Centers for Medicare & Medicaid Services

1. Centers for Medicare & Medicaid Services Physician Quality Reporting Initiative (PQRI) Strategies for Successful Reporting Bruce Quinn MD Medical Director, NHIC (CA Pt B) CMS slides April 19, 2007

2. Before the main presentation • The long view – • Change in the Medicare program

3. U.S. Senate focuses on the FDA • Drug prices are too high. • Drug prices are 1/3 as high in Europe and Canada. • Drugs are over-marketed, side effects are not clearly marketed. • Wasteful industry focus on “me too” variations. • Military pays only a very small fraction of market prices – why not the rest of us?

4. Senate focuses on the FDA • Drug prices are too high. • Drug prices are 1/3 as high in Europe and Canada. • Drugs are over-marketed, side effects are not clearly marketed. • Military pays only a very small fraction of market prices – why not the rest of us? Senate Subcommitee on anti-trust, December 1959 (Sen. Kefauver) Harris, R (1964) The Real Voice. MacMillan.

5. Senator on Medicare? In attempting to explain to myself just why the administration should have devised and offered us so strange a proposal, I have found one conclusion inescapable… It was intended to lead the American people into believing that the administration was seriously concerned and was really doing something about the impossible costs of health care, while at the same time it would lull into a sense of security those who had contributed so much time, effort and money to the political campaign because they believed that a vested interest in the established system of paying for medical care would be protected.

6. Senator on Medicare? In attempting to explain to myself just why the administration should have devised and offered us so strange a proposal, I have found one conclusion inescapable… It was intended to lead the American people into believing that the administration was seriously concerned and was really doing something about the impossible costs of health care, while at the same time it would lull into a sense of security those who had contributed so much time, effort and money to the political campaign of 1952 because they believed that a vested interest in the established system of paying for medical care would be protected. Senator Murray, on the executive branch health plan of 1953 Harris, R (1966) Sacred Trust, New American Library.

7. Quotations for comparison onlynot a political comment. 1952 2004 In attempting to explain to myself just why the administration should have devised and offered us so strange a proposal, I have found one conclusion inescapable… It was intended to lead the American people into believing that the administration was seriously concerned and was really doing something about the impossible costs of health care, While at the same time it would lull into a sense of security those who had contributed so much time, effort and money to the political campaign of 1952because they believed that a vested interest in the established system of paying for medical care would be protected. The final push for 2003 Medicare legislation…pharmaceutical industry, HMOs and related interests spent more money and hired more lobbyists than ever before, according to a report issued today… …Spent a combined $141 million last year, according to Public Citizen’s analysis … nearly 10 lobbyists for every U.S. senator. “Safeguard industry profits at the expense of America’s taxpayers,” said the director of Public Citizen’s Congress Watch. http://www.citizen.org/pressroom/release.cfm?ID=1733

8. Medicare…. Nothing in this act is to be construed as interfering with the practice of medicine.

9. Medicare…. Nothing in this act is to be construed as interfering with the practice of medicine. Legislative proposals in 1950s (Sen. Kerr, others) Medicare Act (1965), Section 1801 Harris, R (1966) Sacred Trust, New American Library.

10. Things change. • Kefauver hearings started on anti-trust and pricing • Led to FDA Act of 1962 • Proof of efficacy • Labeling of adverse effects • Did not destroy industry profits (barriers to entry) • What was radical in 1961 is taken for granted today • Things change faster than you expect. • Medicare legislation long stalled in committee, 6-14 • Abruptly passed, 14-6 • House vote circa 300-100

11. Voices for Value Based Purchasing • Congress • CMS (e.g. Administration) • MEDPAC • Quasi governmental payment advisory board • Other institutes and authors • E.g. public health journal “Health Affairs” • Business Health Groups (Leapfrog, GM, Paul O’Neill, etc) • Editorials, etc.

12. Interesting things are happening. • Medicare demonstration project on MD house calls for the chronically ill. • One source suggests reduces hospitalizations by 60%. • 5% of beneficiaries = 43%... of $300B. • Will not fly under FFS • (Doctor makes 6 $80 visits a day) • Proposed to save total program costs

13. How boring is this?

14. The long view is never boring. You Are Here 1996 2006 2016

15. Centers for Medicare & Medicaid Services Physician Quality Reporting Initiative (PQRI) Adapted from CMS presentation of April 19

16. One Warning • The full program is complex • I have simplified these slides for a brief lunchtime presentations • Use CMS guidance for billing purposes • Not Lunchtime Speaker

17. Overview • Value-Based Purchasing and the PQRI • Introduction to PQRI • Preparing for PQRI • Participating in PQRI • A bit of F.A.Q.

18. Value-Based Purchasing and PQRI • Value-based purchasing is a key mechanism for transforming Medicare from passive payer to active purchaser • Current Physician Fee Schedule based on quantity and resources consumed • Value = Quality / Cost • Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care

19. Value-Based Purchasing and PQRI • Value-based purchasing is a key mechanism for transforming Medicare from passive payer to active purchaser • Current Physician Fee Schedule based on quantity and resources consumed • Value = Quality / Cost • Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care Speed = Miles / Hour

20. Value-Based Purchasing Support • President’s Budget • FYs 2006, 2007& 2008 • Congressional Interest in Value-Based Purchasing Tools • Medicare Modernization Act, Deficit Reduction Act, and Tax Relief and Health Care Act provisions • MedPAC Reports to Congress • VBP recommendations related to quality, efficiency, health information technology, and payment reform • IOM Reports • Recent report, Rewarding Provider Performance: Aligning Incentives in Medicare • Private Sector • Private health plans • Employer coalitions

21. VBP Demonstrations and Pilots • Premier Hospital Quality Incentive Demonstration • Physician Group Practice Demonstration • Medicare Care Management Performance Demonstration • Nursing Home Value-Based Purchasing Demonstration • Home Health Pay-for-Performance Demonstration • ESRD Bundled Payment Demonstration • ESRD Disease Management Demonstration • Medicare Health Support Pilots • Care Management for High-Cost Beneficiaries Demonstration • Medicare Healthcare Quality Demonstration • Gainsharing Demonstrations

22. Quality and PQRI • Cycle of Performance Improvement • Determine Best Practices • Define Measures • Collect Data • Report Results • Set Targets • Align Incentives • Support Improvement • Improve Systems • Reassess and Repeat the Cycle

23. Benefits of PQRI Participation • You will receive confidential feedback reports to support quality improvement • You may earn a bonus incentive payment • You will be making an investment in the future of your practice • Prepare for higher bonus incentives over time • Prepare for pay for performance • Prepare for public reporting of performance results

24. PQRI Eligible Professionals • Practitioners • Physician Assistant • Nurse Practitioner • Clinical Nurse Specialist • Certified Registered Nurse Anesthetist • Certified Nurse Midwife • Clinical Social Worker • Clinical Psychologist • Registered Dietician • Nutrition Professional • Physicians • MD/DO • Podiatrist • Optometrist • Oral Surgeon • Dentist • Chiropractor • Therapists • Physical Therapist • Occupational Therapist • Qualified Speech-Language Pathologist TRHCA B/101 Tax Relief & Healthcare Act of December 2006

25. PQRI Quality Measures • 74 quality measure statements, descriptions, and detailed specifications now posted at: www.cms.hhs.gov/PQRI • Specifications may be updated and expanded prior to the July 1, 2007 start date

26. PQRI Form and Manner of Reporting • The reporting period: • services from July 1 to December 31, 2007 • Just report CPT “Category II” quality codes on regular claim forms

27. PQRI Determination of Satisfactory Reporting • Report at least 3 of the 74 measures: • each measure must be reported for at least 80% of the cases in which a measure was reportable • Additional measures with lower % report do not count against • Can’t game the system • E.g. ophthalmologist reports no cataract codes on 1000 patients, but 3/3 diabetics meet the DM metrics.

28. PQRI Bonus Payment Calculation Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap • 1.5% bonus calculation is based on total allowed charges during the reporting period for covered professional services billed under the Physician Fee Schedule • Bonus payments will be made to the holder of the Taxpayer Identification Number (TIN) in a lump sum in mid-2008 • 3 partners qualify for $500, $500, $1000 • 1 payment of $2000 to the Group TIN

29. PQRI Validation and Appeals • Validation • Congress does require CMS to sample and validate whether quality measures applicable to the services have been reported • Appeals • Excluded from usual claims appeals and judicial review

30. PQRI Preparation Strategies • Integration of PQRI quality data reporting into your care delivery processes • Select Measures • Define Team Roles • Modify Workflows and Billing Systems

31. NCH Successful Quality Data Reporting Medical Record Encounter Form Coding & Billing National Claims History File Analysis Contractor Carrier/MAC Bonus Payment Confidential Report

32. I am not belaboring some details. • Submitted charge field cannot be blank • Line item charge should be $0.00 • If system does not allow $0.00 line item charge, use a small amount like $0.01 Entire claims with a zero charge will be rejected • Claim line (one penny) does not actually pay

33. You can’t lose. Mr. Jones has diagnosis of CAD. Metrics for Anti Platelet Therapy Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease All of these situations represent successful 2007 PQRI reporting. Situation 3:There is no documentation that Dr. Thomas or other eligible professional addressed antiplatelet therapy 4011F-8P modifier Situation 1: Dr. Thomas documents that Mr. Jones is receiving antiplatelet therapy. CPT II code 4011F* Situation 2: Dr. Thomas documents that antiplatelet therapy is contraindicated for Mr. Jones because he has a bleeding disorder. 4011F-1P modifier

34. PQRI Participation Strategies: • Claims must reach the National Claims History (NCH) file by February 29, 2008 • Won’t count claims submitted only to add PQRI code to claim

35. PQRI Outreach & Education • Engagement through communication • Website at: www.cms.hhs.gov/PQRI contains all publicly available information • Medicare Carrier/Medicare Administrative Contractor (MAC) inquiry management • Join the CMS provider listservs to receive notification • Educational materials (e.g., FAQs) and tools (e.g., worksheets) will be posted as they are available

36. Quinn’s Simplified Q&A

37. Interesting things are happening. • Medicare demonstration project on MD house calls for the chronically ill. • One source suggests reduces hospitalizations by 60%. • 5% of beneficiaries = 43%... of $300B. • Will not fly under FFS • (Doctor makes 6 $80 visits a day) • Proposed to save total program costs