collection Tools

47. Minnesota Gastroenterology Data Collection Tools

48. Question and Answer Session

49. For More Information Visit the AGA Institute Center for Quality in Practice at www.gastro.org/quality for the latest updates on PQRI and other reporting programs. Questions may be submitted to pqri@gastro.org