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Orthopedists’ Survival Kit: How to Succeed with Medicare PQRS and VBPM

By June 30, 2015 No Comments

1319307_73929586Pay for Performance success takes careful thought and management, particularly for specialty practices. Under Medicare’s PQRS and Value-Based Payment Modifier (VBPM), specialties have fewer measures available, which narrows reporting options—making it harder for you to meet PQRS and compare well against your peers.

For Orthopedics, this is especially true. Nearly 200 PQRS measures have a Registry reporting option, but many orthopedic surgeons still have a difficult time finding nine measures across three National Quality Strategy (NQS) Domains (including one cross-cutting measure), where performance is good enough to report.

All too often, orthopedic surgeons get trapped, reporting on measures where performance is poor or, at least, worse than peers, to avoid the automatic PQRS or VBPM penalties associated with non-reporting. But that, along with cost issues, can force you into a lower tier under Medicare’s quality-cost tiering algorithm, triggering yet another VBPM penalty. Those poor results will also be publicized on Medicare’s Physician Compare website.

Here’s how, as an orthopedic surgeon, you can avoid this pitfall and turn your specialty to your VBPM advantage:

Step 1: Fulfill PQRS requirements.

The first step to maximizing your VBPM is to fulfill PQRS requirements. Failing to meet PQRS requirements will trigger a PQRS non-reporting penalty and an automatic VBPM penalty.

As an orthopedic surgeon, you will only have five of the six NQS Domains to choose from (the measures within the Efficiency and Cost Reduction Domain do not apply to orthopedics). Fortunately, within these Domains, you will have some room to pick and choose, depending on where you think you can collect the required information for completing the measure and excelling in performance.   

Step 2: Report “clustered” measures.

Certain measures are tied to the same condition or outcome. For example, measures #24 (Communication with the Managing Physician) and #40 (Management Following Fracture) are both related to fragility fractures (fractures of the hip, spine or distal radius) and subsequent treatment for osteoporosis. In most cases, the patient denominators in these “clustered measures” will be identical. With proper planning, you can complete an extra measure with minimal effort.

Furthermore, clustered measures do not always appear in the same Domain (#24 and #40 are in Communication and Care Coordination, and Effective Clinical Care, respectively), meaning that you are even closer to covering the domain component of reporting requirements. As you are already limited in NQS Domains from the outset, using this cluster to cover two Domains will be especially helpful.

Step 3: Track your performance against Medicare specifications—professionally.

Ironically, perhaps the greatest challenge in quality reporting has less to do with quality of care than with documentation. Each year since Medicare opened PQRS to Registries in 2008, we have had clients arrive mid-to-late year, certain that they were on track for success, only to find out that they were far behind. Frequently this can be traced back to a discrepancy between the CMS measure specifications and the practice’s actions.

The measures are not always intuitive, and seeing the discrepancy between your expected results and what your Registry reveals can be a jarring wake-up call (unless you’ve reported EHR-Direct, in which case, your surprises will come after Medicare calculates your results). This is one key reason you should consider reporting through a Registry, because the CMS authorization process includes validation of the Registry’s mapping of measure specifications.

Some of these issues are measure-specific. Here’s an example we frequently see with Orthopedic measures: the Falls Risk Assessment measure (#154). The goal of the measure is to identify whether the patient has had recent falls, and, if so, to complete a risk assessment. It sounds simple, but many patients have not had falls. According to the spec, a patient who has not fallen is considered “excluded” from performance, rather than “meeting performance.” The result is that we’ll see the measure completed 100/100 times, but only 10 patients have had falls. Of those, only 2 patients have documentation of the risk assessment. This translates into 100 responses, 90 exclusions, 10 performance-eligible, 2 performance met. In the reporting world, you’re in great shape: 100 percent completion. But, when we evaluate pay for performance (VBPM), you’re in trouble—your performance is only 20 percent! That’s where the performance-based penalties can catch you by surprise.

You may be collecting information on tobacco, BMI and blood pressure, but are you paying attention to the thresholds Medicare has defined? If your measures are out of range, you are supposed to have a follow-up plan in the record. But, you ask, why is this an issue if you are not managing this condition? Look again. The specifications include a referral back to the managing physician as an acceptable plan for you. If you’ve done that, you are able to report for everyone and your performance will be met, as well. For these measures, you’re not penalized if your patient’s blood pressure is high, or BMI is outside of the CMS-defined healthy ranges, provided that you’ve documented that you are aware of the problem and have communicated back to the primary care provider. In addition to PQRS, this open dialogue regarding patients’ risk factors will be beneficial as a way to help your patients have better outcomes.

Step 4: Get everyone involved to meet the newly required “all-patients” cross-cutting measure.

As an orthopedist, you’ll be required to use at least one “cross-cutting measure” in your PQRS measure selection. These are measures with a wide focus, meant to include as many patients as possible. Medicare, in an effort to ensure continuity of care, is steering those who see a patient in a “face-to-face” encounter to report at least one of these measures. Examples include Medication Verification (#130), Screening for Tobacco Use and Cessation Advice (#226), BMI Screening and Follow Up (#128) and Blood Pressure Screening and Follow Up (#317).

The good news is that a great number of practices are already collecting this information through an intake form before the patient sees any clinician. By devising a workflow to transfer this information from the form to your EMR (or to a Quality Data Code on your superbill/routing slip), you’ve already completed the measures that require the most responses. Practices can take this one step further by creating a similar process for nursing staff and assistants to document blood pressure and BMI.

Step 5: Prepare for future “retired” measures while meeting present performance.

One of Medicare’s strategies for raising the bar is to retire measures where performance is met almost universally. The thinking is that, if a measure has had performance rates beyond 90 percent for several years in a row, it has “maxed out.” The gap between the high quality group and low quality group is so small that it becomes tough (and risky) to reward one group and penalize the other, as there may be only a few percentage points separating them.

For that reason, CMS had intended to retire all of the perioperative measures in 2015, which include measures related to Antibiotic Timing, Antibiotic Selection, Antibiotic Discontinuation and VTE Prophylaxis (#20-#23, respectively). So far, only measure #20 was retired in 2015 (if you’re still using this measure, stop now and find an alternate!), although all four were proposed for retirement. For orthopedic surgeons, this will make things more difficult; these measures have been traditional mainstays since the inception of PQRS. Orders are often standing, and so no additional effort is required; but that’s exactly why CMS will likely remove them next year.

These process measures are being replaced by measures focused on outcomes, overutilization and shared decision-making. This year, many will use the Patient-Centered Surgical Risk Assessment and Communication (#358) to replace the retired Antibiotic Timing measure (#20). It’s clear that Medicare is moving away from measuring processes and towards results, including the patient’s view. Now would be the time to begin looking at newer measures that follow this theme—they’ll likely be the ones used to grade you next year. Read the measure specs now, and try a variety of data collection techniques.  Performing well in January will help you lead the pack, rather than scrambling to beat them in July.

Download your free copy of the ICLOPS Insider’s Guide to PQRS 2015 Reporting: How to Succeed in the Value-Based Health Care Environment.

Founded in 2002, ICLOPS has pioneered data registry solutions for improving population health. Our industry experts provide comprehensive PQRS Reporting with VBPM ConsultationPQRS Consultation and ACO Reporting and Population Health Solutions that help you both report and improve your performance. ICLOPS is a CMS Qualified Clinical Data Registry.

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Image Credit: Xray by Nick Albufairas