MDinteractive

Accountable Care Organization (ACO) Accelerated Development Learning Program

2011-06-27T15:30:00.009-04:00

I just came back from a conference organized by Medicare for Accountable Care Organizations (ACO) in Minneapolis.

These are some of the interesting ideas/thoughts/tips that I got there:
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Don Berwick, MD, MPP, Administrator, Centers for Medicare & Medicaid Services:

- You don't need to lock patients to reach the Triple Aim of the ACO. Triple Aim is the business plan of the ACO.

- We need medical boards that celebrate when hospital beds are empty. We need to move away from an acute care system

- Medicare got 1200 comments on the Medicare ACO proposed rules.

- ACOs need to change health care delivery - this is not negotiable.

- Medicare is offering different options for ACOs with levels of experience. Using a skiing metaphor: Black diamond - Pioneer ACO. Blue Square - Track 2 Shared Savings ACO (takes risk on all 3 years). Green circle - Track 1 Shared Savings (takes risk only on third year).

- ACOs need to emulate best practices. For example, there are medical groups that have almost 0% complications on hip replacements and send most patients home after 2 days

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James Rogers, MD, St. John’s Health System, Springfield, Missouri

Dr. Rogers has experience working with Medicare on a Medicare ACO Prototype — Medicare's Physician Group Practice Demonstration.

You can read more about this program at the New England Journal of Medicine

As you can see in this NEJM table, St. John's received no money on year 1 or 2, received $3,143,044 on year 3 and $8,185,757 on year 4.

One of the focus on this group was heart failure and nursing home transitions. Also putting nurse case manager on the ER was very important for their success during PGP. That prevented some hospital admissions related with "social" reasons.

There were able to decrease COPD admissions by vaccinating all COPD (they even send nurses to patients homes to give them shots) and worked on a smoke cessation program. An "emergency box" with prednisone and antibiotics was given to COPD patients. When the patient was short of breath, he could call the doctor and get permission to take the meds. Dr. Rogers found out that sending a prescription to the pharmacy of a patient with a COPD exacerbation would take an extra few hours and by then patient would be too short of breath and come to ER.

Dr. Rogers also found out that with direct phone calls between the hospitalists and the PCPs ("warm transfer"), the hospital readmissions drop significantly.

This group had experience already with the Medicare Advantage program and they translated some of this experience into the PGP demonstration program.

St. John's had no EHR initially and they used a homegrown registry to keep track of patients. Their initial billing system was IDX and they used it to track all the diagnosis and visits. The registry produced a "Visit Planner" with lists of all tests that patient is missing at the time a patient visits a doctor.

The PGP Medicare bonus was distributed the following way: Medicare got 20% savings and group got 80%. The group divided 50% to providers and 50% to system to pay for investment.

St John's managed 29000 medicare patients under the PGP. St. John Clinic changed job descriptions to some of their staff and it was able to only spend an extra $0.5m during first year and then $250-350k on the following years with infrastructure. St. John realized 3% savings on Medicare total costs.

There was a 30% change between year 3 and 4 on the Medicare population under PGP.

It is very important to keep track of the patient in almost real-time. Claims data sent from Medicare to St. John's was not used to track patients. St. John's used their own billing data. Around the 4th year, St. John's made a transition to an EHR and they lost some of the tracking abilities for a few months. For example, nurse care managers were not able to track CHF patients. That may affect their bonus payments for PGP year 5.

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Barbara Walters, MD
Senior Medical director, Dartmouth-Hitchcock Medical Center

Dr. Walters also had experience with the PGP program at Dartmouth-Hitchcock Medical Center.

Dartmouth received no money on year 1, received $6,689,879 on year 2 and $3,570,173 on year 3 and $378,798 on year 4. They attribute the later decrease on the PGP bonus amount to a transition to an EHR.

Interesting, Marshfield Clinic, another PGP group (they didn't present their data on this meeting) made $4.5M on year 1, $5,8M on year 2, $13,8M on year 3 and $16,2M on year 4. This Wisconsin group already had an EHR before joining the PGP.

Dr. Walters thinks that another factor on the success under PGP is related with population size. It seems that no PGP group was able to get a bonus by managing Medicare populations below 15,000 patients. Dartmouth managed 32,000 patients and St. John's managed 29,000 patients.

Dartmouth also a focus on managing patients with CHF.
They selected high risk patient populations based on:
3 comorbidities, > 7 E&M visits, >10K on total Medical expenses or patients on 3 different classes of medications. They marked this patients as "Goldstar".

Dr. Walters had a practical way to define patients that are attributed to the Medicare ACO/PGP program- if >3 visits with the group doctors, they belong to the group.

Dartmouth also used commercial software to define high risk populations ("Episode Treatment Groups") and they got the same results by just asking medical offices about who were the high risk patients. Medical offices were advised to give same day appointments to anyone on the priority list (Goldstar patients) that called.

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Craig Samitt, MD, Chief Executive Officer, Dean Health

Dr. Samitt talked about his experience of doing a transition from a volume based healthcare system to a value based system. He previously worked with Harvard Pilgrim and with Fallon Clinic in Massachusetts.

PCPs are essential on this transition. Interestingly, PCPs only earn 4% of total medical expenses (TME). Dean gave a 15% payment increase to PCPs (with a negligible effect on TME) and saved a lot of money.

Dean moved to a Value system by paying doctors based on Access/Growth (the doctor can choose new patient growth or appointment availability), patient satisfaction, quality (doctors can choose quality measures on the first year, then improve quality on second year) and achieving meaningful use.

They reward doctors with a blend of corporate performance (total cost of care), department level performance (quality) and individual performance (patient satisfaction).

They measure performance first then link to compensation. They offer a menu of options to make transition palatable.

Dean System made the incentive small initially (1-2% each) with low thresholds and then changed the metrics, increased the weights, decreased the options and raised the thresholds over time.

Received $18,000 check from Medicare for Meaningful Use Attestation with Care360 EHR

2011-06-27T14:16:00.006-04:00

I submitted my Medicare EHR Incentive Attestation with Care360 EHR on April 18, 2011
I got a $18,000 Medicare check today:

"CMS FAQ on Payment for the Medicare EHR Incentive Program:

Question: I am an eligible professional (EP) who has successfully attested for the Medicare EHR Incentive Program, so why haven't I received my incentive payment yet?

Answer: For EPs, incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year.

The Medicare EHR incentive payments to EPs are based on 75% of the estimated allowed charges for covered professional services furnished by the EP during the entire payment year. Therefore, to receive the maximum incentive payment of $18,000 for the first year of participation in 2011 or 2012, the EP must accumulate $24,000 in allowed charges. If the EP has not met the $24,000 threshold in allowed charges at the time of attestation, CMS will hold the incentive payment until the EP meets the $24,000 threshold in order to maximize the amount of the EHR incentive payment the EP receives. If the EP still has not met the $24,000 threshold in allowed charges by the end of calendar year, CMS expects to issue an incentive payment for the EP in March 2012 (allowing 60 days after the end of the 2011 calendar year for all pending claims to be processed).

Payments to Medicare EPs will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. The form of payment (electronic funds transfer or check) will be the same as claims payments.

Bonus payments for EPs who practice predominantly in a geographic Health Professional Shortage Area (HPSA) will be made as separate lump-sum payments no later than 120 days after the end of the calendar year for which the EP was eligible for the bonus payment.

Want more information about the EHR Incentive Programs?
Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs."

Medicare EHR Incentive Attestation with Care360 EHR

2011-04-18T09:17:00.051-04:00

I submitted my Medicare EHR Incentive Attestation with Care360 EHR today at 9.10am.
I was the 25th physician in the US to submit the attestation to Medicare.
I started the attestation process at 8.10am.

"
These are steps for the attestation using the "Medicare & Medicaid EHR Incentive Program Registration and Attestation System":

Medicare ACO proposed rules: Highlights

2011-04-02T13:49:00.021-04:00

The Medicare ACO proposed rules can be found at:

Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

These are some of the highlights of this 429 pages document:

"The following groups of providers of services and suppliers are eligible to participate:
• ACO professionals in group practice arrangements.
• Networks of individual practices of ACO professionals.
• Partnerships or joint venture arrangements between hospitals and ACO professionals.
• Hospitals employing ACO professionals.
• Such other groups of providers of services and suppliers as the Secretary determines appropriate.

The ACO shall enter into an agreement with the Secretary to participate in the program for not less than a 3-year period.

At a minimum, the ACO shall have at least 5,000 such beneficiaries assigned to it in order to be eligible to participate in the Shared Savings Program.

The ACO shall demonstrate to the Secretary that it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans.

ACO is eligible to receive payment for shared savings if the following occur:
• The ACO meets quality performance standards established by the Secretary;
• The ACO meets the requirements for realizing savings.

We will focus on achieving, as our highest-level goal, the three-part aim which consists of the following:

• Better care for individuals – as described by all six dimensions of quality in the Institute of Medicine report: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity;
• Better health for populations with respect to educating beneficiaries about the upstream causes of ill health – like poor nutrition, physical inactivity, substance abuse, economic disparities – as well as the importance of preventive services such as annual physicals and flu shots; and
• Lower growth in expenditures by eliminating waste and inefficiencies while not withholding any needed care that helps beneficiaries.

For purposes of this proposed rule, we propose definitions for the following
terms:
• Accountable care organization (ACO) means a legal entity that is recognized
and authorized under applicable State law, as identified by a Taxpayer Identification Number (TIN), and comprised of an eligible group (as discussed in section II.B. of this
proposed rule) of ACO participants that work together to manage and coordinate care for
Medicare FFS beneficiaries and have established a mechanism for shared governance that
provides all ACO participants with an appropriate proportionate control over the ACO's
decision making process,
• ACO participant means a Medicare-enrolled provider of services and/or a supplier, (as discussed in section II.B. of this proposed rule, as identified by a TIN).
• ACO provider/supplier means a provider of services and/or a supplier (as
discussed in section II.B. of this proposed rule) that bills for items and services it
furnishes to Medicare beneficiaries under a Medicare billing number assigned to the TIN
of an ACO participant in accordance with applicable Medicare rules and regulations.

We note that by proposing that the ACO be required to have a TIN, we are not
proposing to require that the ACO itself be enrolled in the Medicare program, in contrast to this requirement for each ACO participant.

We are not proposing to require that existing legal entities appropriately recognized under State law must form a separate new entity for the purpose of participating in the Shared Savings Program.

The Act requires that an ACO have a "mechanism for shared governance"

We believe that such a governance mechanism should allow for appropriate proportionate control for ACO participants, giving each ACO participant a voice in the
ACO's decision making process, and be sufficient to meet the statutory requirements
regarding clinical and administrative systems.

The governing body may be a board of directors, board of managers, or any other governing body that provides a mechanism for shared governance and decision-making for all ACO participants, and that has the authority to execute the statutory functions of an ACO, including for example, to "define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care,".

We propose that in order to be eligible for participation in the Shared Savings Program, the ACO participants must have at least 75 percent control of the ACO's governing body.

In addition, each of the ACO participants must choose an appropriate representative from within its organization to represent them on the governing body. This proposal ensures that ACOs remain provider-driven, but also leaves room for both non-providers and small provider groups to participate in the program.

We are proposing that ACOs meet the following criteria:
• The ACO's operations would be managed by an executive, officer, manager, or
general partner, whose appointment and removal are under control of the organization's
governing body and whose leadership team has demonstrated the ability to influence or
direct clinical practice to improve efficiency processes and outcomes.

• Clinical management and oversight would be managed by a senior-level medical director who is a board-certified physician, licensed in the State in which the ACO operates, and physically present in that State.

• ACO participants and ACO providers/suppliers would have a meaningful commitment to the ACO's clinical integration program to ensure its likely success.
Meaningful commitment may include, for example, a meaningful financial investment in
the ACO, or a meaningful human investment (for example, time and effort) in the
ongoing operations of the ACO such that the potential loss or recoupment of the
investment is likely to motivate the participant to make the clinical integration program
succeed.
• The ACO would have a physician-directed quality assurance and process improvement committee that would oversee an ongoing quality assurance and improvement program. The quality assurance program would establish internal performance standards for quality of care and services, cost effectiveness, and process and outcome improvements, and hold ACO providers/suppliers accountable for meeting the performance standards. The program would also have processes and procedures in place to identify and correct poor compliance with such standards and to promote continuous quality improvement.
• The ACO would develop and implement evidence-based medical practice or
clinical guidelines and processes for delivering care consistent with the goals of better care for individuals, better health for populations, lower growth in expenditures. The guidelines and care delivery processes would cover diagnoses with significant potential for the ACO to achieve quality and cost improvements, taking into account the circumstances of the individual beneficiary, and could be accomplished, for example, through an integrated electronic health record with clinical decision support. ACO participants and ACO providers/suppliers would have to agree to comply with these guidelines and processes and to be subject to performance evaluations and potential remedial actions.
• The ACO would have an infrastructure, such as information technology, that enables the ACO to collect and evaluate data and provide feedback to the ACO providers/suppliers across the entire organization, including providing information to influence care at the point of care via, for example, shared clinical decision support, feedback from patient experience of care surveys or other internal or external quality and utilization assessments.

It is our expectation that ACO participants and ACO providers/suppliers participating in the ACO would make a commitment to participate in the ACO for not less than 3 years.

In order to determine an ACO's compliance with these requirements, as part of the
application process, we are proposing that an ACO would submit all of the following:
• ACO documents (for example, participation agreements, employment contracts,
and operating policies) that describe the ACO participants' and ACO providers/suppliers' rights and obligations in the ACO, the shared savings that will encourage ACO participants and ACO providers /suppliers to adhere to the quality assurance and improvement program and the evidenced-based clinical guidelines;
• Documents that describe the scope and scale of the quality assurance and
clinical integration program, including documents that describe all relevant clinical
integration program systems and processes, such as the internal performance standards
and the processes for monitoring and evaluating performance;
• Supporting materials documenting the ACO's organization and management
structure, including an organizational chart, a list of committees (including names of
committee members) and their structures, and job descriptions for senior administrative
and clinical leaders; and
Evidence that the ACO has a board-certified physician as its medical director
who is licensed in the State in which the ACO resides and that a principal CMS liaison is identified in its leadership structure.
• Evidence that the governing body includes persons who represent the ACO
participants, and that these ACO participants hold at least 75 percent control of the
governing body.

If the ACO is approved for participation, we propose that an authorized representative -- specifically, an executive who has the ability to bind the ACO, must certify to the best of his or her knowledge, information, and belief that the ACO participants agree to the requirements set forth in the 3-year agreement between the ACO and us -- sign a 3-year participation agreement and submit the signed agreement to us.

Distribution of Savings

We propose to make any shared savings payments directly to the ACO as identified by its TIN.

This is part of the rationale for the payment withhold described in more detail in section II.

Therefore, we propose to require ACOs to provide a description in their application of the criteria they plan to employ for distributing shared savings among ACO participants and ACO providers/suppliers, and how any shared savings will be used to align with the aims of better care for individuals, better health for populations, and lower growth in expenditures.

Sufficient Number of Primary Care Providers and Beneficiaries

The Act requires participating ACOs to "include primary
care ACO professionals that are sufficient for the number of Medicare fee-for-service
beneficiaries assigned to the ACO …" and that at a minimum, "the ACO shall have at
least 5,000 such beneficiaries assigned to it"

We discuss our proposal to assign beneficiaries to an ACO on the basis of
primary care services rendered by physicians with primary care specializations in general practice, internal medicine, family practice, and geriatric medicine. We are proposing that this algorithm will also be used to assign beneficiaries during the baseline years in order to establish a historical per capita cost benchmark against which the ACO would be evaluated during each year of the agreement period.

An ACO would be determined to have a sufficient number of primary care ACO professionals to serve the number of Medicare beneficiaries assigned to it if the number of beneficiaries historically assigned over the three-year benchmarking period using the ACO participant TINs exceeds the 5,000 threshold for each year.

We are also proposing to require an ACO to maintain, update, and annually report to us the TINs of its ACO participants and the NPIs associated with the ACO providers/suppliers.

• Patient involvement in ACO governance. As discussed in more detail later in
the document, the ACO would be required to have a Medicare beneficiary on the governing board.

In order to safeguard against any conflicts of interest, any patient(s) included in an ACO's governing body, or an immediate family member, must not have any conflict of interest, and they may not be an ACO provider/supplier within the ACO's network.

We are proposing that all ACO marketing materials, communications, and activities related the ACO and its participation in the Shared Savings Program, such as mailings, telephone calls or community events, that are used to educate, solicit, notify, or contact Medicare beneficiaries or providers/suppliers regarding the ACO and its participation in the Shared Savings Program, be approved by us before use to protect beneficiaries and to ensure that they are not confusing or misleading. This requirement would also apply to any materials or activities used by ACO participants or ACO providers/suppliers on behalf of the ACO to communicate about the ACO's participation in the Shared Savings Program in any manner to Medicare beneficiaries. In addition, we would want to ensure that materials distributed to beneficiaries do not misrepresent Shared Savings Program policies or suggest that we endorse the ACO, its ACO participants, or its ACO providers/suppliers.

We do not believe that the following materials and activities would be subject to our approval:
Beneficiary communications that are informational materials, that are
customized or limited to a subset of beneficiaries;
and materials that do not include information about the ACO or providers in the ACO;
materials that cover beneficiary specific billing and claims issues or other specific individual health related issues; and
educational information on specific medical conditions, (for example, flu shot reminders), or referrals, for example, as discussed in section II. C. of this proposed rule, exceptions to the definition of "marketing" under the HIPAA Privacy Rule.

C. Establishing the 3-year Agreement with the Secretary
1. Options for Start Date of the Performance Year

We propose:
(1) to adopt the general requirement that ACO applications must be submitted by a deadline established by us;
(2) we will review the applications and approve applications from eligible organizations prior to the end of the calendar year;
(3) the requisite 3-year agreement period will begin on the January 1 following approval of an application; and
(4) the ACO's performance periods under the agreement will begin on January 1 of each respective year during the agreement period.

2. Timing and Process for Evaluating Shared Savings

Based upon historical trends, a 3-month run-out would result in a completion percentage of approximately 98.5 percent for physician services and 98 percent for Part A services.
A 6-month run-out of claims data results in a completion percentage of approximately 99.5 percent for physician services and 99 percent for Part A services.

We propose using a 6-month claims run-out to calculate the benchmark and per capita expenditures for the performance year.

3. Data Sharing

"We could provide data to ACOs in different forms with a focus on different levels
of information, for example, aggregated population level data or beneficiary identifiable data. These data could be combined with data collected within the ACO."

4. Sharing Aggregate Data

In the PGP demonstration, we provided several types of aggregate data to the
participating group practices. We generated an annual profile report that provided the
following information:
• Financial performance including number of patients seen, number of patients assigned, per capita expenditures, risk score, benchmark, total assigned beneficiary expenditures, minimum savings amount, shareable savings, and annual performance payment.
• Quality performance scores, including numerator, denominator, and rate for each measure along with the target benchmark for each measure.
• Aggregated metrics on the assigned beneficiary population, including a breakdown of the population into high risk score beneficiaries, beneficiaries with 1 or more hospitalizations, and chronic disease subpopulations such as patients with congestive heart failure, coronary artery disease, hypertension, chronic obstructive
pulmonary disease, and diabetes.
• The number of patients overall and in each subpopulation with emergency department visits, hospital discharges, physician visits and their corresponding rate for the assigned population.

In general, by making similar types of aggregate, data available to ACOs
participating in the Shared Savings Program, we believe ACOs would have a more
complete picture of the services rendered to their assigned FFS beneficiaries

We further propose to include these data in conjunction with the yearly financial and quality performance reports. Additionally, we propose to provide quarterly aggregate data reports to ACOs based upon the most recent 12 months of data from potentially assigned beneficiaries.

5. Identification of Historically Assigned Beneficiaries

We propose to make certain limited beneficiary identifiable data available at the beginning of the first performance year.

Accordingly, we propose to disclose the name, date of birth (DOB), sex and Health Insurance Claim Number (HIC) of the historically assigned beneficiary population.

Therefore, at the beginning of the agreement period, at the request of the ACO,
we are proposing to provide the ACO with a list of beneficiary names, date of birth, sex, and HICN derived from the assignment algorithm used to generate the 3-year benchmark.
As discussed in section II.B. of this proposed rule, these are beneficiaries who received the plurality of primary care services from primary care physicians who are ACO participants.

6. Sharing Beneficiary-Identifiable Claims Data

For these reasons we believe sharing beneficiary identifiable claims data with ACOs will assist them in improving care for individuals, improving health of their population, and reducing the growth in expenditures for their assigned beneficiary population.

Additionally, when an ACO is accepted to participate in the Shared Savings
Program, we propose to require ACOs to enter into a Data Use Agreement (DUA) prior
to receipt of any beneficiary identifiable claims data. Under the DUA, the ACO would be prohibited from sharing the Medicare claims data that we provide through the Shared Savings Program with anyone outside the ACO.

(1) Sharing Data Related to Medicare Parts A and B

(2) Sharing Data Related to Medicare Part D

a. Beneficiary Opportunity to Opt-Out of Claims Data Sharing

Therefore, we propose affording beneficiaries the ability to opt-out of sharing their protected health information with the ACO. We believe this opportunity coupled with notification of how protected health information will be shared and used affords beneficiaries meaningful choice.

An example of the opt-out approach would be that when a beneficiary has a visit with their primary care physician, their physician would inform them at this visit that he or she is an ACO participant or ACO provider/supplier and that the ACO would like to be able to request claims information from us in order to better coordinate the beneficiary's care. If the beneficiary objects, we propose that the beneficiary would be given a form stating that they have been informed of their physician's participation in the ACO and explaining how to opt-out of having their personal data shared. The form could include a phone number and/or email address for beneficiaries to call and request that their data not be shared.

As noted previously, ACOs will only be allowed to request beneficiary identifiable claims data for beneficiaries who have
1) visited a primary care participating provider during the performance year, and
2) have not chosen to opt-out of claims data sharing.

7. New Program Standards Established During 3-Year Agreement Period

We propose that ACOs be subject to future changes in regulation with the
exception of the following program areas:
• Eligibility requirements concerning the structure and governance of ACOs;
• Calculation of sharing rate; and
• Beneficiary assignment.

For example, ACOs would be subject to changes in regulation related to the
quality performance standard. The language of the ACO agreement would be explicit to
ensure that ACOs understand the dynamic nature of this part of the program and what
specific programmatic changes would be incorporated into the agreement.

D. Assignment of Medicare Fee-for-Service Beneficiaries

However, assignment of beneficiaries to ACOs is to be determined only on the basis of primary care services provided by ACO professionals who are physicians.

The term "assignment" in this context refers only to an operational process by which Medicare will determine whether a beneficiary has chosen to receive a sufficient level of the requisite primary care services from physicians associated with a specific ACO so that the ACO may be appropriately designated as exercising basic responsibility
for that beneficiary's care.

It is important to note that the term "assignment" for purposes of this provision in no way implies any limits, restrictions, or diminishment of the rights of Medicare FFS beneficiaries to exercise complete freedom of choice in the physicians and other health care practitioners and suppliers from whom they receive their services.

Therefore, we are proposing to identify an ACO operationally as a collection of Medicare enrolled TINs.

In particular, NPI data will be useful to assess the quality of care furnished by an ACO. For example, NPI information will be necessary to determine what percent of physicians and other practitioners in the ACO are registered in the HITECH program
We are also proposing to require that organizations applying to be an ACO must provide not only their TINs but also a list of associated NPIs for all ACO professionals, including a list that separately identifies physicians that provide primary care.

2. Definition of Primary Care Services

In that section, "primary care services" are defined as a set of services
identified by these HCPCS codes: 99201 through 99215; 99304 through 99340; and
99341 through 99350. Additionally, we would consider the Welcome to Medicare visit
(G0402) and the annual wellness visits (G0438 and G0439) as primary care services for
purposes of the Shared Savings Program.

Assign beneficiaries with physicians designated as primary care providers (internal medicine, general practice, family practice, and geriatric medicine) who are providing the appropriate primary care services to beneficiaries.

3. Prospective vs. Retrospective Beneficiary Assignment to Calculate Eligibility for Shared Savings

We believe that the retrospective approach to beneficiary assignment for purposes of determining eligibility for shared savings is compelling.

Therefore, we are proposing the combined approach of retrospective beneficiary assignment for purposes of determining eligibility for shared savings balanced by the provision of aggregate beneficiary level data for the assigned population of Medicare beneficiaries during the benchmark period.

When the PGP data is modeled with the Shared Savings Program assignment methodology, the assigned patient population would vary by approximately 25 percent from year to year.

4. Majority vs. Plurality Rule for Beneficiary Assignment

Therefore, we are proposing to assign beneficiaries for purposes of the Shared Savings Program to an ACO if they receive a plurality of their primary care services from primary care physicians within that ACO.

E. Quality and Other Reporting Requirements

The collection of information should minimize the burden on providers to the
extent possible. As part of that effort, we have begun and will continuously seek to align Shared Savings Program measures with the methods and measures included in the Medicare and Medicaid EHR Incentive Programs to enable the collection and reporting of performance information to be a seamless part of care delivery and the meaningful use of certified EHR technology.

Align with other Medicare incentive programs such as the Physician Quality Reporting System ("PQRS"; formerly known as the Physician Quality Reporting
Initiative), Electronic Prescribing Incentive Program, Electronic Health Records (EHR)
Incentive Programs, Hospital Inpatient Quality Reporting Program, and also Medicaid
and private sector initiatives that align with the three-part aim.

c. Proposed Quality Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings

Based upon the principles described, we are proposing 65 measures (see Table 1) for use in the calculation of the ACO Quality Performance Standard.

Specifically, for the first year of the program, we propose for the quality performance standard to be at the level of full and accurate measures reporting; for subsequent years, we propose the quality performance standard be based on a measures scale with a minimum attainment level as described in section II.E.4 of this proposed rule.
ACOs that do not meet the quality performance thresholds for all proposed measures would not be eligible for shared savings, regardless of how much per capita costs were reduced.

In an effort to provide focus to ACO quality improvement activity, we have
identified 5 key domains:
• Better Care for Individuals:
++ Patient/Caregiver Experience
++ Care Coordination
++ Patient Safety
• Better Health for Populations:
++ Preventive Health
++ At-Risk Population/Frail Elderly Health

As illustrated in the "Method of Data Submission" column of Table 1, we propose to
calculate results for the first program year measures via claims, the Group Practice Reporting Option (GPRO) data collection tool, as discussed in section II.E.4. of this proposed rule, and survey instruments. The ACO GPRO tool would be a new tool based on the data collection tool currently used in the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative) group practice reporting option (GPRO) and Physician Group Practice (PGP) demonstration.

Identical to the sampling method used in the 2011 Physician Quality Reporting System
GPRO I, we plan to require that the random sample for measures reported via ACO GPRO must consist of at least 411 assigned beneficiaries per measure set/domain. If the pool of eligible, GPRO assigned beneficiaries is less than 411 for any measure set/domain, then we plan to require the ACO to report on 100 percent, or all, of the assigned beneficiaries.

We propose aggregating the quality domain scores into a single overall ACO score which would be used to calculate the ACOs final sharing rate for purposes of determining shared savings or shared losses

(4) The Quality Performance Standard Level

That is, under the one-sided model, we propose that an ACO would receive 50 percent of shared savings based on 100 percent complete and accurate reporting on all quality measures.
Similarly, we propose that under the two-sided risk model, ACOs would receive 60 percent of shared savings based on 100 percent complete and accurate
reporting on all quality measures.

5. Incorporation of Other Reporting Requirements related to the Physician Quality Reporting System and Electronic Health Records Technology Under Section 1848 of the Act

We propose to incorporate a Physician Quality Reporting System group practice
reporting option (GPRO) under the Shared Savings Program and further propose that the eligible professionals that are ACO participant providers/suppliers would constitute a group practice for purposes of qualifying for a Physician Quality Reporting System incentive under the Shared Savings Program.

In addition, as a Shared Savings Program requirement separate from the quality measures reporting discussed previously, we propose requiring that at least 50 percent of an ACO's primary care physicians are determined to be "meaningful EHR users"

Such a requirement would be similar to the previous proposal for primary care physicians and would require 50 percent of eligible hospitals that are ACO providers/suppliers achieve meaningful use of certified EHR technology by the start of the second performance year in order for the ACO to continue participation in the Shared Savings Program.

6. Public Reporting

We propose that the following information regarding the ACO be publicly reported:
• Name and location.
• Primary contact.
• Organizational information including--
++ ACO participants;
++ Identification of ACO participants in joint ventures between ACO professionals and
hospitals;
++ Identification of the ACO participant representatives on its governing body; and
++ Associated committees and committee leadership.
• Shared savings information including--
++ Shared savings performance payment received by ACOs or shared losses payable to
us; and
++ Total proportion of shared savings invested in infrastructure, redesigned care
processes and other resources required to support the three-part aim goals of better health for populations, better care for individuals and lower growth in expenditures, including the proportion distributed among ACO participants.
• Quality performance standard scores.

F. Shared Savings Determination

Specifically, we are proposing that ACOs participating in the Shared Savings Program
will have an option between two tracks:

Track 1: Under Track 1, shared savings would be reconciled annually for the first 2 years of the 3-year agreement using a one-sided shared savings approach, with ACOs not being responsible for any portion of the losses above the expenditure target. However, for the third year of the 3-year agreement, an ACO would be required to agree to share any losses that may be generated as well as savings.

Track 2: More experienced ACOs that are ready to share in losses with greater opportunity for reward may elect to immediately enter the two-sided model.

"Benchmark for each agreement period using the most recent available 3 years of per-beneficiary expenditures for parts A and B services for Medicare fee-for-service beneficiaries assigned to the ACO."

Table 8: Shared Savings Program Overview

(e) Ensuring ACO Repayment of Shared Losses

As discussed in section II.F.of this proposed rule, we propose a flat 25 percent withholding rate will be applied annually to an ACO's earned performance payment.

We propose to require that an ACO establish a
self-executing method for repaying losses to the Medicare program by indicating that funds may be recouped from Medicare payments to the ACO's participants, obtaining reinsurance, placing funds in escrow, obtaining surety bonds, establishing a line of credit as evidenced by a letter of credit that the Medicare program can draw upon, or establishing another repayment mechanism, such as those previously discussed.

We propose that an ACO must demonstrate having established a repayment
mechanism, using one or more of the recoupment methods proposed previously, sufficient to ensure repayment of losses equal to at least 1 percent of per capita expenditures for its assigned beneficiaries from the most recent year available. (? $8000 per patient x 1% = $80 per patient x 5000 patients = $400,000 ?)

As a result, it is important to ensure that prior to entry into the Shared Savings Program, the ACO has an appropriate plan for how it will repay any losses incurred during the third year of its agreement when it is automatically transitioned to the two-sided model.

H. Monitoring and Termination of ACOs

In general, the methods we could use to monitor ACO performance may include, but are not limited to the following:

● Analysis of specific financial and quality data as well as aggregated annual and quarterly reports.
● Site visits.
● Assessment and following up investigation of beneficiary and provider complaints.
● Audits (including, for example, analysis of claims, chart review, beneficiary
surveys, coding audits).

1. Waivers of CMP, Anti-Kickback, and Physician Self-Referral Laws

We expect that the waivers applicable to ACOs participating in the Shared Savings
Program will be issued concurrently with our publication of the Shared Savings Program final rule.

For comments regarding the proposed rules see:

http://motorcycleguy.blogspot.com/2011/04/patient-and-healthit-centric-summary-of.html

How a physician can send a secure Direct message from Care360 EHR to a patient's Healthvault PHR account

2011-02-12T18:51:00.029-05:00

As described by Sean and by Halamka with the Direct Project any medical Provider with an EHR that offers a Direct email account, can send secure email messages to a patient.

I am going to demo it with my Care360 EHR account:

First type a message to the patients Direct email or his regular email. When you don't know your patient Direct email on Healthvault you just send an email to newuser@direct.healthvault.com with a subject line containing the patient's existing email account. I also attached to the message the patient's Continuity of Care Document (CCD).

The patient John Doe will get a regular email from you:

Then the patient will sign to his HealthVault account or create one

My patient John Doe can now see my Care360 EHR message and also his Continuity of Care Document (CCD).

Patient John Doe can decide or not to add the CCD to his HealthVault account

The CCD sent from Care360 EHR looks like this on HealthVault:

These are really very exciting times in healthcare :-)

PQRI for emergency medicine

2009-09-07T09:58:00.003-04:00

The 2009 PQRI consists of 153 quality measures and 7 measures groups. Nine (9) may be reported as “emergency medicine” measures:
#28 Aspirin at Arrival for Acute Myocardial Infarction (AMI) †
#31
Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage†
#34
Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered†
#54
12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain†
#55 12-Lead Electrocardiogram (ECG) Performed for Syncope†
#56 Community-Acquired Pneumonia (CAP): Vital Signs*
#57
Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation*
#58 Community-Acquired Pneumonia (CAP): Assessment of Mental Status*
#59
Community-Acquired Pneumonia (CAP): Empiric Antibiotic*

†The Part B claim form place of service field must indicate emergency department

* Clinicians utilizing the critical care code (99291) must indicate the emergency department place of service (23) on the Part B claim form in order to report this measure.

Source: http://m.acep.org/practres.aspx?id=32148

PQRI for physical therapists and occupational therapists

2009-08-31T12:42:00.006-04:00

Beginning in 2009, physical therapists or occupational therapists who report on quality measures will receive a 2% bonus. The reporting period for 2009 is January 1 - December 31, 2009.

With CPT codes 97001-97546, physical and occupational therapists could report the following individual PQRI measures:

#114. Inquiry regarding tobacco use (CPT 97003, 97004)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_114_09.pdf

#124. Adoption/use of electronic health records (EHR) (CPT 97001,
97002 (physical therapy evaluation),
and 97003, 97004 (occupational therapy evaluation))
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_124_09.pdf

#126. Diabetic foot and ankle care, peripheral neuropathy:
neurological evaluation (CPT 97001, 97002 (physical therapy
evaluation))
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_126_09.pdf

#127. Diabetic foot and ankle care, ulcer prevention: evaluation of
footwear (CPT 97001, 97002 (physical therapy evaluation))
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_127_09.pdf

#128. Body mass index (BMI) screening and follow-up (CPT 97001,97003)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_128_09.pdf

#130. Documentation and verification of current medications in the
medical record (CPT 97001, 97002, 97003, 97004)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_130_09.pdf

#131. Pain assessment prior to initiation of patient therapy and
follow-up (CPT 97001, 97003)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_131_09.pdf

#134. Screening for clinical depression and follow-up plan (CPT 97003)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_134_09.pdf

#154. Falls - Risk assessment (CPT 97001, 97002, 97003, 97004)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_154_09.pdf

#173. Unhealthy alcohol use - screening (CPT 97003, 97004)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_173_09.pdf

#181. Elder maltreatment screen and follow-up plan (CPT 97003)
http://www.ama-assn.org/ama1/pub/upload/mm/370/2009/Individual_Measures/wrksht_181_09.pdf

"We have not recorded BMI or done a Fall assessment on a regular basis. Is there an opportunity to go back and check our documentation for this item and report that, even if this is an omission, and report forward in 2009?"

Yes - with a registry like MDinteractive you can go back and report
old PQRI 2009 data and then report forward.

Also please be aware that there is no performance requirement with
PQRI. Your providers will get 2% bonus just for reporting data. For
example if when you go back and check the BMI you find out that the
BMI was not calculated or that BMI (≥ 30 or < style="font-weight: bold;">

"How many patients need to be reported and what population to qualify
for your registry requirements?"

You need to report 3 individual PQRI measures to be eligible for the 2% bonus.
On each individual PQRI measure, you will need to report at least on
80% of Medicare patients on which that measure applies.

For example, for the BMI measure (#128) you would need to report on at
least 80% of your 2009 Medicare patients aged 18 years and older on
date of of visit with CPT 97001 and 97003.

"We have an EHR, however, within physical therapy we do not record the medications and laboratory so it's my understanding we do not meet the guidelines."

You only qualify for the EHR measure if:
- You have 97001, 97002 (physical therapy evaluation) and 97003, 97004
(occupational therapy evaluation) CPT codes.
- You are using CCHIT-certified EMR or, if not CCHIT certified, the
system must be capable of all of the following:
1) Ability to manage a medication list
2) Ability to manage a problem list
3) Ability to manually enter or electronically receive, store and
display laboratory results as discrete searchable data elements
4) Ability to meet basic privacy and security elements

PQRI for Pulmonologists

2009-07-27T11:20:00.008-04:00

There are several individual PQRI measures that apply for pulmonologists:

COPD Care

#51 - Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
Measure description
Percentage of patients aged 18 years and older with a diagnosis
of COPD who had spirometry evaluation results documented
Data Collection Sheet
Coding Specifications

#52 - Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy
Measure description
Percentage of patients aged 18 years and older with a diagnosis
of COPD and who have an FEV1/FVC less than 70% and have
symptoms who were prescribed an inhaled bronchodilator
Data Collection Sheet
Coding Specifications

Asthma Care

#53 - Asthma: Pharmacologic Therapy
Measure description
Percentage of patients aged 5 through 40 years with a diagnosis
of mild, moderate, or severe persistent asthma who were
prescribed either the preferred long-term control medication
(inhaled corticosteroid) or an acceptable alternative treatment
Data Collection Sheet
Coding Specifications

#64 - Asthma: Asthma Assessment
Measure description
Percentage of patients aged 5 through 40 years with a diagnosis
of asthma who were evaluated during at least one office visit
within 12 months for the frequency (numeric) of daytime and
nocturnal asthma symptoms
Data Collection Sheet
Coding Specifications

Pneumonia Care

#56 - Community-Acquired Pneumonia (CAP): Vital Signs
Measure description
Percentage of patients aged 18 years and older with a diagnosis
of community-acquired bacterial pneumonia with vital signs
documented and reviewed
Data Collection Sheet
Coding Specifications

#57 - Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation
Measure description
Percentage of patients aged 18 years and older with a
diagnosis of community-acquired bacterial pneumonia
with oxygen saturation documented and reviewed
Data Collection Sheet
Coding Specifications

#58 - Community-Acquired Pneumonia (CAP): Assessment of Mental Status
Measure description
Percentage of patients aged 18 years and older with a
diagnosis of community-acquired bacterial pneumonia
with mental status assessed
Data Collection Sheet
Coding Specifications

#59 - Community-Acquired Pneumonia (CAP): Empiric Antibiotic
Measure description
Percentage of patients aged 18 years and older with a diagnosis
of community-acquired bacterial pneumonia with an appropriate
empiric antibiotic prescribed
Data Collection Sheet
Coding Specifications

To get the 2% PQRI bonus, a pulmonologist will need to report at least 3 of the measures above for at least 80% of the applicable Medicare patients seen during the year of 2009.

For reporting purposes, it is easier for a pulmonologist to choose the Community-Acquired Pneumonia measures because we need a set of 3 measures and the COPD and asthma sets only have 2 measures each. Technically you could pick one COPD measure, one Asthma measure and one Community-Acquired Pneumonia but then you will reporting on 3 different patient populations. With Community-Acquired Pneumonia, once you identified the patient population you can report 4 measures on each patient.

There are 2 main options to report the above measures.

1 - Add the appropriate quality codes regarding each measure to each billing claim you send to Medicare.
For example when using Community-Acquired Pneumonia add the following codes to your Medicare patients
2010F (#56 - Vital signs checked)
3028F (#57 - Oxygen saturation results documented and reviewed)
2014F (#58 - Mental status assessed)
4045F (#59 - Appropriate empiric antibiotic prescribed)

You just need to bill the same way as before but add
CPT 2010F, 3028F, 2014F and 4045F on section 24 of the billing form
and charge $0.00 or $0.01 for each code.

Example from 2009 PQRI Implementation Guide

However if you start reporting now using this method you may not be able to receive the full PQRI bonus because you already missed reporting more than half of your 2009 patients (you need to report at least 80%). So you should report PQRI using a qualified PQRI registry:

2 - Using a qualified PQRI registry like MDinteractive a pulmonologist may report 3 of the above PQRI measures and make your 2% bonus. For the complete list of 2009 PQRI qualified registries check the PQRI CMS website

For further info read:

2009 Measure-Applicability Validation Process for Claims-Based Participation

2009 PULMONARY PQRI PERFORMANCE MEASURES

PQRI Measures for Radiologists

2009-07-25T10:54:00.002-04:00

There are several individual PQRI measures that apply for radiologists:

#10 - Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports

Measure description
Percentage of final reports for CT or MRI studies of the brain
performed within 24 hours of arrival to the hospital for patients
aged 18 years and older with either a diagnosis of ischemic
stroke or transient ischemic attack (TIA) or intracranial
hemorrhage or at least one documented symptom consistent
with ischemic stroke or TIA or intracranial hemorrhage that
include documentation of the presence or absence of each of the
following: hemorrhage and mass lesion and acute infarction
AMA Data Collection Form
AMA Coding specifications

#11 - Stroke and Stroke Rehabilitation: Carotid Imaging Reports

Measure description
Percentage of final reports for carotid imaging studies (neck
MR angiography [MRA], neck CT angiography [CTA], neck
duplex ultrasound, carotid angiogram) performed for patients
aged 18 years and older with the diagnosis of ischemic stroke or
transient ischemic attack (TIA) that include direct or indirect
reference to measurements of distal internal carotid diameter
as the denominator for stenosis measurement1
AMA Data Collection Form
AMA Coding specifications

#145 - Radiology: Exposure Time Reported for Procedures Using Fluoroscopy

Measure description
Percentage of final reports for procedures using fluoroscopy that
include documentation of radiation exposure or exposure time
AMA Data Collection Form
AMA Coding specifications

#146 - Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening

Measure description
Percentage of final reports for screening mammograms that are
classified as “probably benign”
AMA Data Collection Form
AMA Coding specifications

147 - Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

Measure description
Percentage of final reports for all patients, regardless of age,
undergoing bone scintigraphy that include physician
documentation of correlation with existing relevant imaging
studies (eg, x-ray, MRI, CT, etc.) that were performed
AMA Data Collection Form
AMA Coding specifications

To get the 2% PQRI bonus, a radiologist will need to report at least 3 of the measures above for at least 80% of the applicable Medicare patients seen during the year of 2009.

There are 2 main options to report the above measures.

1 - Add the appropriate quality codes regarding each measure to each billing claim you send to Medicare. However if you start reporting now using this method you may not be able to receive the full PQRI bonus because you already missed reporting more than half of your 2009 patients (you need to report at least 80%). So you should report PQRI using a qualified PQRI registry:

2 - Using a qualified PQRI registry like MDinteractive a radiologist may report 3 of the above PQRI measures and make your 2% bonus. For the complete list of 2009 PQRI qualified registries check the PQRI CMS website

For further info read:

2009 Measure-Applicability Validation Process for Claims-Based Participation

CMS releases PQRI reporting measures that affect radiologists

Highlights of the proposed PQRI rules for 2010

2009-07-04T21:55:00.006-04:00

New proposed PQRI rules for 2010 were published on July 1, 2009 on the Federal Registry. You can read the full rules here. CMS will accept comments on the Proposed Rule until August 31, 2009.

During the PQRI Registry Kick-Off Meeting some people complained that they haven't enough time to read the Federal Registry. I felt very patriotic after a nice July 4th display of fireworks in Vermont and decided to read the Federal Registry.

These are some of the highlights:

- "In addition, given our desire to transition from the use of the claims based reporting mechanism as the primary reporting mechanism for clinical quality measures for PQRI after 2010 to rely more heavily on registry-based reporting (see section II.G.2.d. of this proposed rule for further discussion), we do not believe it appropriate to add a new 6-month reporting period for claims-based reporting of individual measures.

- "Beginning with the 2010 PQRI, group practices who satisfactorily submit data on quality measures also would be eligible to earn an incentive payment equal to 2.0 percent of the estimated total allowed charges for all covered professional services furnished by the group practice during the applicable reporting period."

- "We propose that a “group practice” would consist of a physician group practice, as defined by a TIN, with at least 200 or more individual eligible professionals (or, as identified by NPIs) who have reassigned their billing rights to the TIN.

- "We note that the 6-month reporting period, beginning July 1, 2010, is proposed to be available for reporting on measures groups and for reporting using the registry-based reporting mechanism only.

- "If we finalize this proposal, then, unlike in prior years, an eligible professional would be able to earn a PQRI incentive payment through the EHR-based reporting mechanism in 2010."

- "Therefore, we propose to add an EHR-based reporting mechanism for the 2010 PQRI in
order to promote the adoption and use of EHRs and to provide both eligible professionals and CMS experience on EHR-based quality reporting."

- "In summary, we propose that for 2010, an eligible professional may choose to report data on PQRI quality measures through claims, to a qualified registry (for the qualification requirements for registries, see section II.G.2.i.(4) of this proposed rule), or through a qualified EHR product (for the qualification requirements for EHR vendors and their products, see section II.G.2.i.(5) of this proposed rule)."

- "While we propose to retain the claims-based reporting mechanism for 2010, we note that we are considering significantly limiting the claims-based mechanism of reporting clinical quality measures for the PQRI after 2010. This would be contingent upon there being an adequate number and variety of registries available and/or EHR reporting options."

- "Reducing our reliance on the claims-based reporting mechanism after 2010 will allow us and eligible professionals to devote available resources to maximizing
the potential of registries and EHRs for quality measurement reporting. Both mechanisms hold the promise of more sophisticated and timely reporting on clinical quality measures. Clinical data registries allow the collection of more detailed data, including outcomes, without the necessity of a single submission contemporaneously with claims billing, which overcomes some of the limitations of
the claims-based reporting mechanism. Registries can also provide feedback and quality improvement information based on reported data. Finally, clinical data registries can also receive data from EHRs, and therefore, serve as an alternative means to reporting clinical quality data extracted from an EHR. As we continue to qualify additional registries, we believe that there will be a sufficient number of qualified PQRI registries by 2011 to make it possible to reduce or even discontinue the claims-based reporting mechanism for most measures after 2010."

- "All claims for services furnished between January 1, 2010 and December 31, 2010 must be processed by no later than February 28, 2011 to be included in the 2010 PQRI analysis.

- "We propose the following new requirements for registries for the 2010
PQRI:
● Registries must have at least 25 participants;
● Registries must provide at least 1 feedback report
per year to participating eligible professionals;
● Registries must not be owned and managed by an
individual locally-owned single-specialty group (in other
words, single-specialty practices with only 1 practice
location or solo practitioner practices would be prohibited
from self-nominating to become a qualified PQRI registry);
● Registries must participate in ongoing 2010 PQRI
mandatory support conference calls hosted by CMS
(approximately 1 call per month);
● Registries must provide a flow and XML of a
measure’s calculation process for each measure type that
the registry intends to calculate; and
● Registries must use PQRI measure specifications to
calculate reporting or performance unless otherwise stated."

- "Regardless of the reporting mechanism chosen by the
eligible professional, we propose that the minimum patient
sample size for reporting individual quality measures be 15
Medicare Part B FFS patients for the 12-month reporting
period. An eligible professional would need to meet this
minimum patient sample size requirement for at least one
measure on which the eligible professional chooses to
report."

- "Unlike the 2009 PQRI, which required that eligible
professionals report on consecutive patients (that is,
patients seen in order, by date of service), the 30
patients on which an eligible professional would need to
report a measures group for 2010 would not need to be
consecutive patients."
- "In addition, the questions we receive from eligible
professionals indicate that many eligible professionals are
not clear on how to determine which patients are
“consecutive” and should be included in the patient sample.
We believe that any adverse effect on the reliability or
validity of the quality information received as a result of
the removal of the requirement to report on patients seen
consecutively and allowing eligible professionals to report
on any 30 patients would be minimal."

- "Group practices interested in participating in the 2010 PQRI through the group practice reporting option would be required to submit a self-nomination letter to CMS or a CMS designee requesting to participate in the 2010 PQRI group practice reporting option. We propose that each group practice would be required to meet the following requirements:
● Have an active Individuals Access to CMS Systems
(IACS) user account;
● Provide CMS or a CMS designee with the group
practice’s TIN and the NPI numbers and names of all
eligible professionals who will be participating as part of
the group practice (that is, all individual NPI numbers
CMS-1413-P 258
associated with the group practice’s TIN). This
information must be provided in an electronic format
specified by CMS, such as in an Excel spreadsheet; and
● Agree to have the group practice’s PQRI quality
measurement performance rates for each measure publicly
reported by posting of the results on a CMS Web site."

- "We propose that group practices
would be required to submit information on these measures
using a data collection tool based on the data collection
tool used in CMS’ Medicare Care Management Performance
(MCMP) demonstration and the quality measurement and
reporting methods used in CMS’ PGP demonstration. We
propose that physician groups selected to participate in
the 2010 PQRI through the group practice reporting option
would be required to report on a common set of 26
NQF-endorsed quality measures that are based on measures
currently used in the MCMP and/or PGP demonstration and
that target high-cost chronic conditions and preventive
care. These quality measures are identified in Table 34.
Additional information on the MCMP and PGP demonstrations
is posted on the Medicare Demonstrations section of the CMS
Web site at http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp#Top
OfPage

- "We propose a unique reporting mechanism for the group
practice reporting option that would not be available to
individual eligible professionals participating in the 2010
PQRI. We propose that each physician group selected to
participate in the group practice reporting option would
have access to a database (that is, a data collection tool)
that would include the assigned beneficiary sample and the
quality measures."

- "Identical to the sampling method used in the PGP demonstration, the random
sample must consist of at least 411 assigned beneficiaries."

- "We anticipate being able to provide the selected physician groups with access
to this prepopulated database by the fourth quarter of 2010. The physician group would be required to populate the remaining data fields necessary for capturing quality measure information on each of the assigned beneficiaries."

- "TABLE 34: Measures Proposed for Physician Groups
Participating in the 2010 PQRI Group Practice Reporting
Option"

- "For example, information on the measure development process
employed by us when CMS or a CMS contractor is the measure
developer is available in the “Measures Management System
Blueprint” found on the CMS Web site at
http://www.cms.hhs.gov/apps/QMIS/mmsBlueprint.asp.
Eligible professionals also have the opportunity to
provide input on a measure as the measure is being vetted
through the NQF consensus endorsement process (and
previously, the AQA consensus adoption process). In
particular, the NQF employs a public comment period for
measures vetted through its consensus endorsement process
(and previously, for the AQA, its consensus adoption
process).
Finally, eligible professionals have an opportunity to
provide input on the measures proposed for inclusion in the
2010 PQRI through this proposed rule, which provides a
60-day comment period."

- "Measures that are high impact and support CMS and
HHS priorities for improved quality and efficiency of care
for Medicare beneficiaries. These current and long term
priority topics include: prevention; chronic conditions;
high cost and high volume conditions; elimination of health
disparities; healthcare-associated infections and other
conditions; improved care coordination; improved
efficiency; improved patient and family experience of care;
improved end-of-life/palliative care; effective management
of acute and chronic episodes of care; reduced unwarranted
geographic variation in quality and efficiency; and
adoption and use of interoperable HIT."

- "TABLE 17: Proposed 2010 Measures Selected From the 2009
PQRI Quality Measure Set Available for Either Claims-based
Reporting or Registry-based Reporting"

1 - Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus.
2 - Diabetes Mellitus: Low Density Lipoprotein (LDL–C) Control in Diabetes Mellitus.
3 - Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus.
6 - Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Perscribed for Patients with CAD.
9 - Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD.
10 - Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports.
12 - Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation.
14 - Age-Related macular Degeneration (AMD): Dilated Macular Examination.
18 - Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy.
19 - Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care.
20 - Perioperative Care: Timing of Antibiotic Prophylaxis— Ordering Physician.
21 - Perioperative Care: Selection of ProphylacticAntibiotic—First OR Second Generation Cephalosporin.
22 - Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures).
23 - Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients).
24 - Osteoporosis: Communication with the Physician Managing On-going Care Post Fracture.
28 - Aspirin at Arrival for Acute Myocardial Infarction (AMI).
30 - Perioperative Care: Timing of Prophylactic Antibiotics—Administering Physician.
31 - Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage.
32 - Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy.
35 - Stroke and Stroke Rehabilitation: Screening for Dysphagia.
36 - Stroke and Stroke Rehabilitation: Consideration for Rehabilitation Services.
39 - Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older.
40 - Osteoporosis: Management Following Fracture.
41 - Osteoporosis: Pharmacologic Therapy
43 - Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery.
44 - Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery.
45 - Perioperative Care: Discontinuation of Prophylactic Antiobitics (Cardiac Procedures).
46 - Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility.
47 - Advance Care Plan
48 - Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 6 Years and Older.
49 - Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older.
50 - Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older.
51 - Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation.
52 - Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy.
53 - Asthma: Pharmacologic Therapy
54 - 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain.
55 - 12-Lead Electrocardiogram (ECG) Performed for Syncope.
56 - Community-Acquired Pneumonia (CAP): Vital Signs.
57 - Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation.
58 - Community-Acquired Pneumonia (CAP): Assessment of Mental Status.
59 - Community-Acquired Pneumonia (CAP): Empiric Antibiotic.
64 - Asthma: Asthma Assessment
65 - Treatment for Children with Upper Respiratory Infection (URI): Avoidance of Inappropriate Use.
66 - Appropriate Testing for Children with Pharyngitis.
67 - Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow.
68 - Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy.
69 - Multiple Myeloma: Treatment with Bisphosphonates.
70 - Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry.
71 - Breast Cancer: Hormonal Therapy for Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer.
72 - Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients.
76 - Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol.
79 - End Stage Renal Disease (ESRD): Influenza Immunization with Patients in ESRD.
84 - Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment.
85 - Hepatitis C: HCV Genotype Testing Prior to Treatment.
86 - Hepatitis C: Antiviral Treatment Prescribed
87 - Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment.
89 - Hepatitis C: Counseling Regarding Risk of Alcohol Consumption.
90 - Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy.
91 - Acute Otitis Externa (ACE): Topical Therapy
92 - Acute Otitis Externa (ACE): Pain Assessment.
93 - Acute Otitis Externa (ACE): Systemic Antimicrobial Therapy—Avoidance of Inappropriate Use.
99 - Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade.
100 - Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grace.
102 - Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients.
104 - Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients.
105 - Prostate Cancer: Three-Dimensional (3D) Radiotherapy.
106 - Major Depressive Disorder (MDD): Diagnostic Evaluation.
107 - Major Depressive Disorder (MDD): Suicide Risk Assesmment.
108 - Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy.
109 - Osteoarthritis: Function and Pain Assessment.
110 - Preventive Care and Screening: Influenza Immunization for Patients =50 Years Old.
111 - Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older.
112 - Preventive Care and Screening: Screening Mammography.
113 - Preventive Care and Screening: Colorectal Cancer Screening.
114 - Preventive Care and Screening: Inquiry Regarding Tobacco Use.
115 - Preventive Care and Screening: Advising Smokers to Quit.
116 - Antibiotic Treatment for Adults with AcutemBronchitis: Avoidance of Inappropriate Use.
117 - Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient.
119 - Diabetes Mellitus: Urine Screening forMicroalbumin or Medical Attention for Nephropathy in Diabetic Patients.
121 - Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorous, Intact Parathyroid Hormone (iPTH) and Lipid Profile).
122 - Chronic Kidney Disease (CKD): Blood Pressure Management.
123 - Chronic Kidney Disease (CKD): Plan of Care—Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA).
124 - Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR).
126 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy—Neurological Evaluation.
127 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention—Evaluation of Footwear.
128 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up.
130 - Documentation and Verification of Current Medications in the Medical Record.
131 - Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up.
134 - Screening for Clinical Depression and Follow-Up Plan.
135 - Chronic Kidney Disease (CKD): Influenza Immunization.
140 - Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement.
142 - Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications.
145 - Radiology: Exposure Time Reported for Procedures Using Fluoroscopy.
146 - Radiology: Inappropriate Use of ‘‘Probably Benign’’ Assessment Category in Mammography Screening.
147 - Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy.
153 - Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula.
154 - Falls: Risk Assessment
155 - Falls: Plan of Care
156 - Oncology: Radiation Dose Limits to Normal Tissues.
157 - Thoracic Surgery: Recording of Clinical Stage for Lung Cancer and Esophageal Cancer Resection.
158 - Endarterectomy: Use of Patch During Conventional Endarterectomy.
163 - Diabetes Mellitus: Foot Exam
172 - Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula.
173 - Preventive Care and Screening: Unhealthy Alcohol Use—Screening.
175 - Pediatric End Stage Renal Disease (ESRD): Influenza Immunization.
176 - Rheumatoid Arthritis (RA): Tuberculosis Screening.
177 - Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity.
178 - Rhuematoid Arthritis (RA): Functional Status Assessment.
179 - Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis.
180 - Rheumatoid Arthritis (RA): Glucocorticoid Management.
181 - Elder Maltreatment Screen and Follow-Up Plan.
182 - Functional Outcome Assessment in Chiropractic Care.
183 - Hepatitis C: Hepatitis A Vaccination in Patients with HCV.
184 - Hepatitis C: Hepatatis B Vaccination in Patients with HCV.
185 - Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps—Avoidance of Inappropriate Use.
186 - Wound Care: Use of Compression System in Patients with Venous Ulcers.

- "TABLE 20: Proposed 2010 Measures Available for EHR-based
Reporting"

- "The 6 new measures groups proposed for
the 2010 PQRI are:
(1) Coronary Artery Disease (CAD);
(2) Heart Failure (HF);
(3) Ischemic Vascular Disease (IVD);
(4) Hepatitis C;
(5) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS);
(6)Community Acquired Pneumonia (CAP)."

- "In December 2008, we listed, by State, the names of eligible
professionals who participated in the 2007 PQRI on the
Physician and Other Health Care Professionals Directory."

- "Based on the assumptions discussed above, we estimate
the total annual cost per eligible professional associated
with claims-based reporting to range from $174.45 [($0.21
per measure X 3 measures X 15 cases per measure) + $165] to
$617.70 [($10.06 per measure X 3 measures X 15 cases per
measure) + $165]."

- "For registry-based reporting, eligible professionals
must generally incur a cost to submit data to registries.
Estimated fees for using a qualified registry range from a
nominal charge for an eligible professional to use the
registry to costing eligible professionals several thousand
dollars. Thus, we conservatively estimate the cost
incurred by an eligible professional to participate in PQRI
via registry-based reporting to be approximately $500 per
eligible professional.

2009 PQRI Registry Kick-Off Meeting

2009-07-01T23:11:00.001-04:00

Today all PQRI qualified Registries had a meeting at Medicare headquarters.

This is the main Medicare building - I was so excited about visiting Medicare that I forgot to keep my finger away from my lens.

Medicare headquarters are at 7500 Security Boulevard in Baltimore. And they mean security :-) Your car will be thoroughly inspected before entering the parking lot. Then you enter the building and you go through an airport style inspection, with the additional step that they check your laptop id. Then someone escorts you to your final destination.

Inside the main auditorium we finally met Dr. Daniel Green and all his PQRI team.
He put us at ease with his sense of humor - he is an Ob/Gyn doctor, his wife practices internal medicine in the state with the "worst reimbursement rates" in the country and they just bought a pregnant horse last week. Supposedly he also owns a mini-donkey but we are not sure if he was serious about that :-)

These are some of the highlights of the meeting:

- 74 registries qualified this year. Last year there were 32 Medicare qualified registries. 31 sent data. These registries sent PQRI Quality data regarding 10000-99999 patients. They are not sure about the actual numbers yet.

- CMS is working hard to make sure that physicians that reported data can get their 2% reward over their Medicare charges. One of the problems is that sometimes the TIN (tax id number) submitted by the physician has no actual Medicare charges because it is the wrong one (2% of $0.00 is $0.00). Many physicians have several TINs - To avoid this problem - physicians need to be reminded by registries to always use the one they use to submit data to Medicare. I think they have 300 physicians with "wrong" TINs.

- As a aside I have an hypothesis regarding why physicians sent the "wrong" number. In the past I had physicians that requested P4P money from insurances companies to be sent to their personal TINs because they would like the money not to go to the physician group. For example if a doctor works in a group with other 10 physicians that share the same group TIN and this doctor decides to submit PQRI data individually, he/she may hope that the PQRI reward to return to him/her so then he/she tries to send the individual tax id for the PQRI. Unfortunately there are no Medicare charges with this individual TIN - so no reward. DOCTOR - ALWAYS GIVE THE TIN YOU USE TO BILL MEDICARE

- Some registries submitted data in the name of medical residents - big mistake. Always use the attending NPI and TIN.

- Providers can sign electronically the doc authorizing registry to submit data to CMS if state law allows it - I am not sure which states don't allow electronic signatures - I sign electronically all the time when I open a new bank account...

- The quality measures should match the specialists - Technically you can report on diabetes for orthopedic surgeons but that's not the idea behind the PQRI.

- Once a registry gets approved for one specific PQRI measure tag (Procedure, Episode, Patient - Process, etc) it can ask permission by email to add another PQRI measure of the same type. For example if a registry is approved for Measure #176 Rheumatoid Arthritis (RA): Tuberculosis Screening that has type "Patient-Process", it can request to be approved for another measure of similar type like 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear.

- There will be monthly conference calls with the registries. If a registry misses one call, it will be forgiven. If a registry misses two monthly support calls, it will not qualify anymore - the registry will turn into dust...

- Providers submitting PQRI data with claims and registries will be paid using the most favorable method. CMS will not combine methods.

- Two IACS accounts per registry are necessary to submit data. One will be for backup. The actual submission will be done through the PQRI Portal using the IACS authentication. You can submit test data and there is a feedback email that tells the registry if the XML file has the correct format.

- The way we were tested during the registry vetting process using a 4GB DVD to send an encrypted 10k XML test file to CMS was just a test...

- Central Utah registry talked about their PQRI experience. Some of their providers wanted to complicate things and add extra measures. Also suggested that contracts to be signed by the doctors should be easy or else it will scare them. Their physicians signed all authorization forms online. Central Utah reminded everyone to be sure that the right combination TIN/NPI is used by each provider.

- CINA, another 2008 qualified registry reported on 360 providers. CINA reminded us that PQRI measures are not created equal. For example some dialysis measures are reported per month. Be careful with the formal measure type (tag). CINA mentioned that providers got very engaged when they see their reports. Also suggested registries to enter TIN and NPI electronically to avoid errors. However, Dr. Green mentioned earlier that some providers on some registries got "too engaged" regarding their performance reports and didn't want to submit their data to CMS because they thought their performance scores were low. Reminded registries that for now providers will be paid by reporting and not by performance.

- Docsite registry submitted data from ~ 2200 providers. Docsite noticed that doctors got confused with the 30 consecutive patients concept despite being explained a lot on their website. Docsite found the AMA worksheets very useful. Again remind doctors - NPI and TIN use the ones you use to bill Medicare.

- During the meeting, lots of questions regarding the new XML tag encounter-from date and encounter-to-date . CMS wants encounter dates but they may change where they place this tag - one registry suggested to place this XML tag at the level of the provider and Dr. Green thought that idea is very reasonable. The "final 2009" XML specs maybe will not be so final.

- One registry mentioned the 18MB file limit on XML file to submit on the PQRI portal. I didn't understand why this was a problem. Probably with 18Mb we could report PQRI on all doctors on planet Earth... Anyway registries can submit multiple XML files.

- Next year providers can request their PQRIs reports from their respective Medicare carriers and they will be sent to the provider's email.
- This year you can submit more than 100 providers in one XML file.

- You can resubmit PQRI XML data from the same provider again if there is a correction. Last updated data will replace the old one on the CMS PQRI datawarehouse.

- Payments for PQRI 2008 are only coming in the Fall of 2009.

- Dr. Green mentioned that the new proposed PQRI rules for 2010 were published today on the Federal Registry. You can find a summary here and you can read the full rules here. CMS will accept comments on the Proposed Rule until August 31, 2009. "The Proposed Rule is scheduled to appear in the Federal Register on July 13, 2009" - from a good place to get Medicare updates - http://medicareupdate.typepad.com/medicare_update

- One registry commented that it is kind of hard to read the Federal Registry everyday and he would like some kind of summaries to be sent to registries regularly. Dr. Green mentioned that will be one of the functions of the monthly calls.

- I talked with Shiby Thomas from the Boston Medical Center PQRI registry. He mentioned that he had some difficulties implementing the rules for measure #159 - HIV/AIDS: CD4+ Cell Count or CD4+ Percentage - it needs to be done twice a year. CMS worked with measure owner and revised the rule.

- Another registry mentioned that in the foot exam for diabetes there was a rule that required 5 components on this exam but CMS supposedly thinks that 2 components are enough. Other registries were not aware of this change

- I suggested that the registries should create a user group to share their experiences, exchange tips and new information. Dr. Green liked the idea. He is going to collect emails from registries interested in this. In meantime I am suggesting to use twitter with the tag #pqri to post comments during this conference and even after. Registries could also use blogs to share their experiences and support each other efforts. Another suggestion - create a PQRI user group wiki. Someone suggested a facebook PQRI group page where everyone could get updates.

My final impression is that the hard working PQRI CMS team is very transparent, open-minded and looking forward to collaborate with all our registries to improve the quality of care in the US.

As an example of registry collaboration - I ended the day with a dinner at the Inner Harbour paid by the registry Outcome (thanks FX Campion!!) and enjoying the view of the beautiful National Aquarium in Baltimore.

Becoming a Medicare Qualified PQRI Patient Registry

2009-06-28T21:37:00.000-04:00

This will be the first of a series of posts describing MDinteractive's experience of becoming a Medicare Qualified PQRI Registry.

General Introduction

To improve quality of the healthcare in the US, Medicare has a innovative program called Physician Quality Reporting Initiative that rewards physicians for reporting quality measures like checking cholesterol levels on diabetics patients, doing mammograms, giving smoke cessation advice, etc.

This is part of a movement to slowly change the way the system rewards physicians - right now with a fee-for-service payment system, healthcare professionals are paid more for "doing things" to patients and not for keeping patients healthy.

With the PQRI incentive program, physicians can earn an incentive payment of 2% above the regular Medicare Physician Fee charges.

The 153 PQRI Quality measures can be found here:
http://www.cms.hhs.gov/PQRI

Examples of PQRI Measures:

How to Report PQRI

There are basically two main options to report PQRI options:

- Claims Based Reporting
- Registry Reporting

Claims-Based Reporting:

In this case, a physician will need to report at least 3 PQRI Quality Measures for at least 80% of applicable patients.

For example, a pulmonary specialist would report 3 measures from all Medicare patients seen with the diagnosis of community acquired pneumonia(measures 56, 57 and 58).

Measure 56 - Community-Acquired Pneumonia (CAP): Vital Signs
Percentage of patients aged 18 years and older with a diagnosis of
community-acquired bacterial pneumonia with vital signs documented and
reviewed

When the doctor treats someone with the diagnosis of pneumonia (ICD-9 code 481), and a CPT code for a office visit like 99204 then she/he will also add the CPT II code 2010F in the same CMS-1500 billing form. This code means that vital signs like temperature, pulse, respiratory rate, and blood pressure were documented and reviewed.

The worksheet for these measures can be seen at the AMA website:
Participation Tools: Individual Quality Measures for 2009 PQRI and more specifically here for measure #56

On the same CMS-1500 claim form he also enter quality codes for measures #57 (Assessment of oxygen saturation - code 3028F) and for measure #58 (Assessment of mental status - code 2014F).

Each one of the quality codes must be submitted with a line-item charge of $0.00. Charge field cannot be left blank.

At the end of the year, if the above pulmonary specialist saw 10 Medicare patients with community-acquired pneumonia and reported measures #56, #57 and #58 on at least 8 of those patients will receive a 2% bonus over all her/his Yearly Medicare Part B Fee-for-Service revenues.

We should note that the 2% applies to all the Medicare Part B fees charged for all the Medicare patients seen by the doctor and not only to the patients with community-acquired pneumonia. For example if the the yearly revenues were $100000, the bonus would be $2000.

In the next post, we will describe an Alternative Reporting Method using a Qualified Medicare Registry like MDinteractive.