The Qualified Clinical Data Registry (QCDR)
Richard P. Dutton, MD, MBA
Chief Quality Officer, American Society of Anesthesiologists
Executive Director, Anesthesia Quality Institute
Clinical Associate, University of Chicago Department of Anesthesia and Critical Care, Chicago, IL
By now, many readers of the ABC Communiqué will have heard about the Qualified Clinical Data Registry (QCDR) and will be wondering (or dreading) what this means for them and their practice. This article will lay out the basic definitions and requirements.
The QCDR is a new mechanism for eligible professionals (EPs) to report data on their performance to the Centers for Medicare and Medicaid Services (CMS). CMS currently reimburses about one-third of anesthesia care in the United States, and almost every practice derives a portion of its income from CMS. As a federal agency, CMS has been at the forefront of responding to public demand for transparent reporting of healthcare quality from both hospitals and providers. This has led to a steadily escalating requirement for performance reporting.
Under the QCDR, EPs contributing data to a clinical registry can get credit for meeting the requirements of the Physician Quality Reporting System (PQRS) and the Value Modifier (VM) program.
Technically, a QCDR is designated by CMS under the provisions of the ‘Final Fee Schedule Rule’ published in November, 2013. Registries could nominate themselves for this designation during January 2014, and were then required to meet more than 30 requirements before certification. Among the requirements, the registry must have been in existence for a while, must represent a specific specialty or discipline of medicine, must collect data from multiple sites and healthcare systems, must maintain a public list of performance measures and definitions, must provide regular feedback to contributors and must be able to collect, analyze and transmit data to CMS in an approved format.
As noted above, the QCDR is a new vehicle for providers and practices to report performance data to CMS, under the existing Pay for Performance (P4P) systems. The original PQRS program, now more than five years old, was created to encourage individuals to publicly report performance on one or more established quality measures. Through 2014, CMS offered small incentives to do so—for example, providers reporting successful performance on at least three measures in 2014 will receive a bonus payment from CMS equal to 0.5 percent of their Medicare billing for the year. Beginning in 2015, however, this carrot becomes a stick. The PQRS bonus changes to a ‘payment adjustment’ of negative two percent of reimbursements for those who are not reporting successfully, with increasing penalties in the years ahead.
The VM system is a new program, which overlaps and expands on PQRS. In 2016, CMS will assess physician performance data from 2014. EPs not reporting their performance will be penalized; those who do report successfully will be eligible for incentive payments under a complex formula designed to redistribute money from worse performers to better ones. Successful VM reporting requires nine measures, from three different domains of the national quality strategy, and must include at least one outcome measure.
The original method for reporting PQRS performance to CMS was the ‘claims-made’ mechanism. This is still used by the large majority of practitioners who participate in PQRS (61 percent of all anesthesiologists participated in 2013; about the same percentage of nurse anesthetists), including many through ABC. This mechanism requires the billing company to append a code to each eligible case indicating compliance with a given measure. For example, the code for ‘anesthesia for upper abdominal laparoscopic surgery’ would be accompanied by an additional code indicating ‘prophylactic antibiotics were given at the correct time.’ CMS then conducts an annual audit of all cases for every provider to determine which cases were eligible for each measure, whether performance was met and whether the provider is eligible for an incentive payment based on their results.
A newer mechanism for reporting performance under both PQRS and VM is the group reporting option, whereby aggregate performance for the year for an entire practice group is sent to CMS as a single file by a certified vendor. This moves some of the burden for scoring performance from CMS to the vendor, without changing other aspects of the program. In 2014 group reporting became mandatory for groups of 100 or more providers, and in 2015 this requirement will be extended to all groups of 10 or more, as CMS seeks to de-emphasize the claims-made approach.
PQRS and VM use the same set of CMS-approved measures. Most of these are derived from a larger set of measures collected and endorsed by the National Quality Forum (NQF), set up as a public-private partnership a decade ago specifically for this purpose. The process of creating a measure, validating it, and achieving NQF endorsement and CMS inclusion can take years of work. In theory, any EP can report on any of the 300+ approved measures, but in practice this is hard to do because eligibility for a given measure is usually determined by a billing code (e.g., the Current Procedural Terminology™ or CPT code for anesthesia providers). If the EP is not billing that code, then they are not eligible for that measure. For example, an anesthesia provider might feel that they have some involvement in the measure developed by the Society for Thoracic Surgeons to encourage early extubation after coronary artery bypass surgery. But because this measure is specific to the CPT codes for the surgery (not the anesthesia care) this measure is not actually available to our specialty. Most medical disciplines—including anesthesia—do not have enough measures approved by CMS for the average clinician to meet the new nine-measure requirement of the VM system.
Performance reporting to CMS through a QCDR is similar to group reporting through a certified system—the registry will send a single report to CMS summarizing the provider’s performance on a given measure for the entire year. Unlike PQRS and VM, however, a QCDR can use specialty-specific measures drawn from outside the existing pool approved by CMS. These ‘non-PQRS measures’ can be from any credible source, and must be clearly defined, publicly transparent and valid for the stated purpose.
Plans for the future of P4P programs can be glimpsed in existing regulations, in comments by officials and in legislation being debated in Congress. First, it is clear that P4P will not go away. A steadily increasing percentage of every provider’s reimbursement from the federal government will be linked to documentation of compliance with performance measures, and will be publicly reported. In 2015 this is a two-percent risk—or $2000-$5000 per year for most anesthesia practitioners—but the planned evolution of PQRS and VM will bring the total at risk to about ten percent by 2020, or tens of thousands of dollars per EP. Further, it is likely that where CMS leads, the entire fee-for-service universe will follow; PQRS requirements have already been extended to some state Medicaid programs and private insurers are likely to follow suit. It is clear that registry-based reporting is the most favored mechanism going forward. Federal officials believe that physician participation in clinical registries, with regular public benchmarking, is an important tool to achieve the triple aim of improved outcomes, improved efficiency and improved patient experience. Strategies to enhance registry reporting can be seen in the evolution of the Meaningful Use program, in proposals and demonstrations for alternative payment models and in Congressional efforts such as the proposal to reform the Sustainable Growth Rate formula. More cynically, the QCDR approach also relieves CMS of much of the burden of collecting, cleaning and scoring performance data from individual providers.
QCDR and the Anesthesia Practitioner
The American Society of Anesthesiologists (ASA) recognized in 2008 the value of a specialty-specific clinical registry, including the ability to meet regulatory requirements. The ASA has invested millions of dollars in development of the Anesthesia Quality Institute (AQI) and its product, the National Anesthesia Clinical Outcomes Registry (NACOR), to which many ABC practices contribute. NACOR was certified for group reporting of PQRS measures in 2012, and earlier in 2014 became one of the first QCDRs approved by CMS. In doing so, AQI scoured the existing NQF and CMS measure lists, then combined this with years of work by the Committee on Performance and Outcome Measures to propose a list of measures comprehensive enough that almost any clinical anesthesia provider will be able to find the minimum nine measures required to earn future incentives. The 19 measures approved for submission through NACOR include eight PQRS measures and 11 non-PQRS measures, and are briefly listed in Table 1. Specifics are available on the AQI website at http://www.aqihq.org/PQRSOverview. aspx. In this pilot year of the QCDR, both CMS and the AQI will be assessing the value and reportability of these measures, with anticipation of adjustments in future years. The 2015 proposed final rulemaking will allow up to 30 non-PQRS measures for inclusion in the QCDR; this will enable AQI to include subspecialty measures for pain, obstetrics, pediatrics and cardiac practitioners.
QCDR submission of performance data to CMS is available to any eligible professional in a practice that is contributing data to NACOR. Participation in NACOR is on a per-group basis at a fee of $1000 per attending physician anesthesiologist or independently-practicing nurse anesthetist. This fee is discounted to $0 for ASA members; most practices in the care team model thus participate in NACOR at no cost, as a benefit of ASA membership. QCDR reporting to CMS will be available at no additional charge to ASA members and for $295 per year to non-member EPs, with discounts available to large groups. To meet PQRS and VM requirements through the QCDR, practices must self-nominate to CMS, must complete waivers and submit National Provider Identifier (NPI) numbers for each EP to AQI, must collect and code the primary measure information in their electronic systems (either billing or medical record) and must transmit this information to NACOR as part of their regular data contribution. ABC is positioned to facilitate this activity on behalf of their client practices.
While QCDR reporting appears to be the favored approach to P4P in the next decade, the claims-made and group reporting options for PQRS are still a reasonable approach to avoid negative payment adjustments. The lack of sufficient measures for anesthesiologists in these systems will make it difficult to qualify for incentives in the years to come, however. At present, NACOR is the only QCDR available to anesthesia practitioners, but in time practices may have several alternative QCDRs to choose from, using the same or similar measure sets. Which one is most appropriate for a given group will likely depend on other aspects of the registry, such as its interaction with the electronic medical record and its utility for quality improvement activities, clinical research or other regulatory reporting.
As has been the case over each year in the past decade, specific requirements for P4P will continue to change going forward. The AQI follows this evolving landscape closely, and recognizes that facilitating performance reporting for anesthesia providers is an important mission of the registry. In this way, we hope to continue to serve our participants and advance the quality of anesthesia care.
Richard P. Dutton, MD, MBA is Executive Director of the Anesthesia Quality Institute (AQI). He also serves as Chief Quality Officer for the American Society of Anesthesiologists. Dr. Dutton is a Clinical Associate at the University of Chicago Department of Anesthesia and Critical Care. To contact Dr. Dutton or the AQI, visit www.aqihq.org.