2016 ACO GPRO Web Interface Reporting Documents/ACO...CMS ACO GPRO Web Interface reporting, (2016, May 18). Retrieved from: -assessment instruments/pqrs/gpro_web_interface.html ©2011

“2016 CMS Quality Measures-How

can we be successful?””

August 2016

©2011 Proprietary and Confidential

ACO Announcements

• Reminders:

– ACO Notifications

– Requests for Tax ID information from PECOS

• 2016 MSSP Population Reports

– Upcoming provider/Office manager meetings:

• 8/18/2016 MACRA 101 WebEx

• 9/13/2016 Primary Care Surgical Specialty Meeting

• 11/10/2016 Primary Care Meeting

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Agenda

• How quality is measured for the ACO by CMS

• 2016 ACO Quality Measures

• CMP data collection

• Q&A section

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• 34 quality measures are separated into the following four key domains

1. Patient/Caregiver Experience

2. Care Coordination/Patient Safety

3. Preventive Health

4. Clinical Care for At Risk Population

Quality Measurement: Domains

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Pay for Performance Status

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Agreement Start Date

Measures in P4R in 2016 Measures in P4P in 2016

2014, ACOsin their second agreement period, and Pioneer ACOs

11 measures: Patient/Caregiver Experience Domain:ACO-7, ACO-34Care Coordination/Patient Safety Domain:ACO-35, ACO-36, ACO-37, ACO-38, ACO-39Preventive Health Domain:ACO-42At-Risk Population Domain:ACO-40, ACO-27, ACO-41

23 measures: Patient/Caregiver Experience Domain:ACO-1, ACO-2, ACO-3, ACO-4, ACO-5, ACO-6Care Coordination/Patient Safety Domain:ACO-8, ACO-9, ACO-10, ACO-11, ACO-13Preventive Health Domain:ACO-14, ACO-15, ACO-16, ACO-17,ACO-18, ACO-19, ACO-20, ACO-21At-Risk Population Domain:ACO-28, ACO-30, ACO-31, ACO-33

CMS ACO GPRO Web Interface reporting, (2016, May 18). Retrieved from: https://www.cms.gov/medicare/quality-initiatives-

patient-assessment-instruments/pqrs/gpro_web_interface.html


• 18 of the 34 measures are reported through the Web Interface

Note: New measures introduced to the Shared Savings Program will be set at pay-for-reporting for 2 years before phasing into performance, unless the measure was finalized as pay-for-reporting all years.

2016 Web Interface Measures

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CMP


2016 Web Interface Measures List

10CMS ACO GPRO Web Interface reporting, (2016, May 18). Retrieved from: https://www.cms.gov/medicare/quality-initiatives-


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2016 Web Interface Measures List

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Patient Confirmation

Status

• Data from Medicare claims are used to determine if a patient is eligible for quality reporting.

• ACO will remove a patient from all modules, measures and performance calculations based upon various CMS allowed circumstances.

• Example: Group practice 4 providers all using the same EMR is a participant in the ACO. Dr Jones receives review for Dr Smith. Who’s responsibility is it to complete the review? It is the practice responsibility! The review can be completed by either Dr Jones or Dr Smith.

NOTE: Failure to mark the specific reason for removing the patient during Patient Confirmation will result in the patient record remaining incomplete



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CARE

COORDINATION/PATIENT

SAFETY


CARE-2: Screening for Future Fall Risk

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Description:Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

Denominator Exclusions: None

What is the Quality Action?Completion of a fall risk screening. The screening may be done with a formal screening tool as long as it fulfills the fall history documentation requirements.

Who may perform the Quality Action?

Eligible professionals reporting this measure may document measure information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources .




CARE-2: Screening for Future Fall Risk

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When must the Quality Action be performed?

The screening must take place within the measurement period.

What are the documentation requirements relative to the Quality Action?

The patient’s medical record must contain:

• Documentation of whether the patient has been assessed for a history of falls or any fall with injury. Documentation of no falls is sufficient;

NOTE: Screening may be done with any formal screening tool as long as it fulfills thefall history documentation requirements.




CARE-3: Documentation of Current Medications

in the Medical RecordDescription:

• Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using allimmediate resources available on the date of the encounter.

• This list must include ALL known prescriptions, over-the-counters, herbals, andvitamin/mineral/dietary (nutritional) supplements AND must contain themedications' name, dosage, frequency and route of administration.


What is the Quality Action?

Documenting, updating or reviewing the patient’s current medications using all immediate resources available on the date of the encounter. Current medications is defined as medications the patient is presently taking including all prescriptions, over-the-counter (OTC) medications, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and route ofadministration.


patient-assessment-instruments/pqrs/gpro_web_interface.html13



in the Medical Record

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Eligible professionals reporting this measure may document measure information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources .

When must the Quality Action be performed?Medication reconciliation should be done on all visits





in the Medical Record

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The patient’s medical record must contain the following for each visit:

• A list of all of the patient’s current medications, including each

medication’s name, dosage, frequency, and route of administration;

or

• Indication that the patient is not currently taking any medications



AT RISK POPULATION


CAD-7: ACE Inhibitor or ARB Therapy –

Diabetes or LVSD (LVEF < 40%)

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Description:

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy.



Prescription of either an ACE inhibitor or ARB therapy.





Diabetes or LVSD (LVEF <40%)

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Any eligible professional with prescribing authority may prescribe ACE inhibitor or ARB therapy.


The prescription of an ACE inhibitor or ARB therapy must be documented as either initiated or continuing during the measurement period.





Diabetes or LVSD (LVEF <40%)



• An active diagnosis of coronary artery disease or history of cardiac surgery;

and

• An active diagnosis of diabetes and/or LVEF < 40% (or documentation ofmoderate or severe LVSD) at anytime in their history, up through the lastday of the measurement period;

and

• An active prescription for an ACE inhibitor or ARB therapy anytime during the measurement period.



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DM-2: Hemoglobin A1c Poor Control

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DM-2 is one of two component measures comprising the DM Composite

Description:

Percentage of patients 18 – 75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.



Performance of an HbA1c test and documentation of its result. The beneficiary meets the numerator criteria if the most recent HbA1c level is

> 9.0% OR is missing a result OR if an HbA1c test was not done.

Note - this is an inverse measure where a lower score indicates better quality.




DM 2: Hemoglobin A1c Poor Control

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Any qualified healthcare professional may obtain the HbA1c test and record its result.


The HbA1c test must be performed, and its results documented, within themeasurement period. If there is more than one HbA1c test performed, usethe most recent.



• A diagnosis of diabetes;

and

• The date and value of the HbA1c test.




DM-7: Eye Exam

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DM-7 is one of two component measures comprising the DM Composite

Description:

Percentage of patients 18 – 75 years of age with diabetes who had a retinal ordilated eye exam by an eye care professional during the measurement periodor a negative retinal exam (no evidence of retinopathy) in the 12 months priorto the measurement period.



Performance of a retinal or dilated eye exam. Retinal imaging is also acceptable if reviewed by an appropriate professional as described below.




DM-7: Eye Exam

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The eye exam must be performed by or results reviewed by an ophthalmologist or optometrist.


The retinal or dilated eye exam can occur during the measurement period OR a negative retinal exam (no evidence of retinopathy) in the year prior to the measurement period.




DM-7: Eye Exam

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• A diagnosis of diabetes;

and

• If the eye exam was performed during the measurement period, the date of the exam;

• or

• If the eye exam was performed the year prior to the measurementperiod, the date and result of the eye exam;

or

• If retinal imaging was performed, the date imaging was performed and evidence that it was reviewed by an eye care professional.




DM-7: Eye Exam

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What are the documentation requirements relative to the Quality Action? (cont.)

NOTE: The measure permits the use of retinal imaging provided it includesthe date the fundus photography was performed and evidence that an eyecare professional (optometrist or ophthalmologist) reviewed the results.Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.

For example, if an endocrinologist or PCP performs the appropriate imaging in their office and the results are reviewed by an eye care professional (optometrist or ophthalmologist) during the measurement period or the year prior to the measurement period (if negative for retinopathy) then it is eligiblefor use in reporting.




HF-6: Beta-Blocker Therapy for LVSD

(LVEF < 40%)

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Description:

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF)< 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.



Prescription of beta-blocker therapy. Beta-blocker therapy is limited to the prescription of bisoprolol, carvedilol, or sustained release metoprolol succinate.





(LVEF < 40%)

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Any eligible professional with prescribing authority may prescribe the beta-blocker therapy.


The prescription for beta-blocker therapy must be either initiated or continued during the measurement period.





(LVEF < 40%)

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• An active diagnosis of heart failure;

and

• LVEF of < 40% (or documented as moderate or severe) at anytime in the

patient’s history, up through the last day of the measurement period;

and

• An active prescription for beta-blocker therapy anytime during the measurement period,

or

• Documentation of the reason why the Quality Action is not performed dueto an exception (see Data Guidance for specific medical, patient or systemreason exceptions).




HTN-2: Controlling High Blood Pressure

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Description:Percentage of patients 18 – 85 years of age who had a diagnosis of hypertensionand whose blood pressure was adequately controlled (<140/90 mmHg) duringthe measurement period.

Denominator Exclusions:• Dialysis or renal transplant before or during the measurement period• ESRD• Chronic kidney disease stage 5• Pregnancy during the measurement period

What is the Quality Action?Performance of a blood pressure reading and documentation of its result. A result of < 140/90 mmHg is required for numerator inclusion (in control).





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Any qualified healthcare professional may take the patient’s blood pressure. Patient reported blood pressure readings, including readings directly from home monitoring devices, are not acceptable.


The blood pressure must be taken and the value recorded during the measurement period. If there is more than one blood pressure reading, use the most recent.



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• A diagnosis of essential hypertension within the first six months of themeasurement period or any time prior to the measurement period butdoes not end before the start of the measurement period;

and

• The date and value of the most recent systolic and diastolic blood pressure readings. (Note: If there are multiple blood pressure readings on the samedate of service, use the lowest systolic and lowest diastolic pressures onthat date);

or

• Documentation of exclusion criteria.




IVD-2: Use of Aspirin or Another

Antithrombotic

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Description:

Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period.



Prescription of aspirin or another antithrombotic.





Antithrombotic

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Any eligible professional with prescribing authority may prescribe the use of aspirin or another antithrombotic. In addition to aspirin, antithrombotic medications may include: clopidogrel, a combination of aspirin and extended release dipyridamole, Prasugrel, Ticagrelor, or Ticlopidine.


The prescription for aspirin or another antithrombotic must be either initiated or continued during the measurement period.





Antithrombotic

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• An active diagnosis of ischemic vascular disease or discharged alive for AMI, CABG or PCI;

and

• An active prescription for aspirin or another antithrombotic anytime during the measurement period.




MH-1: Depression Remission at 12 MonthsDescription:

Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

Denominator Exclusions:• Permanent nursing home residents• Active diagnosis of bipolar or personality disorder


Remission attained at 12 months (+/- 30 days) from the index date. Remission is defined as a PHQ-9 score less than five. The index date is defined as the first

PHQ-9 score greater than 9 between 12/1/2014 to 11/30/2015



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MH-1: Depression Remission at 12 Months

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Any designee of the beneficiary’s provider may administer the screening tool; however an eligible professional must see the patient and determine if the patient has a diagnosis of depression.


An initial PHQ-9 score greater than 9 between 12/1/2014 and 11/30/2015. Afollow-up PHQ-9 score less than 5 at 12 months (+/- 30 days) from the indexdate.




MH-1: Depression Remission at 12 Months

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• A diagnosis of major depression or dysthymia;

and

• A PHQ-9 score greater than 9 during an outpatient encounter between 12/1/2014 and 11/30/2015;

and

• A follow-up PHQ-9 score less than 5 at 12 months (+/- 30 days) of the initial PHQ-9 score greater than 9;

or





Examples:

MH-1: Depression Remission at 12

Months (4 of 4)



PREVENTIVE HEALTH

MEASURSES


PREV 5: Breast Cancer Screening

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Description:

Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months.

Exclusions: A bilateral mastectomy or two unilateral mastectomies

Exceptions: None


A mammogram to screen for breast cancer.

Note: 3D mammography, MRI, and ultrasound are not considered breast cancer screening for this measure.


Any qualified healthcare professional may perform the mammogram.




PREV 5: Breast Cancer Screening

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The mammogram must be performed during the measurement period, or 27 months prior to the end of the measurement period (i.e., between October 1, 2014 –December 31, 2016); however, it may not precede the patient’s 50th birthday.



• Date the mammogram was performed and the results



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1


PREV 6: Colorectal Cancer Screening

10

Description:

Percentage of adults 50 – 75 years of age who had appropriate screening for colorectal cancer.

Denominator Exclusions: A diagnosis or past history of total colectomy or colorectalcancer


An appropriate colorectal cancer screening defined by any one of the following criteria:

• Fecal occult blood test (FOBT) during the measurement period

• Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period

• Colonoscopy during the measurement period or the nine years prior to the measurement period



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2


PREV 6: Colorectal Cancer Screening

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Any qualified healthcare professional may perform the cancer screening.


The colorectal cancer screening must be current, which is defined by the type of screening administered.



• Indication of a current colorectal cancer screening as evidenced by the completion of one of the previously mentioned tests or procedures within its corresponding timeframe and must indicate the date the screening was performed and the result;

or





PREV 7: Influenza Immunization

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Description:

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

Denominator Exceptions: Medical reasons, patient reasons, or system reasons


Receipt of an influenza immunization between August 1, 2015 and March 31, 2016.




PREV 7: Influenza Immunization

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Any healthcare professional may provide the influenza immunization.


The influenza immunization must be given between August 1, 2015 and March 31, 2016.



• Indication the patient received an influenza immunization between August 1, 2015 and March 31, 2016




PREV 8: Pneumonia Vaccination Status

for Older Adults

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Description:

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.



Receipt of a pneumonia vaccination.


Any healthcare professional may provide a pneumonia vaccination.


The pneumonia vaccination may occur at any time in the patient’s history, but must be prior to the end of the measurement period.




PREV 8: Pneumonia Vaccination Status

for Older Adults

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• Documentation of receipt of a pneumonia vaccination.– The medical record should state the year (up through the last day of the measurement period) and

type of pneumonia vaccination provided

– If patient reported prior to 2015, documentation indicating receipt of a pneumonia vaccination is sufficient

– If patient reported in 2015 or 2016, documentation indicating the year of the vaccination and confirmation of the type as PPSV23 or PCV13 is required

Note: While the measure provides credit for adults 65 years of age and older who have ever received either the PCV13 or PPSV23 vaccine (or both) to adults 65 years of age and older, according to ACIP recommendations, patients should receive both vaccines.




PREV 9: BMI Assessment and Follow-up

Description:

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.

Denominator Exclusions: Pregnancy, medical reasons, or patient reasons


Completion of a BMI screening that is calculated using a patient’s height and weight. If the screening is outside of normal parameters, documentation of a follow-up plan is also required.• Normal Parameters are as follows:

Aged 18 – 64 years: BMI > 18.5 and < 25 kg/m2

Aged 65 years or older: BMI > 23 and < 30 kg/m2



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Examples of a follow-up plan may include but are not limitedto:

• Providing an educational document (e.g., exercise, nutrition,healthy living)

• Referring the patient to another healthcare professional, i.e., dietician, nutritionist, occupational therapist, physical therapist,primary care provider, exercise physiologist, mental healthprofessional, surgeon, etc.

• Prescribing weight loss medication or dietary supplements

• Providing exercise or nutrition counseling





• Who may perform the Quality Action?

Any healthcare professional may perform a BMI screening andrecommend an appropriate follow-up plan.

Patient reported values of height, weight, or BMI are not acceptable



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The BMI screening may take place during the most recent visit within the measurement period or within the 6 months prior to that visit.

A follow-up plan must be documented during the current visit or within the last 6months if the BMI is outside normal parameters.



• BMI screening date and results;

• If a follow-up plan is required, documentation of discussion of the plan.

The follow- up plan must be specified as an intervention that pertains to the BMIoutside of normal parameters




PREV 10: Tobacco Use: Screening

and Cessation Intervention

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Description:

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user.



Screening for tobacco use at least once within 24 months. For any patient identified as a tobacco user, tobacco cessation intervention must also be provided. Tobacco use includes any type of tobacco.




PREV 10: Tobacco Use: Screening

and Cessation Intervention

20


Any healthcare professional may screen for tobacco use.


The screening for tobacco use must occur within the 24 months prior to the end of the measurement period. The same time frame also applies for cessation intervention for those patients identified as tobacco users.

If there is more than one tobacco screening, use the most recent.



• The date and results of a query of the patient’s use of tobacco;

• If identified as a tobacco user, documentation of a related cessation intervention



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PREV 11: Hypertension Screening

and Follow-up Documented

21

Description:

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.

Denominator Exclusions: Active diagnosis of hypertension


Completion of high blood pressure screening, which consists of a systolic and diastolic blood pressure reading. If the screening indicates pre-hypertension or hypertension, a follow-up plan is also required. Blood pressure classifications and the recommended follow-up plans are specified in the data guidance.



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4


PREV 11: Hypertension Screening and Follow-

up DocumentedWho may perform the Quality Action?

Any healthcare professional may perform a high blood pressure screening. Patient reported blood pressure readings, including readings directly from home monitoring devices, are not acceptable. The appropriate healthcare professional for recommending the follow-up plan is dependent on the specific plan outlined for that patient.


The blood pressure screening must take place during the measurement period. If more than one blood pressure screening is performed, use the most recent. If follow-up is necessary based on the result of the blood pressure screening, the recommended follow-up must be documented during the visit where the screening took place.

Note: If the blood pressure is pre-hypertensive (SBP > 120 and <139 OR DBP >80 and<89) at a PCP encounter no additional follow-up would be needed, this would meet theintent of the measure, then select "Yes" to follow-up plan.



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PREV 11: Hypertension Screening

and Follow-up Documented

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• Date and values of the most recent systolic and diastolic blood pressure measurements. If there are multiple blood pressure measurements on the same date of service, use the most recent as the representative blood pressure;

• If a follow-up plan is required, documentation of the plan is also required. Thefollow-up plan must be specified as an intervention that pertains to the bloodpressure measurement.




PREV 12: Depression Screening and

Follow-up Plan

Description:

Percentage of patients aged 12 years and older screened for clinical depression onthe date of the encounter using an age appropriate standardized depression screening tool (that is normalized and validated) AND if positive, a follow-up plan is documented on the date of the positive screen.

Denominator Exclusions: Active diagnosis of depression or bipolar disorder


Completion of a depression screening using an age appropriate standardized depression screening tool. If the screening is positive, a follow-up plan is also required.




PREV 12: Depression Screening and

Follow-up Plan

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A follow-up plan for a positive screen must contain one or more of the following:

• Additional evaluation for depression

• Suicide risk assessment

• Referral to a practitioner who is qualified to diagnose and treat depression

• Pharmacological interventions

• Other interventions or follow-up for the diagnosis or treatment of depression


A qualified healthcare professional must administer the screening tool.




PREV 12: Depression Screening

and Follow-up Plan

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The depression screening must be performed during the measurement period. If a follow-up plan is required, it must be documented on the date of the positive screen.



• The date and results of an age appropriate standardized depression screening tool;

• If a follow-up plan is required, documentation of discussion of the plan. The follow-up plan must be specified as an intervention that pertains to depression;

or

• Documentation of the reason why the Quality Action is not performed due to an exception (see Data Guidance for specific medical or patient reason exceptions);

or





PREV 13: Statin Therapy for the Prevention

and Treatment of Cardiovascular Disease

(NEW)

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Description:

Percentage of the following patients—all considered at high risk of cardiovascularevents—who were prescribed or were on statin therapy during the measurementperiod:

• Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR

• Adults aged >=21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL; OR

• Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL







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Prescription of statin therapy.


Any eligible professional with prescribing authority may prescribe statin therapy.


The prescription of statin therapy must be documented as either initiated or continuing during the measurement period.






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• An active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD);

or

• A fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL (any time prior to the end of the measurement period)

or

• Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL (during the measurement period or two years prior);

AND

• An active prescription for statin therapy anytime during the measurement period;



WHY IMPORTANT?


Why is reporting important?

• As an ACO, we must report all measures within each domain.

• Incomplete reporting, failure to meet minimum attainment, and poor performance on the audit may result in a Corrective Action Plan (CAP) or termination

• Dual sided risk contract!

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PQRS Alignment

• ACO participants may only participate in PQRS via the Shared Savings Program. No separate PQRS registration is required.

• If the ACO satisfactorily reports measures, then all ACO participants with PQRS eligible professionals will not be subject to the 2018 PQRS payment adjustment.

• EPs working for more than one organization need to meet the PQRS reporting criteria for each TIN under which (s)he works during the 2016 PQRS program year to avoid the 2018 PQRS payment adjustment for each TIN.

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QUESTIONS


Announcements

• Next Lunch & Learn: 9/21/2016

• 2016 MSSP Population Reports

• Provider Meetings

• 8/18/2016 MACRA 101 WebEx

• 9/13/2016 Primary Care Surgical Specialty Meeting

• 11/10/2016 Primary Care Meeting

• Reminders: ACO Notifications, Requests for Tax ID information from PECOS

Sheree M Arnold

ACO Clinical Transformation Specialist

[email protected]

(716)862-2453

mailto:[email protected]