Quality codes report with a $0.00 charge

Transcription

1 Pay for Performance (P4P) Pay For Performance: Why Surgeons Need to Track Their Own Outcomes Sean P. Roddy, MD Albany, NY Most businesses excel when their employees receive incentives for successful performance Physicians are paid the same regardless of the quality of the healthcare they render In theory, P4P rewards practitioners who follow standardized and evidence-based guidelines Pay for Performance (P4P) Crossing the Quality Chasm published by the Institute of Medicine in 2001 identified: 1. Little financial reward for improvements in the quality of healthcare delivery 2. Fee-for for-service payments encourage overuse 3. Capitated payments encourage under-use use 4. Current payment mechanisms reward defective care because they are unable to reward future benefit. Pay for Performance (P4P) Three distinct stakeholders in P4P: Employers / Employees Health plans Providers 1

2 Pay for Performance (P4P) Employers / Employees Purchase the majority of healthcare Faced with rising costs, new technology, & stricter governmental guidelines Increase use of standardization and evidence- based medicine will, in theory: Lower medical errors Keep the population healthier Avoid improper hospital admissions Pay for Performance (P4P) Health plans Cater to both purchaser and practitioner Must weigh how a P4P plan will effect: Carrier s market image Carrier s market share Overall cost to the purchaser Administrative reporting complexity Health plans with a higher published measure compliance may have an edge in enrollment within competitive regions Pay for Performance (P4P) Providers Guarded about P4P with concerns: Loss of autonomy Presence of big brother dictating care Financial burdens associated with reporting efforts Have a desire for their patients to do well More accepting of measures that are evidence- based and relevant to day-to-day practice Published awards may help image of their practice Avoidance may result in a shift to other practices P4P - Hospital-Based Compliance with evidence-based medicine Use of clinical IT technology Medical records Safety You may be asked to assist in quality improvement programs and pathway creation to ensure hospital compliance 2

3 P4P - Physician-Based Bonus Voluntary participation, no change to current contract, and additional payments over standard fee schedule Withhold Minimum requirements by contract to receive money held in escrow on all professional fees rendered Adjustable (or tiered) fee schedule Usually retroactive based on measured outcomes with higher reimbursement based on improved performance Physician Quality Reporting Initiative PQRI CMS version of P4P is termed PQRI The Tax Relief and Health Care Act of 2006 established a reporting process for measures on Medicare patients with an associated payment incentive (bonus-type) Medicare, Medicaid, and SCHIP Act of 2007 extended the process MIPPA made the program permanent PQRI All Medicare-enrolled enrolled eligible professionals may participate in the program No registration is required to join Provider chooses 3 measures appropriate to his/her practice Each measure must be reported successfully for at least 80% of the cases in which it was reportable Analysis is performed at the unit provider level Requires accurate and consistent use of individual National Provider Identifier (NPI) on claims Performance Measure Creation Quality measures traditionally created by: NQF AQA (National Quality Forum) (Ambulatory Quality Care Alliance) AQA no longer creates such measures NQF extremely strict - bottle neck currently No guarantee an approved measure will be incorporated into a private carrier s policy 3

4 PQRI Measures in Measures in Measures in measures removed and 52 added from 2008 Final list for the upcoming year is published in the Federal Register each November 8 measures appropriate for use in typical vascular surgery practice PQRI - Claims-based reporting CPT Category II codes or G-codes May report on paper-based CMS 1500 claims or electronic 837-P claims Quality codes report with a $0.00 charge Quality codes, the measure numerator, must be reported on the same claims as the payment codes, which supply the measure denominator PQRI Cap Ensures Minimum Cap may apply if you pick a measure where few instances are reported Cap calculation = (Individual s instances of reporting quality data) X (300%) X (National average per measure payment amount) National average per measure payment amount = (National charges associated with quality measures) / (National instances of reporting) PQRI Validation TRHCA requires CMS to use sampling or other means to validate whether quality measures applicable to the services have been reported Validation plan under development Appeals Excluded from formal administrative or judicial review CMS will establish an informal inquiry process 4

5 PQRI Your most likely choices are antibiotics for synthetic bypass grafts & aneurysm repairs: Order written for an approved antibiotic to be given within one hour of skin incision (2 hours for Vancomycin or fluoroquinolones) Choice of a 1st or 2nd generation cephalosporin Antibiotics discontinued in <24 hours (beware of cardiac surgery 48 hr limit with CABG/CEA PQRI Measure #20 Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision PQRI Measure #20 Appropriate antibiotics Ampicillin/sulbactam Aztreonam Cefazolin Cefmetazole Cefotetan Cefoxitin Cefuroxime Ciprofloxacin Clindamycin Ertapenem Erythromycin base Gatifloxacin Gentamicin Levofloxacin Metronidazole Moxifloxacin Neomycin Vancomycin PQRI Measure #20 Reporting guidelines 4047F: Documentation of order for prophylactic antibiotics to be given 4047F with 1P: Documentation of medical reason(s) for not ordering antibiotics 4047F with 8P: Prophylactic antibiotics were not ordered to be given, reason not specified 5

6 PQRI Measure #21 Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis PQRI Measure #22 Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time PQRI Measure #11 Alternatives to the PQRI Antibiotic Measures Certify that the distal ICA diameter is referenced as the denominator for stenosis measurement when interpreting MRA, CTA, NICE, and carotid angiography 18 years and older Diagnosis of ischemic stroke or TIA Many centers have added a line to all carotid duplex conclusions in their EMR to that effect 6

7 PQRI Measure #172 Percentage of patients aged 18 years and older with a diagnosis of advanced Chronic Kidney Disease (CKD) (stage 4 or 5) or End Stage Renal Disease (ESRD) requiring hemodialysis vascular access documented by surgeon to have received autogenous AV fistula PQRI Measure #172 Attempt to lower prosthetic access insertion Does not apply to open revisions or PTA Implies a required 80% autogenous fistula creation rate but remember this is purely a reporting process of what you actually did Reporting prosthetic access is grouped by: Documentation why non-autogenous option No documentation why non-autogenous option New Measures for PQRI in 2009 Exposure time reported for procedures using fluoroscopy PQRI Measure #145 Use of patch closure during conventional carotid endarterectomy (non-eversion) PQRI Measure #158 Use of compression system in patients with venous ulcers PQRI Measure #186 Medicare Payments Based on the total allowed charges for covered services payable under the Medicare Physician Fee Schedule Financial incentives earned for 2009 reporting will be paid in mid % financial incentive for 2007 and % financial incentive for 2009 Reimbursement has been approved to 2010 only Many providers have never received 2007 $$ 7

8 P4P Pitfalls Use among private carriers: Sporadic Varies greatly by region No uniformity with regard to specific measures Poor compliance by physician groups with PQRI Of the $80 billion in total, only $36 million was paid In theory, 1.5% of the $80 billion would be $1.2 billion PQRI created in a republican congress Democrats, as a majority, have stated publicly that do not support continuation PQRI Summary PQRI and P4P are in their infancy PQRI measures created thus far are process measures with financial incentives The long-term goal is to create outcomes measures for each practitioner that will be mandatory Payment in the future may be based on outcomes Surgeons need to track their own outcomes Patients benefit, in theory, through higher quality care Financial benefit when reimbursement intimately linked The Institute for Vascular Health and Disease Albany, NY 8