1. Quality Reporting for Cash:
CMS Incentives and Your Bottom Line
Sandra Pogones
Program Manager, Physician Services
Primaris – Columbia, MO
November 2011
Publication MO-11-20-PR
This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents
presented do not necessarily reflect CMS policy

2. Who is Primaris
Founded in 1983 by the Missouri State Medical Association,
Missouri Hospital Association and Missouri Association of
Osteopathic Physicians and Surgeons
Among other roles, Primaris serves as the federally-
designated Quality Improvement Organization (QIO) for the
state of Missouri.
– Mission of QIOs: To improve the effectiveness, efficiency,
economy and quality of services delivered to Medicare
beneficiaries.
– QIO contract-related services are free to providers.
Slide 2 of 42 2

3. Objectives
Establish the importance of Quality Reporting to physicians
Analyze financial impact of CMS incentive programs
Outline requirements for Meaningful Use, PQRS and e-
Prescribe
Present a cross-walk for quality reporting and examine
specifications for a sample measure
Propose a workflow plan to incorporate quality
measurement into daily practice
Question and Answer
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4. Case for Quality Reporting & Improvement
Success of Practice
– Sense of Accomplishment/Professional Achievement
– Improved Productivity/Set Practice Priorities
– Move away from Defensive Medicine to Evidence-Based
Service to Patients
– Improved Outcomes, Prevention, Diagnosis, Remediation
– More engaged, self-responsibility
– Improved Satisfaction, Better Coordination
Benefit for the Population
– Efficacious care and Improved Population Health
– Less waste, right incentives—Drive Change
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5. Where do CMS Quality Measures Come From?
National Quality Forum (NQF) measures are at the
center of quality measures.
– Experts in the clinical area and stakeholders are convened to
define quality and standards through consensus process
– Measures are adopted that are important, scientifically
acceptable, useable, relevant, and feasible to track
– Caregivers adopt and apply measures to improve their own
practice
– Measures provide benchmarks and best practices
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6. Three Separate and Distinct CMS Programs
EHR Incentive Program (―Meaningful Use‖ of an EHR)
PQRS Incentive Program (Physician Quality Reporting
System—formerly PQRI)
E-Prescribe Incentive Program
EPs MAY participate in all programs for incentives and MUST
participate to avoid payment penalties.
Only Medicare EHR incentives and e-prescribe incentives are
mutually exclusive. Otherwise, eligible providers can
collect from all three
Slide 6 of 42 6

7. Impact on the Bottom Line
Program Incentives Penalties
EHR-Medicare 2011-2015: $44,000 Total 2015: -1.0%
($18,000 Year 1) 2016: -2.0%
2017: -3.0%
EHR Medicare 2011-2015: +10% 2018: -4.0%
HPSA-Bonus 2019: -5.0%
2011-2021: $63,750 Total
EHR-Medicaid ($21, 250 Year 1)
PQRS 2011: +1.0% 2015: -1.5%
2012-2014: +0.5% 2016+: -2.0%
E-Prescribe 2011-2012: +1.0% 2012: -1.0%
2013: +0.5% 2013: -1.5%
2014: -2.0%
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8. Incentives Paid
As of 10/1/2011 almost $870 million has been paid
to hospitals and professionals for EHR incentive
program
– 114,000 providers have registered (EPs and hospitals)
– 8397 EPs have attested; 95% verified
– 302 hospitals have attested; all verified
PQRS and eRx combined paid $382 million in 2009
– Approx. 120,000 professionals participated
– Average payment was $1956 per professional and $18,525
per practice
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9. Other Initiatives with Financial Impact
Accountable Care Organizations – Quality measures
combined with cost savings to share incentive payments
Patient-Centered Medical Homes – Quality-based bonus
payments to physicians who are NCQA-certified
– Missouri Foundation for Health/Healthcare Foundation of
Greater KC/BCBS GKC (2011+)
– Missouri HealthNet – Medicaid (2011+)
– CMS ―Comprehensive Primary Care Initiative (Sept 2011)
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10. Value-Based Reports for Individual
Physicians
Value-based modifier is required for specific physicians
by 1/1/2015 and all physicians by 1/1/2017. Initial
performance year is 2013.
Physicians in IA, KS, MO and NE will receive individual
reports late in 2011/early 2012
– PQRS measures reported
– Some additional clinical measures derived from claims data
– Compare average per capita costs among physicians
– Compare total per capita costs for patients with COPD, heart
failure, CAD and diabetes
– Reports will be refined for future Value-based reports and for
Slide 10 of 42
public reporting
10

11. EHR ―Meaningful Use‖ Incentive Program
Two routes for participation: Medicare or Medicaid
– Medicare includes mostly physicians, doctors—PFS services
– Medicaid also includes NPs, PAs—30% threshold (20% Peds)
Hospital-based EPs excluded
EHR must be certified
EPs must use their EHR to
– Meet specified objectives
– Electronically exchange information
– Submit quality measures
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12. EHR Incentive Program (continued)
Being implemented in stages of increasingly
sophisticated use of EHR technology and higher
thresholds of performance
Measures and objectives apply to all patients
First stage is mainly ―reporting‖
Subsequent stages move toward real goals:
– Patient: Improved Outcomes and Satisfaction
– Practice: Improved Productivity, Quality of Life, Prosperity
– Population: Improved health and affordability of healthcare
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13. Stage 1 Meaningful Use
Core Set of 15 objectives that all EPs must meet
Menu Set of 10 objectives of which EP must select 5
Clinical Quality Measures must be reported
– 3 Core Measures (Weight Screening, Tobacco
Screening/Cessation Counseling, BP Measurement
– 3 Alternate Core if Core don’t apply (Flu vaccine, Childhood
weight screening, Childhood Immunization Status
– 3 Additional Menu Measures selected from 38 possible
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14. Core Objectives
Core Objective Threshold
Use CPOE 30%
Implement drug-to-drug and drug-to-allergy interaction checks Enable
E-Prescribing 40%
Record demographics including ethnicity and race 50%
Maintain up-to-date problem list 80%
Maintain active medication allergy list 80%
Record and chart changes in Vital signs 50%
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15. Core Objectives (continued)
Core Objective Threshold
Record smoking status 50%
Implement one clinical decisions support rule Enable
Capability to exchange key clinical information among providers of 1 test
care
Provide patients with an electronic copy of health information 50% of
requests
Provide clinical summaries for each office visit 50%
Protect electronic health information Security Risk
Analysis
Report Clinical Quality Measures 3 Core
3 Menu
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16. Menu Set of Objectives (Choose 5)
Menu Objective Threshold
Implement drug-formulary checks Enable
Incorporate lab data as structured data 40%
Generate lists of patients by condition for Quality Improvement 1 list
Send reminders to patients (Age 65+ or 5 and under) for 20%
preventive/follow-up care
Provide patients with timely (4 business days) electronic access to 10%
health information
Identify/provide patient-specific education resources 10%
Perform medication reconciliation 50%
Provide summary of care record for transition and referrals 50%
Submit electronic data to immunization registries 1 test
Submit syndromic surveillance data to public health agencies 1 test
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17. Stage 2 & 3: Significant Proposed Changes
STAGE 2 (Delay until 2014?) STAGE 3
Raise the threshold for many objectives Raise threshold again
Add 1 lab or radiology order to CPOE Reconcile lab results with lab orders
requirements (no transmission needed) Manage high priority conditions with lists
Add new CQMs Electronic self-management tools offered
Improve performance using CDS EHR can exchange data with PHRs
Move current menu items to core Patients. Report experience with care
EPs to record advance directives (currently measures online
only hosp) Online access to education in primary
Add Electronic Notes to documentation language
Ability of pt to view and download visit Bidirectional connection with external
within 24 hours providers or HIE
20% of patients must use portal/PHR Longitudinal Care Plan for high-priority pts
Online secure patient messaging Submit patient-generated data to public
List of care team members available to pt health
Slide 17 of 42 immunization
Submit and syndromic data

18. Physician Quality Reporting System
PQRS requires reporting of clinical measures to CMS
Annual program, rules/measures change every year
PQRS incentives are independent of other CMS
programs
Eligible professionals include physicians, NPs, PAs,
therapists
Incentives based on Medicare Part B PFS allowable
charges – effectively excludes RHC/FQHC providers
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19. PQRS Participation Options
Individual eligible professionals may report
– 3 individual PQRS measures, OR
– 1 measures group (14 different Measures Groups)
– A group consists of 4-9 clinically-related measures
– Reportable through Claims or Registry option—not EHR
May also participate as a Group:
– Registration required for group reporting (deadline passed for
2011)
– Group must report 26 measures
Additional incentive (0.5%) for Maintenance of
Certification Program—professional bodies only
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20. PQRS Reporting Options for Individuals
Claims – designed for paper-based systems
– Physician/billing clerk enters QDCs on each claim
– Submit daily
– Some EHRs or PMS have alerts to assist reporting
Qualified Registry - designed for sub-optimal EHRs
– Provider reports data to a registry
– Registry may be integrated as part of the EHR and pull data directly
– Registry submits aggregate data on behalf of provider
– Done once per year – May be a cost
Qualified EHR – ultimate goal for EHR functionality
– EHR pulls data
– Provider submits raw data directly to CMS
– Done once per year
– Only 28 qualified EHRs for 2011
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21. E-Prescribe Incentive Program
To earn an incentive:
– Requires reporting of G-code during specified encounters
where an Rx was transmitted electronically to a pharmacy
– Refills and e-faxes do not count
– Eligible providers include physicians, practitioners and
therapists
– Must use a ―Qualified‖ or ―Certified‖ e-Rx system
– Report on a minimum of 25 unique eligible visits
– Refills and faxes do not count
Reporting Mechanisms:
– Claims, Registry, or EHR to earn incentives
– Annual program; Changes are made every year
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22. E-Prescribe Incentive Program (continued)
Avoid e-prescribe penalties by:
– Be a successful e-prescriber (Report 10 cases via Claims
before 6/30/2011)
– Is not a physician, NP or PA by 6/30/2011 or has no
prescribing privileges
– If <10% of an EP’s allowed charges from 1/1/2011 through
6/30/2011 are comprised of codes in the denominator.
– If the EP has <100 cases containing an encounter code in
the measure’s denominator from 1/1/2011 through
6/30/2011.
– Files a hardship exemption by 11/1/2011.
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23. Physician Compare Website
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24. 2011 Crosswalk for Quality Measures
EHR PQRS Description Meaningful
measure Use CQM
#110 Patients 50+ who received flu vaccine Alt. Core
#111 Patients 65+ who have ever received a Menu
pneumococcal Vaccine
#112 Women 40-69 who had a mammogram within 24 Menu
months
#113 Patients 50-75 appropriately screened for colorectal Menu
cancer
#226 Patients 18+ screened for tobacco use w/in 24 Core
months and received cessation counseling
#237 Patients 18+ with hypertension and BP recorded Core
In 2012 Quality Measures will be aligned for both programs
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25. Quality Measures--Analysis
Each measure has a denominator that defines the
population included. e.g. Pneumoccoccal Vaccine
– Denominator: All Medicare patients greater than or equal to
65 years at the beginning of the measurement period.
Patients must have at least one face-to-face office visit
during the measurement period.
Each measure has a numerator that defines the
portion of population that met the measure
– Patients who received a pneumococcal vaccination before
the end of the measurement period
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26. Quality Measure Analysis (continued)
Some measures have exclusions that remove a
patient from both the numerator and denominator:
– Medical reason for not having the vaccination, such as
Allergy or Adverse effect
Reporting Rate: Accurately identifying all patients in
the denominator
Performance Rate: Numerator/Denominator
– Currently incentives are based only on Reporting—no
threshold for performance—yet
– Performance rate will factor into bonuses for ACOs, PCMHs,
and Value-based Modifiers/Purchasing
Slide 26 of 42 26

27. NCQA Accreditation Benchmarks and
Percentiles--2011 (IA, MO, NE, KS)
Measure for Medicare 90th Percentile Nat’l Your
Patients Benchmark Score
Breast Cancer Screening 84% ?
Colorectal Cancer 69% ?
Screening
Advising Smokers to Quit 88% ?
Flu Shots 83% ?
Pneumococcal 82% ?
Vaccination
Source: 2011 HEDIS Benchmarks and Thresholds: Mid-Year Update
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28. What’s Required for Quality Measurement
Structured Data Capture in Defined Fields
– Drop-down Lists - Dates
– Checkboxes - Positive/Negative
– Numerical values
NOT—scanned documents, dictation, narrative notes
Requires workflow change and team approach to
accomplish change efficiently
Find a balance between structured/unstructured
– May supplement with non-structured data
– Underlying coding/data capture must be present
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29. National Standards for Coding
Underlying Standard Codes
– ICD-9 / ICD-10
– CPT-4
– Healthcare Common Procedure (HCPCS)
– Systematized Nomenclature of Medicine (SNOMED)
– HL7 Standard Vaccination Code Set (CVX)
– Logical Observation Identifiers (LOINC) for lab data
– Nations Council for Prescription Drug Programs (NCPDP)
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30. Workflow (See Attachment 1)
Adult Patient Workflow
Pre-Appt •Incoming labs and diagnostic tests populate EHR or entered
& Check structurally (Menu #2); sent to provider to review, then to patient
in portal (Menu #5)
•Record demographics (Core #7) including race, ethnicity,
preferred language
•Ask if pt. wants portal access, record email, and provide
instructions (Menu #5)
•Record patient preference on how to receive reminders (Menu
#4)
•Ask about preventive services received elsewhere and record
structurally (such as flu & pneumococcal vaccines,
mammograms, colonoscopies). Update smoking status. (Clinical
Quality Measures and PQRS)
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31. Workflow (continued)
Adult Patient Workflow
Review/ •Nurse records Vitals for patients age 2+ (Core #8, Core CQM #1 and Core
Document CQM #2)
•Allergies •If BMI outside parameters, nurse discusses plan or make note to
•Meds physician (Core CQM #1) to discuss later in the visit
•Problems •Nurse send request for clinical information to other providers (Core #14).
• Labs (Best done prior to the visit by reviewing outstanding orders from CPOE
•Flow Sheet functionality)
•PMH, FH, •Nurse records smoking status for patients age 13+ (Core #9 and Core
SH, Proc, CQM #3). If smoker, provide cessation counseling (Core CQM #3)
Hosp, •Nurse reviews allergies and documents structurally or NKA (Core #6)
•Nurse reviews medications and documents structurally or NKM (Core #5)
•Nurse reconciles medications if transferred from another provider (Menu
#7)
•Nurse reviews alerts for overdue care (Core #11) and follows standing
orders to administer, documents on templates.
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32. Workflow (continued)
Adult Patient Workflow
Review/modify •Physician reviews problem list and documents structurally or NKP
nurse notes, (Core #3)
Problems, •Physician reviews recent labs and vitals, PMH, FH, SH
Recent labs •Templates used to record notes with narrative supplement as needed
•PMH, FH, SH,
Proc, Hosp,
Provide Care •Templates used to record notes with narrative supplement as needed
•HPI, ROS, SH, •Physician orders in-house office testing and treatments using CPOE
FH, PE (Core #1)
• Lab tech records in-house results structurally (Menu #2)
ASSESSMENT •Add new diagnoses and problems to problem list using ICD-9 codes or
drop-down lists (Core #3). Update chronic problems.
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33. Workflow (continued)
MEDICATION •Order new meds using CPOE (Core #1).
•Update •Check drug-to-drug and drug-to-allergy (Core #2)
•Order •Check formulary (Menu #1)
•Refill/DC •Transmit electronically (Core #4) and/or print
ORDERS •Use CPOE to order labs, x-rays, other diagnostic tests, and consults
•Labs, x-ray, ( Future stages Core #1)
DME, •Check alerts for preventive, follow-up care, and other quality
consults measures (Core #10 & #11,Menu CQMs and PQRS) and order
using CPOE
WRAP-UP •Provide educational materials for patients (Menu #6)
•Pt. •Generate a Clinical Summary and give to patient/send to portal
Education (Core #13)
•Pt. Action •If patient requests a copy of medical record, notify staff.( Core #12)
Steps •Referral and consults scheduled and Summary of Care/CCD is sent
•Next Visit electronically (Menu #8)
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34. Workflow (continued)
SCHEDULED •Nightly: Set task to transmit immunization (Menu #9) and
TASKS syndromic surveillance data (Menu #10) to state registries
•Monthly: Run CQM and PQRS reports (Core #10). Generate
patient lists (Menu #3) and send reminders (Menu #4) and
schedule follow-up care.
•Monthly: Discuss quality reports at staff meetings. Test
strategies for improvement. Assign responsibilities to all
team members. Re-measure.
•Annually (or when EHR changes are made): Conduct security
risk assessment (Core #15)
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35. Bottom Line
Financial impact of quality measurement is high—
incentives, penalties, value-based purchasing
Close scrutiny of health care spending—accountability
Physicians will be profiled and data publicly reported
on the ―Physician Compare‖ website—reputation
You improve what you Measure
– Identify gaps in performance and take steps to correct
– Meet professionally-recognized standards
– Apply improvement methodology (Plan-Do-Study-Act)
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36. Quality Reporting & Improvement
Builds a culture of ―excellence‖ among team.: ―The
healthcare organization that seeks merely to meet
minimal standards may not ever reach any higher,
and certainly will not achieve excellence.‖
Janet Brown, RN, CPHQ, The Healthcare Quality Handbook, 2010/2011
edition)
―Quality is not an act, it is a habit.‖ (Aristotle,
Philosopher, Scientist, Physician, 384 BC – 322 BC)
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37. Resources
Primaris: www.primaris.org www.PQRSMO.org
– Funding to assist 74 Missouri physicians to report PQRS using their
Qualified EHR as part of our national QIO 10th Scope of Word (began
August 2011). Free onsite and/or remote assistance.
– Qualified EHRs include e-MDs, Aprima, Greenway, Pulse, Sage, Success
EHR, others. See me for details! (Complete listing of PQRS Qualified
EHRs at
http://www.cms.gov/PQRS/Downloads/Qualified_EHR_Vendors_for_20
11_PQRS_and_eRx_05-03-2011.pdf)
– Earn PQRS Incentives for 2012 (and possibly 2011)
– Assistance with performance improvement methodology
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38. Resources (continued)
http://www.cms.gov/EHRIncentivePrograms/
http://www.cms.gov/pqrs
http://www.cms.gov/ERXincentive/
https://www.qualitynet.org/portal/server.pt (for hardship
exemptions--follow the Communications Support Page link)
National Provider Calls and Special Open Door Forums
Office of the National Coordinator (ONC) for Health
Information Technology: http://healthit.hhs.gov
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39. Resources (continued)
QualityNet Help Desk
– http://www.cms.hhs.gov/PQRI/36_HelpDeskSupport.asp
– 7:00 a.m. - 7:00 p.m. CST at 866-288-8912 or
qnetsupport@sdps.org
Missouri Health Connection: Statewide Health
Information Exchange: missourihealthconnect.org/
Missouri Health Information Technology Assistance
Center (MO-HIT):
– Website: ehrhelp.missouri.edu
– E-Mail: EHRhelp@missouri.edu
– Phone: 877-882-9933
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40. Thank You!
Questions? Contact:
– Sandy Pogones
– spogones@primaris.org
Your Local Connection to
Achieving National Health Goals
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