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Physicians use quality metrics to improve practices, earn incentives

The ongoing federal push to ensure that care paid for under the Medicare program produces measurable results for patients has been a major factor in the increased importance of quality reporting and evidence-based medicine over the past few years. For dermatologists, reporting on the four most applicable measures in Medicare’s Physician Quality Reporting System (PQRS) — three related to melanoma and one related to biopsies — can not only help their practices implement the sort of evidence-based care that Medicare is increasingly seeking to reward, but can help them earn Medicare incentive payments and prepare for a future in which non-reporting will trigger a penalty.

PQRS and care coordination

At present, PQRS is the highest-profile quality reporting system. Formerly known as the Physician Quality Reporting Initiative (PQRI), PQRS was established by the Centers for Medicare and Medicaid Services (CMS) to promote the use and reporting of best-practice quality measures for Medicare patients through financial incentives provided to physicians who report on selected metrics. At present, reporting is completely voluntary and there are no penalties for not participating in 2012. Physicians who report in 2013, however, can avoid the first round of penalties, slated to begin in 2015. According to family physician Bruce Bagley, MD, who writes about quality measures for the American Academy of Family Physicians, the push toward evidence-based quality measures fits in with the current administration’s efforts to reduce costs.[pagebreak]

“Not only is fragmentation costly to the health care system, but the results aren’t as good as integrated care. I think that there are good patient-oriented reasons to do good coordinated care, but it’s also the way the system is heading at present,” Dr. Bagley said. “Look at ACOs and what they frame as the role of a primary care physician, a dermatologist, or a surgeon, in those organizations. One of a physician’s biggest obligations in that setting is integration, communication, and a shared responsibility for cost and quality. I do think that’s going to be increasingly important, which is why we’re seeing the drive toward quality reporting.”

Alison Shippy, senior manager of quality for the American Academy of Dermatology, said that dermatologists who report on quality measures in 2012 can earn a 0.5 percent bonus from Medicare. Those who reported during 2011 earned a 1 percent bonus, slated to be distributed later this year. As the PQRS reporting system and measures evolve, she said, the overall process should become clearer to practitioners.

“Some practices have reported on these measures and they’ve taken this as a performance improvement effort, which is really what you want measurement to be all about. You don’t want it to be measurement for measurement’s sake; you want this data to be taken to improve something,” Shippy said. “You implement a change or alter practice and you measure again you want to see if that intervention really made a difference.”

In addition to PQRS measures, a number of states and private organizations have begun to experiment with greater integration of quality reporting. Minnesota’s 2008 health reform law required the state to implement a system of quality incentive payments based on provider performance in comparison to specified targets over time; this year’s measures focus on diabetes, vascular care, and, for hospital-based physicians, cardiology and pulmonology conditions. California has a number of pay-for-performance programs implemented through the Integrated Health Care Association, but none of the programs include dermatology-specific measures. The Cleveland Clinic reports quality data to patient groups as well as CMS, and continues to push for more data-driven treatment strategies. The organization also recently introduced a prospective quality incentive program for end-stage renal disease in concert with CMS, the first pay-for-performance program in a Medicare prospective payment system.

“The whole world is changing around us, and medicine’s one big part of that. The effort to decrease fragmentation, increase care coordination — that’s what the patient-centered approach is all about,” Dr. Bagley said. “It’s about patient self-management support, and a team approach to care. The medical home obviously has to interact with the medical neighborhood, so having regular interaction with specialists, service agreements, is part of what the medical home is about.”[pagebreak]

Earning incentives in dermatology

According to Shippy, CMS is slow to release specialty-specific information on physician participation in and reimbursement from PQRS. Yet from the most recent numbers available, she said, it’s clear that dermatologists have been able to not only receive reimbursement, but earn incentives that surpass their colleagues in other specialties. The figures from both 2009 and 2010 show dermatologists earning incentives in similar percentages to their colleagues across medicine. In addition, Shippy noted, participating dermatologists who qualify for incentives earn significantly more, on average, than other physicians. Among the 196,000 MDs and DOs who participated in PQRS reporting in 2010 either as individuals or groups, via claims or registry, the mean incentive earned was $2,519.87, with a median incentive payment of $1,364.14. The 1,900 dermatologists, though, earned a mean payment of $7,462.06 and a median payment of $4,910.12. Among the total population of physicians who reported individual claims or registry data, 61.5 percent and 89.0 percent, respectively, earned reimbursement. Among dermatologists, 59.1 percent reporting claims data earned reimbursement, while 91.1 percent reporting registry data earned reimbursement.

Reporting on quality measures is also a component of the meaningful-use reporting conducted to earn incentive payments from Medicare for electronic health record adoption. Torrance, Calif.-based Dermatology Group of Southern California successfully reported these quality measures in 2011. The group, which employs four dermatologists and a total of 30 employees, spent years ramping up to its initial quality reporting year, according to CEO Vimala Karukonda, MBA.

“We had to have the right practice management software to report all these measures and capture all the data. That’s where our whole program started. We had to do a lot of research and figure out what system was right for us. Once we got that, we had to roll it out in different phases. There were a couple of years of work that we did prior to starting to collect the data,” Karukonda said.

In addition, Karukonda said, the group wanted to build in time for testing and working the bugs out of the system, as well as additional time to fall back on should the practice have failed to meet some of the quality measures. The group began a six-month test period in January 2011, she said, and spent the entire time fine-tuning the workflow process to make data collection as efficient as possible.

“The first six months included employee training, management training, and resolving each of the issues that we had to around every topic and measure. We had some issues capturing the information exactly the right way. We had to go back a few times and tweak the software to where it was finally working and collecting the data the way it was supposed to,” Karukonda said. “After the long trial period, we picked the 90-day period from August through October for reporting. We still wanted to have those two additional months of cushion in case we didn’t make it on any of the measures. It had to be planned and executed in a very systematic and organized manner.”

In terms of unexpected hurdles to the meaningful use reporting process, Karukonda said that the time needed for educating and rallying employees turned out to be far more than she expecting heading into January 2011.

“I didn’t think that I was going to end up spending the amount of time I spent in educating them and coaching them and walking them through the data and every single piece of the measures as much as I did,” she said. “People beginning reporting need to allocate some time to revisit and reinforce topics with your employees almost every single week and keep them motivated. At the end of the day, it was a very good learning experience for all of us.”

Karukonda said the practice made sure to capture data on each measure for 80 percent of patients to ensure that it would be compliant with any increase in reporting requirements CMS might mandate. As a result, she said, the staff got very good at capturing data efficiently, analyzing nightly meaningful use reports generated by the EHR software, and internalizing each part of the quality reporting process. This helped the practice to successfully complete reporting for all of the necessary measures during the 90-day reporting period.

Additionally, Karukonda said that once the practice’s physicians internalized the meaningful use measures, she noted a number of changes in physician behavior in accordance with the new workflow.

“Our physicians moved away from paper charts to EHR, and it required them to learn how and where to access all the relevant information. We had a huge shift in our focus from an IT standpoint,” Karukonda said. “Initially our IT was designed to capture data and retrieve it as needed by our providers and now we are sharing it with patients. We provide a care summary report to a patient after every physician encounter and this change forced our physicians to change their behavior from doing the notes at a later time to real time as much as possible. We’re also doing e-prescribing and checking drug interactions, which we weren’t able to do before. It’s been a serious paradigm shift in terms of the information available to patients — overall, we are more patient-centric than ever before.”[pagebreak]

Measuring coordination

In addition to potential reimbursement and lowering the cost of care, one of the benefits of this new model touted by CMS has been greater coordination of care. One of the current measures seen as an indicator of encouragement toward coordination is Measure 265, related to biopsy follow-up, which requires communication and documentation to pass between a patient’s dermatologist and primary-care physician. (A full description of the four dermatology-specific measures is available at Dermatologist Oliver Wisco, DO, who chairs the Academy’s Performance Measurement Task Force, said that the philosophy behind the measure is laudable, and an important step toward improving one’s practice and encouraging greater coordination of care. The execution, he said, must be considered by practitioners without a system already in place to deal with the reporting requirements. It illuminates the difference between the theory and execution of quality reporting in terms of practical application.

“Right now, the biopsy measure, in theory, is really good,” Dr. Wisco said. “It’s a great measure to try to improve your practice, but it’s not the most efficient measure for determining whether you are taking care of your patients appropriately.” The measure is set up, he said, in a way that requires dermatologists to input information about 80 percent of the Medicare patients for whom they performed biopsies into a registry system after that information has already been submitted separately through the claims process — a significant burden for small practices that does not necessarily help achieve any practice improvement. “Eventually the system will improve to where you can upload data directly from your electronic medical record to Medicare,” he said, which would make reporting on a measure that has definite relevance for dermatologists easier to actually accomplish. “I believe in the measure,” he said. “I just don’t think it’s set up in the most efficient manner right now.”

Early participation in quality reporting, Dr. Wisco said, will help physicians prepare for the ethos of life under accountable care organizations (ACOs).

“Eventually the ACOs will be using various quality metrics to measure their physicians. The productivity, the access for patients, the CME — these will all be measured to determine whether you’re performing at a certain standard,” Dr. Wisco said. “The underlying drive to gather and report data related to quality metrics should be improving your practice or improving the care of your patients. Right now we’re trying to develop new metrics, but it’s a long process, and there are only a few evidence-based guidelines that enable us to create good quality metrics.”

What’s next in quality measurement? Demonstration project may show the way

Wisconsin’s Marshfield Clinic health care system, which operates more than 50 locations throughout that state, has been a leader in quality reporting as Medicare has sought ways to encourage evidence-based medicine and cost reductions. In 2011, the clinic completed a five-year Centers for Medicare and Medicaid Services (CMS) demonstration project to reduce costs at a rate 2 percent better than other regional health systems. Ted Praxel, MD, has been in charge of Marshfield’s quality reporting efforts for five years.

“The goals of the demo were to improve efficiency and at the same time improve quality. CMS wanted to promote coordination between part A and part B expenditures and to reward people who were making improvements by sharing savings with them. It was based off of the rate of growth of expenditures in your area versus a local geographic comparison group,” Dr. Praxel said. “For the purposes of the demo, when people have the plurality — not the majority — of their care with us, they were assigned to us. We were responsible for them in their entirety.”

Patients in that group, he said, were set into a comparison group with patients who never received care from the Marshfield system. Patients who did receive care, but not the plurality of care, from Marshfield were excluded from comparison. The clinic then had to report on an increasing number of quality measures for those patients over a three-year demonstration period that was eventually extended to five years.

“The goal was that we had to have a rate of growth more than 2 percent below the rate of growth of expenditures for that local geographic comparison area. And only above that 2 percent part were we eligible to share in savings. Over time, the reporting went from 30 percent quality vs. 70 percent efficiency to 50/50 in the last three years,” Dr. Praxel said. “There were 32 quality measures. Year one there were 10 measures. Year two there were 17 more added, and year three they added five.”

The broad array of services offered by Marshfield, along with the varying backgrounds of clinic physicians and practice employees, required a significant coordination of effort to meet the program’s goals. Eventually, Dr. Praxel said, the data-driven methods employed evolved into an advanced quantitative charting of each patient’s interactions with the Marshfield system.

“We’re a fairly large system, we have people who were educated at different times and in different places, so the goal was to make sure everyone had an idea of what we thought was the desirable way to take care of these chronic conditions, and we educated people about that through guidelines. We had computer-based CME to reinforce the guidelines,” he said. “We also worked to improve processes within departments, to work toward improving the workflow so that we didn’t miss opportunities to draw blood, check cholesterol, or intervene in treatment. We also worked on providing feedback to the providers and individual patients. That’s evolved through the years. We started with Excel spreadsheets and it’s evolved to the point where we have population health management dashboards.”

The result, at the end of the project, was that Marshfield met 130 of 133 quality metrics set by CMS over the five-year demonstration period. Dr. Praxel remains convinced that the approach taken has given Marshfield physicians feedback that has helped change their practice patterns and helped them provide even better care to patients. Having successfully completed the demonstration project, the clinic is now in the midst of a two-year transitional CMS program, where Marshfield and other health systems are benchmarked and ranked nationally, rather than regionally, on their ability to control costs and improve the quality of patient care. (Neither program included dermatology-specific measures.) In addition to cost controls, Marshfield also measures outcomes, according to Dr. Praxel.

“We look at the outcomes for diabetes regarding long-term blood sugar and cholesterol control; for hypertension looking at getting the patient’s blood pressure to the desired level; for coronary artery disease getting cholesterol control; for preventive services getting colorectal cancer screening and breast cancer screening done to name a few,” Dr. Praxel said. “One can differentiate between process measures — was a test done? — and outcome measures — meaning is the metric in question under control?”

AAD offers measure reporting tool

The Academy’s Quality Reporting System offers the opportunity to use evidence-based dermatology measures supported by clinical guidelines to earn a 0.5 percent bonus payment from Medicare. For dermatologists who want to begin quality reporting, seek resources on earning PQRS incentives, or share their experiences with staff, there are additional resources available on the Academy’s quality reporting Web page, Alison Shippy, senior manager of quality, said that the Academy’s reporting system is tailored to dermatology-specific measures to streamline the approach for members.

“We have constructed the registry to include the measures that we think dermatologists are most likely to report on,” she said. “We could certainly include multiple other measures in the QRS registry but we figured it was in the dermatologist’s best interest to focus the measures on the few that they are mostly likely to report on.” A list of all of the quality measures that may be reported for PQRS is available from CMS; visit for more information.

Program timeline for 2012 reporting

December 14, 2012: Last chance to purchase AAD quality reporting system.

January 31, 2013: Last day to submit data to AAD registry.

Early 2013: Submitted information validated. Physicians with data problems contacted to remedy issue.

March 2013: Registry submits all data to CMS.

Fall 2013: Reimbursement arrives.



What’s next in quality measurement? Demonstration project may show the way
AAD offers measure reporting tool