Quality Queries and Quandaries:
By: Emil Engels, MD, MBA, CPC
At the invitation of Anesthesiology News, this is a recurring column in which experts attempt to answer many of the questions regarding quality reporting. This column will address topics such as: What is a qualified clinical data registry (QCDR)? How do the reporting requirements of a QCDR differ from claims and qualified registries? What are other differences between a qualified registry and a QCDR? Which QCDRs are available and how do I report? Which measures should an anesthesia provider report? How does the use of a QCDR fit in with the newly released Medicare Access and CHIP Reauthorization Act (MACRA) of 2015?
Anesthesia providers can participate in the Physician Quality Reporting System (PQRS) through claims, qualified registries, qualified clinical data registries (QCDRs) and electronic health records. Most clinicians use one of the first three methods to submit data to the Centers for Medicare & Medicaid Services (CMS). Given the uncertainty with claims-based reporting, many anesthesia providers are moving to qualified registries and QCDRs. Last month’s column provided a roadmap for qualified registry reporting in 2016. In this month’s article, the author will provide the information necessary to participate using a QCDR.
What is a QCDR?
According to CMS, “A QCDR is a CMS-approved entity (such as a registry, certification board, collaborative, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients.” Furthermore, “The QCDR reporting mechanism provides a new standard to satisfy PQRS requirements based on satisfactory participation.” Like a qualified registry, one reports approved quality measures into a database, and then the QCDR submits the information to CMS. Quality data from performance year 2016 will be submitted during the first quarter of 2017.
How do the reporting requirements of a QCDR differ from claims and qualified registries?
When reporting via a qualified registry or claims, eligible professionals must report nine PQRS measures across three National Quality Strategy (NQS) domains, plus a cross-cutting measure if applicable, on at least 50% of Medicare fee-for-service patients. The requirements for QCDR reporting are slightly different: Eligible professionals must report nine measures (both PQRS and non-PQRS) across three National Quality Strategy (NQS) domains, including two outcome measures, on at least 50% of all patients, even those with commercial insurance!
An outcome measure, as its name implies, focuses on health care outcomes, rather than on a process. For example, think about the old (retired) antibiotic measure. It was a process measure, since providers reported on the administration of antibiotics during an appropriate time frame. If this were an outcome measure, you would report whether or not the patient got an infection. Increasingly, measuring quality in health care is shifting toward reporting outcomes, rather than processes.
It is worth noting that the Medicare Access & CHIP Reauthorization Act (MACRA) proposed rule changes requirements for registry reporting in 2017. Qualified registries will need to report measures on all patients (and not just Medicare). In addition, as opposed to 2016 reporting, QCDR participants under the merit-based incentive payment system (MIPS) are no longer exempt from reporting a cross-cutting measure. A full discussion of MACRA will be published in Anesthesiology News later this year.
What are other differences between a qualified registry and a QCDR?
These differ in several notable ways. One of the most important differences relates to the reporting population. With a qualified registry, an anesthesia provider must report on at least 50% of Medicare patients. With a QCDR, you are required to report on at least 50% of all patients, including those with commercial insurance.
As mentioned above, eligible professionals report a cross-cutting measure when using a qualified registry. Those who submit data using a QCDR are required to report two outcome measures instead of a cross-cutting measure. Please note: These outcome measures can be two of the nine measures required to be reported.
The measures available to report are significantly different when comparing a qualified registry and a QCDR. When using a qualified registry, anesthesia providers can only choose from approved PQRS measures (see the article in last month’s Anesthesiology News for a list). On the other hand, those who participate with a QCDR can choose from many non-PQRS measures in addition to the list of approved PQRS measures. This provides greater flexibility when reporting and makes it easier to meet the reporting requirements.
Which QCDRs are available and how do I report?
A list of CMS-approved QCDRs (2015) can be found at www.cms.gov/?Medicare/?Quality-Initiatives-Patient-Assessment-Instruments/?PQRS/?Downloads/?2015QCDRPosting.pdf.
As of this writing, the author is aware of six QCDRs available for anesthesia providers. Four of them are public and available for anyone to use, and two are private. The list includes:
Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)
Anesthesia Business Consultants (ABC)
ABG (Anesthesia Business Group) Anesthesia Data Group, LLC
MPOG/ASPIRE (Multicenter Perioperative Outcomes Group)
Quantum Clinical Navigation System (MEDNAX)
Team Health Patient Safety Organization (THPSO)
The first four QCDRs in the list are available for public use.
The mechanism by which a provider submits data to a QCDR varies depending on the design of the QCDR and the workflow of the practice. Some practices use a paper checklist to collect the information from providers. Others have built platforms into their electronic health record. An example of a paper form can be found on the Anesthesia Quality Institute’s website: www.aqihq.org/?files/?/?2016%20QCDR_SAMPLE_Data%20Capture%20Form_updated%20041116.pdf.
At least two QCDRs provide apps for reporting.
Once the data have been collected, it is often necessary to enter them into a database or Excel spreadsheet. Your billing company and the individual QCDRs can help you develop the processes and infrastructure necessary to transfer your data to the QCDR.
Which measures should an anesthesia provider report?
The American Society of Anesthesiologists’ (ASA) Anesthesiology Quality Institute National Anesthesia Clinical Outcomes Registry (AQI/NACOR) was the first anesthesia-specific QCDR to be certified. In addition, it has the most publicly available information and is the easiest to discuss. Please visit the AQI website at www.aqihq.org/?index.aspx.
AQI/NACOR participants can choose from 45 measures. These measures can be found on the AQI website and include both PQRS and non-PQRS measures.
An example of nine measures that meet the reporting requirements is shown in the Table.
Remember, QCDR participants are required to report two outcome measures as part of the nine measures submitted.
According to CMS, “We further note that measure types listed as an ‘intermediate outcome’ are considered outcome measures for the purposes of scoring.”
Table. Examples of Measures That Meet Reporting Requirements
Measure Code Description (abbreviated titles) Outcome Measure (Y/N) Domain
ASA 11 Perioperative Cardiac Arrest Y Patient Safety
ASA 12 Perioperative Mortality Rate Y Patient Safety
ASA 13 PACU Re-intubation Rate Y Patient Safety
ASA 14 Assessment of Acute Postoperative Pain Y Person and Caregiver Centered Experience
PQRS 404 Anesthesiology Smoking Abstinence Y Effective Clinical Care
PQRS 424 Perioperative Temperature Management N Patient Safety
PQRS 426 Checklist or Protocol for Direct Transfer of Care to PACU N Communication and Care Coordination
PQRS 427 Checklist or Protocol for Direct Transfer of Care to ICU N Communication and Care Coordination
PQRS 430 Prevention of Post-Operative Nausea and Vomiting (PONV) N Patient Safety
Which measures should you report?
Select the nine that are most applicable to your practice, as long as you meet the QCDR reporting requirements: nine measures (both PQRS and non-PQRS) across three National Quality Strategy (NQS) domains, including two outcome measures.
As a member of ASA, a health professional can participate in either the qualified registry or the QCDR at no additional charge. The ASA charges nonmembers for use, but these fees can be reduced if providers become educational members of the ASA.
How does the use of a QCDR fit in with the newly released MACRA of 2015?
For years, physicians lamented the flawed sustainable growth rate (SGR) formula. This formula linked Medicare reimbursement to the growth in Gross Domestic Product, but over time this led to annual proposed cuts to physician reimbursement. It became routine to call your congressman and encourage him or her to pass an emergency patch to avoid a drastic cut in Medicare reimbursement. In 2015, the SGR formula was finally repealed and replaced with the MACRA.
MACRA will be discussed more fully in the future, but suffice it to say that it continues a CMS shift to pay for value rather than volume of care. From the CMS website, MACRA changes Medicare by “Making a new framework for rewarding health care providers for giving better care not just more care.” CMS released a proposed rule in April 2016 that details how the program will be implemented.
Under the new system, providers will continue to have multiple methods to report quality measures, including a QCDR. However, the use of a QCDR has been proposed as a “clinical practice improvement activity.”
A more detailed discussion of this is beyond the scope of this article, but CMS is clearly encouraging providers to use registries for reporting, and specifically QCDRs.
Health care reform is progressing rapidly. As the saying goes, “The only thing that is constant is change.” Anesthesia providers should continue to shift toward qualified registry and QCDR reporting to allow full participation in government quality programs.
Look for future columns on PQRS for pain physicians and a discussion of MACRA, the MIPS and alternative payment models.
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