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Reporting Physician Quality to Medicare as an Accountable Care Organization

Even among healthcare professionals, reporting physician quality can often be a confusing subject. Different entities have different quality requirements, and even within a single organization, different programs require reporting for different measurements to satisfy payment goals.

Of course, as federal standards are often used as a baseline for all other programs, the Center for Medicare/Medicaid Services (CMS) requirements are most frequently discussed and, just as often as not, misunderstood. Depending on what type of organization a physician practice belongs to, different sets of standards and submission requirements may apply.

For Accountable Care Organizations (ACO), this process can often be even more puzzling, especially among large group practices. One crucial step an ACO can take in minimizing the stress of reporting physician quality to CMS is simply ensuring that every participant of the ACO understands what the requirements are and how their reporting will be affected. Some of the most commonly misunderstood factors of ACO reporting are:

  • When a practice joins an ACO, this replaces the requirement for submitting Physician Quality Reporting System (PQRS) measures to CMS. Not only is the requirement removed, but practices will be unable to report these measures themselves, as the ACO is required to submit on their behalf.
  • Whereas a PQRS submission can choose between at least 9 measures covering 3 separate focus areas, ACO reporting always consists of the same measure set. For the 2016 reporting year, there are a fixed set of 18 patient quality measures that must be submitted, as well as patient/caregiver experience and patient safety measures that are often reported through third-party vendors and through claims data.

For reporting year 2016, all ACOs must report on the same 18 measures measuring care coordination, at-risk populations, and preventive care:

  • Screening for Future Fall Risk
  • Documentation of Current Medications in the Medical Record
  • Coronary Artery Disease: ACE/ARB therapy for CAD patients with either Diabetes or Left Ventricular Systolic Dysfunction
  • Diabetes: Hemoglobin A1c Poor Control
  • Diabetes: Eye Exam
  • Heart Failure: Beta-Blocker Therapy for LVSD patients
  • Hypertension: Controlling High Blood Pressure
  • Ischemic Vascular Disease: Use of Aspirin or Other Antithrombotic
  • Mental Health: Depression Remission at 12 Months
  • Preventive: Breast Cancer Screening
  • Preventive: Colorectal Cancer Screening
  • Preventive: Influenza Immunization
  • Preventive: Pneumonia Vaccination for Older Adults
  • Preventive: Body Mass Index Screening and Follow-up
  • Preventive: Tobacco Use Screening and Cessation
  • Preventive: Screening for High Blood Pressure and Follow-up
  • Preventive: Screening for Clinical Depression and Follow-up
  • Preventive: Statin Therapy for Prevention and Treatment of Cardiovascular Disease

The process of submission itself can also vary widely among organizations – generally speaking, larger organizations will choose to gather information and produce a report through a certified EHR or registry vendor, while smaller practices that may still have some records on paper charts will need to review each chart individually. Some might even choose to supplement EHR reporting through manual chart abstraction in order to maximize quality outcomes and capture all possible physician actions, as coding and documentation practices are often not standardized across the different practices that make up an ACO.

Of course, this leads into one of the biggest missed opportunities within the realm of reporting on quality metrics. CMS often sets the bar much higher than other healthcare quality entities, meaning that documentation of every relevant item is crucial to ensuring an appropriate quality score with CMS. Organizations looking to maximize all their quality scores, then, must set their standards to CMS’s guidelines in order to see consistent quality scores across all forms of measurement.

While clear documentation of actions taken by physicians may seem like a no-brainer, consider the following examples:

  • A Medicare patient with severe dementia comes to their annual Medicare wellness visit appointment with his daughter because he can’t take care of himself. The physician sees his cognitive difficulty and chooses not to screen him for depression, as she can’t rely on the accuracy of his answers. Unless the physician specifically notes that her patient was not screened for depression due to his cognitive impairment, that patient would not count toward the depression screening measure.
  • A new patient comes to the physician’s office and notes that they had a colonoscopy done with their old PCP last year and gives a date. If this is documented within the medical record without an indication of what the results of the colonoscopy were (i.e. normal or abnormal), CMS will not consider that measure satisfied.

On top of these documentation concerns, each measure has its own idiosyncrasies –for example, diabetes A1c control counts patients who do not have their A1c levels under control, while all other measures count patients who are managing their diseases successfully.

Ultimately, the best way to maximize quality scores for any organization across the board is to fully understand the strictest quality guidelines and have a standard method of applying the documentation of those guidelines into practice. From there, by regularly monitoring quality scores throughout the year and checking in with physicians, the organization can avoid any surprises with scoring and more accurately predict their potential shared savings dollars.

For more information on ACO quality measure reporting and associated programs, see CMS’s website.

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For more information, contact Kristen Webb at kristen.webb@infoworks-tn.com.