QCDR Made Simple—Ha!
Richard P. Dutton, MD, MBA
Chief Quality Officer, American Society of Anesthesiologists Executive Director, Anesthesia Quality Institute, Schaumburg, IL
Matthew T. Popovich, Ph.D.
Director of Quality and Regulatory Affairs, American Society of Anesthesiologists, Washington, D.C.
The fact is, folks, that the Qualified Clinical Data Registry (QCDR)—and pay for performance reporting in general— is ridiculously complex. And the rules are changing every year. This article will lay out some of the basics, using simple lists and bullets, in the hope of making the options more intuitive. We wish to acknowledge also the editorial assistance of Karin Bierstein, herself an expert, who will correct any inadvertent misstatements we might make. Between the three of us we should be able to lift the fog a little bit.
Let’s begin with some Q&A:
Do I have to participate in performance reporting?
Leaving aside the local advantages of an effective quality management program, external performance reporting is already required for hospital and ambulatory surgery center accreditation. Performance reporting at the federal level is also required for every “eligible professional” (EP)—physician, certified registered nurse anesthetist (CRNA) and anesthesiologist assistant (AA)—paid by Medicare, or else payments will be docked. The penalties at this moment are small, but the government is committed to increasing them to as much as 10 percent of total payments over the next five years. Many anesthesiologists have already received letters from Medicare noting their failure to participate in performance reporting in 2013, and informing them that their payments will be decreased in 2015.
Sooner than you think. For practices with minimal Medicare billing, the financial penalties for not reporting will be small at first. But Medicaid will soon follow, and private insurers likely after that. One way or another, every practice will need to measure and report on quality if it wants to stay in business for the next decade.
What are my options?
Sixty-one percent of anesthesiologists in 2012 reported quality measures to the Physician Quality Reporting System (PQRS). Most anesthesiologists report via the claims-based reporting option. This requires appending a code to each case billed to Medicare, saying that the antibiotics were given on time, that you washed your hands before placing the central line, or that the patient was normothermic when they hit the Post- Anesthesia Care Unit (PACU). (These were three of the five measures most commonly reported by anesthesiologists in 2012.) In 2014 reporting these measures successfully yielded a 0.5 percent (half of one percent!) incentive from Medicare, but beginning in reporting year 2015, satisfactorily reporting will only prevent a -2.0 percent penalty. Worse still, the number of measures that must be reported has increased from the current three up to nine, with required inclusion of at least one cross-cutting measure for claims-based and “traditional” qualified registry reporting. And yes, the average anesthesia provider currently has only a few measures to choose from when using these mechanisms and no outcome measures or cross-cutting measures. More on this below.
There are alternatives to the individual claim reporting mechanism, as Medicare attempts to phase it out. One is the Group Practice Reporting Option (GPRO), which allows groups to present their data through an aggregation service. Often involving the same measures but through a different mechanism, it allows for EPs to receive the 0.5 percent incentive in 2014 while attempting to avoid penalties in the future. Another alternative is to be part of an Accountable Care Organization—a consortium of physicians and facilities accepting a risk- and/or savings-sharing payment from Medicare—in which case you are probably a salaried employee of an HMO like Kaiser or a large university system, and can safely stop reading now—you’re most likely covered.
The final, and newest, alternative is the Qualified Clinical Data Registry (QCDR), intended to give eligible providers credit for participation in external benchmarking for quality improvement. While the reporting mechanism is similar to other reporting mechanisms described above, the set of measures that can be reported is much broader. Medicare has given these approved registries in each specialty the autonomy to define their own important quality metrics, in exchange for doing the data capture, analysis and reporting that Medicare used to have to do itself. We can expect Medicare to continue to promote registries in order to offload the data management burden onto private entities.
I’m already lost—Help!
OK, let’s look at a glossary. Here is a handy list of the critical acronyms:
CMS—The Centers for Medicare and Medicaid Services. In round numbers about 1/3 of all healthcare payments in the US are from Medicare, with another 1/6 through Medicaid. So about 50 percent of all healthcare is bought by the federal or state government. It’s a little less than that for anesthesia, but this is still a big hunk of our business.
P4P—Pay for Performance. What the government intends to do, instead of paying for quantity or service or time. The burden of demonstrating performance is on us.
PQRS—The Physician Quality Reporting System. The first steps toward P4P—in reality, Pay For Reporting and not for Performance in the sense of “outcomes” for practitioners by CMS. Now about eight years old, the program began as a scheme of incentive payments to eligible providers who reported either performing or not performing one or more approved quality improvement measures.
EP—Eligible Professional. Any individual who bills CMS for their professional clinical services to a patient. This includes anesthesiologists, CRNAs, AAs and others.
NQF—The National Quality Forum. A not-for-profit, membership-based organization created to endorse measures for use by CMS and others for quality reporting. Highly bureaucratic—approval of a measure through NQF can take years of effort and costs hundreds of thousands of dollars. CMS-approved measures often form a subset of all NQF-approved measures.
VM—The Value-Based Payment Modifier. The CMS companion program to PQRS, just getting started. Uses the same set of measures and combines PQRS and QCDR measures with outcome and cost measures. EPs not satisfactorily reporting PQRS will be penalized under the VM program cumulatively; this money will fund an incentive pool for those who meet all of the requirements. The VM system is already active in 2014, with results to be applied in 2016.
MAV—The Measure Applicability Validation process. Groups and providers using the claims-based or “traditional” qualified registry reporting mechanisms who cannot find enough applicable measures to report are subject to the MAV test, which assesses whether more measures would have been available. Assuming CMS agrees that there were none, the EP will not be penalized under PQRS.
QCDR—The Qualified Clinical Data Registry. A new mechanism for practices to report PQRS and that will, in the future, impact their VM. QCDRs are developed and maintained by medical specialty societies, and must seek to improve quality within that specialty by means of data aggregation and periodic feedback to participants (benchmarking). The QCDR can use both approved PQRS measures and its own non-PQRS measures. In 2015, the QCDR will be authorized to include up to 30 of these non-PQRS, specialty-specific measures, thus allowing any participant in a QCDR that takes advantage of this authorization to find the minimum nine that must be reported.
GPRO—The Group Practice Reporting Option. Practices can send their data to CMS as a group (all providers using one Tax Identification Number for their business). This is different from the QCDR, as the GPRO only allows reporting the existing PQRS measures and requires different minimums.
OK, I get it. I have to report performance on quality measures to CMS. What next?
Talk to your office manager and your practice management company. This is complicated material and everyone should get professional advice. Then consider your exposure—the percent of cases your eligible professionals bill to CMS. Then decide what your practice posture will be. Do you want to do everything possible to earn VM incentives? Or are you satisfied with avoiding penalties? Do you have an existing system to capture clinical data, or are you starting from scratch? Once you’ve answered these basic questions, you should check out the following publicly available resources:
What are my options?
CMS—The definitive source, but not always easy to understand! http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html
The AQI website—Information on the QCDR. http://www.aqihq.org/PQRSOverview.aspx
The ASA website—https://www.asahq.org/For-Members/Quality-Management/QCDR.aspx (requires member log-in).
ABC weekly e-Alerts on PQRS, VM and QCDR topics—http://www.anesthesiallc.com/publications/anesthesia-industry-ealerts
What measures can I report on?
The following currently approved PQRS measures apply to most anesthesiologists. These measures can be reported through any mechanism: claims-made, group-reporting or through the QCDR. When reviewing the measures, EPs should pay attention to the CPT Codes in the denominator of the measures. If the specified denominator codes for a measure are not included on the patient’s claim (for the same date of service) as submitted by the individual eligible professional, then the patient does not fall into the denominator population, and the PQRS measure does not apply to the patient.
#30—Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics (this measure has been ‘retired’ by CMS, and can no longer be reported to PQRS in 2015)
#44—Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
#76—Prevention of Catheter-Related Bloodstream Infections (CRBSI): Use of a Central Venous Catheter (CVC) Insertion Protocol
#130—Documentation of Current Medications in the Medical Record (the denominator codes do not include anesthesia codes)
#193—Perioperative Temperature Management—For General anesthetics > 60 minutes, the percentage of patients reaching the PACU at greater than 36 degrees, or in whom active warming devices were used
#226—Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (non-anesthesia codes)
#342—Pain Brought Under Control within 48 Hours of admission to palliative care (non-anesthesia codes)
#358—Patient-Centered Surgical Risk Assessment and Communication: The Percent of Patients who Underwent Non-Emergency Major Surgery Who Received Preoperative Risk Assessment for Procedure-Specific Postoperative Complications using a Data-Based, Patient-Specific Risk Calculator, and who also Received a Personal Discussion of Risks with the Surgeon (non-anesthesia codes)
How do I report?
This is the question you should ask your practice managers. The short version is that someone (possibly including the provider at the point of care) indicates in the medical record that the patient is eligible and the measure has been met. Someone else abstracts this information from the medical record or the billing documentation and turns it into a code. That code is reported directly to CMS with the bill for the case (under claims made) or to the GPRO or QCDR. Performance on the measure is calculated at the end of the year, based on the rate of successful reporting over all eligible cases.
What’s different about the QCDR?
EPs participating in the QCDR report their performance on a case-bycase basis just as they would to CMS under claims made. The QCDR then analyzes performance and reports on the EP’s behalf to CMS. The difference is that the QCDR may measure other elements than those reported to CMS (it’s a real registry, not just a billing mechanism). The QCDR will provide regular feedback to the provider throughout the year. And—most important—the QCDR can provide reporting credit for non-PQRS measures.
Aha! That’s how I can find nine measures to report!
Exactly! Here are the 11 non-PQRS measures available in the ASA-QCDR (the National Anesthesia Clinical Outcomes Registry, or "NACOR") for 2014. Even more will be added in 2015.
- Anesthesiology: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit
- Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
- Prevention of Post-Operative Nausea and Vomiting (PONV)— Combination Therapy (Adults)
- Prevention of Post-Operative Vomiting (POV)—Combination Therapy (Pediatrics)
- Composite Anesthesia Safety— The percentage of all patients who complete a scheduled procedure without a major complication
- Immediate Perioperative Cardiac Arrest Rate
- Immediate Perioperative Mortality Rate
- PACU Reintubation Rate
- Short-term Pain Management
- Composite Procedural Safety for Central Line Placement
- Composite Patient Experience
OK, I know this is important, and I have to do it. How much is it going to cost me to prevent penalties or earn incentives?
Costs will depend on the current sophistication of your practice information technology and on your billing or quality capture vendor. Talk with them first! Participation in NACOR is open to any anesthesia practice in America and is free to ASA members. The ASA-QCDR service is also free to ASA members participating in NACOR. Non-member EPs (i.e. your nurse anesthetists and AAs) can use the ASA-QCDR service for $295 per EP per year, with discounts available for large groups. This is likely a fraction of the penalty and incentive money at risk, but each group will need to make this assessment on their own.
Can I still participate in 2015?
Yes, although you need to get moving. CMS has threshold levels of reporting required under each mechanism, so you will need to have your data flowing soon. For the QCDR, EPs using the QCDR option will need to report at least nine measures covering at least three National Quality Strategy domains for at least 50 percent of their patients seen during 2015.
If you’re reading this at the ASA Conference on Practice Management or the Tulane-ABC-Medical Business Solutions Advanced Institute for Anesthesia Practice Management (AIAPM), please stop by the AQI, ASA or ABC exhibits to learn more. There will be presentations at each meeting on the topic of PQRS reporting and the QCDR. The AQI is here to help you manage federal performance reporting in our brave new world of healthcare quality. Complicated, yes. But you can do it!
Richard P. Dutton, MD, MBA is Visiting Professor of Anesthesiology, University of Maryland School of Medicine and AQI Executive Director. To contact Dr. Dutton or the AQI, visit www.aqihq.org.
Matthew T. Popovich, Ph.D. is the Director of Quality and Regulatory Affairs for the American Society of Anesthesiologists. He is based out of the ASA Washington, D.C. office and may be reached at firstname.lastname@example.org.