Via Electronic Submission ( April 5, 2013

Transcription

1 Via Electronic Submission ( April 5, 2013 Ms. Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services 7500 Security Blvd. Baltimore, MD Re: Request for Information on the Use of Clinical Quality Measures (CQMs) Reported Under the Physician Quality Reporting System (PQRS), the Electronic Health Record (EHR) Incentive Program, and Other Reporting Programs, File Code CMS-3276-NC Dear Ms. Tavenner: The Association of American Medical Colleges (AAMC or the Association) welcomes this opportunity to comment on the Centers for Medicare and Medicaid Services (CMS or the Agency s) solicitation entitled Request for Information on the Use of Clinical Quality Measures (CQMs) Reported Under the Physician Quality Reporting System (PQRS), the Electronic Health Record (EHR) Incentive Program, and Other Reporting Programs, 78 Fed. Reg (February 7, 2013). The AAMC represents all 141 accredited U.S. medical schools, nearly 400 major teaching hospitals and health systems, and nearly 90 academic and scientific societies. Through these institutions and organizations, the AAMC represents 128,000 faculty members, 75,000 medical students, and 110,000 resident physicians. The Association appreciates the opportunity to provide feedback on how to align quality reporting in current federal programs, such as PQRS and the EHR Incentive Program, with other reporting requirements. Because the AAMC represents clinical faculty who practice in large group practices, the Association is particularly interested in increasing the alignment and reducing the burden for measurement at the group practice level. While most of the questions in the RFI focus on reporting for individual clinicians, several academic practices will have to submit quality data to PQRS as a group or face a negative 1 percent penalty in 2015 from the Value Modifier (VM) program. This penalty is in addition to penalties for PQRS or the EHR Incentive Program. Although PQRS has expanded its group practice reporting options (GPRO) for 2013, there is no corresponding group reporting option for the EHR Incentive program. This will change in 2014, when groups will have the option, for CQM reporting only, to report the quality data at the group level. However, many details about that group reporting option still need to be finalized. On March 15, the AAMC sent the memo in Appendix A to CMS staff which outlined many of the outstanding issues that still need to be resolved if CMS really wants to align group reporting for PQRS and the EHR Incentive Program. The outstanding issues fall into three categories: Questions regarding GPRO Web Interface and Accountable Care Organization (ACO) Reporting. ACO reporting and GPRO reporting via a web interface (GPRO Web) use a reporting structure that is fundamentally different than the EHR Incentive Program. This section of the memo outlines the barriers of alignment and how those barriers can be removed.

2 Marilyn Tavenner April 5, 2013 Page 2 Questions regarding group CQM. The EHR Incentive Program requires attestation at the individual level. The questions in this section of the memo focus on how the group CQM interfaces with the individual attestation. For example, how does group reporting work when a physician practices in more than one group? Questions regarding PQRS GPRO EHR option. The PQRS GPRO has an EHR option starting in 2014 which is very similar to individual CQM reporting for the EHR Incentive Program. The questions in this section focus on the alignment issues with PQRS and the EHR Incentive program and the issues of aggregating information across the group. For example, how does group reporting align with the requirement that for 2014 (due to the first year of Stage 2), physicians only need to report for a quarter and for PQRS the traditional reporting period is one year? The AAMC encourages CMS to review the memo and consider the recommendations as it refines its group reporting policies. We would be pleased to meet with you to discuss the issues described in the memo as well as our recommendations to remove barriers. Finally the AAMC strongly supports the long term goal of electronic reporting of quality metrics, thereby minimizing the burdensome process for data collection and submission. However, the Association also believes it is also important to ensure the clinical quality data is accurate and reliable. Currently, the EHR Incentive Program requires that the CQM submission be reported directly from a certified system. The AAMC believes that a parallel process is needed to allow providers and vendors to validate the data from the EHR and correct any data that is invalid or missing. Allowing providers to review and validate their information ensures accurate data for public reporting and pay-for-performance purposes while practices adopt EHRs. The AAMC appreciates the opportunity to provide comments on aligning CQM reporting. If you have any questions or issues regarding our comments, please feel free to contact me at or mwheatley@aamc.org. Sincerely, Mary Wheatley Director, Physician Quality and Payment Policies Cc: Ivy Baer, AAMC Scott Wetzel, AAMC

3 Appendix A Objective MEMO to Centers for Medicare and Medicaid Services (CMS) Aligning Group Reporting Across the EHR Incentive Program and the Physician Quality Reporting System This document highlights unresolved policy and operational questions that must be addressed in order to successfully align group practice reporting options (GPRO) for the Physician Quality Reporting System (PQRS) and for the Electronic Health Record (EHR) Incentive Program s Clinical Quality Measures (CQM). Where possible, the memo also includes suggestions to resolve these issues. Background Starting in 2014, group practices that use Certified EHR Technology (CEHRT) have the option to report group-level quality data once and meet the requirements of both the Medicare EHR Incentive Program CQM and PQRS. Having an aligned group reporting option is particularly important because the Value Modifier (VM) program requires most large group practices to report quality data as a group or face a penalty. In 2014, the group reporting options are: Accountable Care Organization (ACO) reporting, GPRO Web, and GPRO EHR. While CMS has outlined a framework around how group reporting programs will align across programs, many details still need to be clarified. Groups need this information in order to make an informed decision about which group reporting option to select and implement the necessary changes before the 2014 reporting period begins. The Association of American Medical Colleges (AAMC) and University HealthSystem Consortium (UHC) have worked with members of the GPRO Academic Network, a network of faculty practices participating in GPRO Web, and with other members to identify their implementation questions. We have categorized the questions into three buckets: Questions regarding GPRO Web and ACO Reporting. GPRO Web and ACO use a reporting structure that is fundamentally different than the EHR Incentive Program. This section outlines the barriers of alignment and how those barriers can be removed. Questions regarding group CQM. The EHR Incentive Program requires attestation at the individual level. The questions in this section focus on how the group CQM interfaces with the individual attestation. Questions regarding PQRS GPRO EHR option. The GPRO EHR option is very similar to individual CQM reporting for the EHR Incentive Program. The questions in this section focus on the alignment issues with PQRS and the EHR Incentive program and the issues of aggregating information across the group.

4 Page 2 of 6 Finally, we discuss the role of chart abstraction and measures in all of these reporting options. Questions related to GPRO Web/ACO Reporting According to the Stage 2 Final Rule and the Certification Final Rule, eligible professionals (EPs) must directly report CQM from a certified record and/or reporting repository. The EP can only report on the subset of measures for which the EHR/repository is certified. This reporting mechanism assumes that all data necessary for reporting will be located within the EHR. The method for GPRO Web and ACO reporting is completely different. In this reporting system, CMS (not CEHRT) identifies the patients that are assigned to the ACO or group practice by evaluating all the services the Medicare beneficiary has received. CMS then identifies a subset of patients for reporting. Unlike the EHR Incentive program where groups select which measures to report, ACO and GPRO Web participants must report on a predetermined set of measures. Some GPRO Web/ACO measures are not included in the EHR Program, and even for measures that are in both programs, the CEHRT may not be certified for all the available measures. In the Stage 2 Final Rule, CMS indicated that ACOs and GPRO Web can receive credit for the EHR Incentive program if they use CEHRT. However, given the differences between the reporting programs, the Agency did not provide specifics about how that process would work. The following questions are specific to GPRO Web/ACO reporting and how it aligns with the EHR Incentive Program. Questions Is GPRO Web submission going to continue via Web interface or will groups need to submit directly to CMS (as with the EHR option)? What are the criteria for using CEHRT? Comments As described above, the two reporting protocols are completely different. If we assume that GPRO Web and ACOs will continue to use the same Web Interface reporting portal and the same patient assignment methodology, then the requirements of the EHR Incentive Program need to be modified to allow groups to receive credit for using their EHR for quality reporting in a meaningful way. Based on interviews from the UHC-AAMC GPRO Academic Network, we know virtually all group practices participating in GPRO Web use their EHR in some capacity to perform their GPRO Web reporting. In addition, many groups will supplement the EHR data with chart information (particularly for services performed outside of the system see the comments on Chart Abstraction at the end of this document). We suggest CMS adopt a very flexible definition of using CEHRT for purposes of aligning ACO and GPRO Web reporting with the EHR Incentive Program. Group practices that access data from their CEHRT should be able to attest to that fact and get credit for the EHR Incentive program, even if the way the data is reported is different than the certified reporting identified in Stage 2.

5 Page 3 of 6 General Questions about Group CQM Submission Questions Is a group allowed to do a group CQM submission for the EHR Incentive Program if Certified EHR Technology is not available (or 100% functioning) at all locations? Are EPs that bill under multiple tax ID numbers (TINs) covered under the group submission? Comments There are legitimate reasons why a large group may not have CEHRT implemented in every site. Typically, large groups have multiple sites and will phase-in the EHR adoption across different departments and/or locations. In addition, the group practices may absorb another outside practice and will need time to transition the new group to CEHRT. CQM reporting is only one of several requirements necessary before an EP can attest for EHR Incentive payments. Therefore, for the CQM requirement, groups should have the flexibility to submit group CQM for the sites where they have CEHRT. EPs will still be required to show they are meaningfully using the system before any payments are made or penalties are assessed. In individual reporting, an EP has to consolidate performance from multiple sites before attesting. This is not really possible for group reporting because the units of measurement will be different (group measurement v. individual measurement at other locations.) To make group CQM reporting operationally feasible, CMS should allow the EP to attest for CQM if any of the TINs the EP is associated with has submitted CQM measures under the group reporting option. Does CQM group reporting align with EPs attesting for Medicaid? Group reporting is available for PQRS and for the CQM component of the Medicare EHR Incentive Program, but not for the CQM component of the Medicaid EHR Incentive Program. This means that groups have to manage two quality reporting systems: group-level reporting for Medicare EPs and individual-level reporting for Medicaid EPs. To facilitate alignment across all the reporting programs, we encourage CMS to allow group reporting to cover the CQM requirements for both the Medicare and the Medicaid EPs.

6 Page 4 of 6 Questions Does the CQM group reporting cover EPs in their first year of attesting? Comments In the Stage 2 Final Rule, CMS finalized that group reporting of CQMs can cover individuals in the first year of attesting for Stage 1. However, timing requirements effectively eliminate first-time attesters from being covered by group reporting. Starting in 2014, most EPs in their first year of Stage 1 have to attest by October 31, 2014 or face a penalty for the Medicare EHR Incentive Program in The group reporting CQM option is a year-long reporting period and the group does not submit data until after the calendar year is over; long after the October 31 st deadline for EPs attesting for Stage 1, Year 1. Below are two suggestions that would remove this timing issue and prevent practices from have to again implement two systems (one for group reporting and one for EPs in first year of stage 1): Allow the EP attesting in Stage 1, Year 1 to attest that they are part of an ACO or a TIN that is registered to do group reporting. Unlike individual reporting, we believe most groups that select group reporting are able to successfully submit data. If for any reason a group is not able to complete reporting, then CMS can adjust the EPs payment retroactively. A second alternative (which could start in 2015) is to allow the firsttime attester to be covered under the group reporting from the previous year. For example, if a group successfully reports CQM in 2014, then the first time attesters in 2015 would be covered by the 2014 submission. A secondary issue associated with having first-time attesters not being covered by the group policy is determining how that EP s data will be reported on Physician Compare. Will the EP be listed with the group if CMS does not accept the group reporting for that EP s attestation? Or will the individual EP s CQM data be reported instead? Having all EPs (regardless of what year or stage they are in) covered by the group CQM reporting submission would streamline the reporting process.

7 Page 5 of 6 Questions related to the PQRS GPRO EHR Reporting Mechanism Questions How does group reporting align with the requirement that for 2014 (due to the first year of Stage 2), EPs only need to report for a quarter? How does a group report if the group has multiple EHRs? Does the EHR need to be modified for group data submission? Comments Many groups plan to upgrade their EHR to meet Stage 2 requirements in Because of this transition, CMS has allowed EPs beyond the first year of Stage 1 to report for only one quarter in However, the group reporting options in PQRS have a one-year reporting period. To align the reporting periods across the two programs, CMS can establish a 90-day reporting period for the 2014 PQRS EHR Group Practice Reporting Option. A single group may have multiple EHRs and have different measures certified for each EHR. For the group submission, CMS might consider allowing the group to provide one submission from each EHR, or it may request the group to consolidate the reporting for the measures that are reported commonly across different EHRs. Currently, all measurement for the EHR Incentive Program is done at the clinician level. If CMS expects to receive CQM data electronically, how does the EHR (and CMS s system) need to be modified to accept group-level reporting? Ability to Supplement EHR with Chart Reviews An important consideration with EHR reporting is the ability to validate and correct information extracted from an EHR with chart reviews. The AAMC and UHC have spent much time with the academic practices to understand how they implement GPRO Web reporting. Most of the practices do some combination of EHR and chart reporting. The chart abstraction allows groups to identify elements that might be missing in the discrete data fields. It also identifies services done outside of the organization, but that are documented in notes. For example, the following excerpt came from one of the GPRO participants and illustrates the amount of work that may be required to find information that is hidden in an EHR record. [In its file extract,] CMS includes dates that are pre-filled with data from claims that originated outside of our organization. We have to supply the result or confirm that we have documentation of the result. If we can t confirm that we have documentation of the result/value, then we have to indicate no, which will lower our performance on this measure. For example, in diabetic eye exams, if we get a beneficiary with a pre-filled date for an eye exam outside our TIN, we still have to go to our EHR and confirm the result and that all of the elements are documented that constitute a diabetic eye exam. If the data is outside our organization, that causes us to have to read notes because the reports won t be electronically stored or they are scanned documents. Any data reported through PQRS has to be as accurate as possible because the performance information will be posted on Physician Compare and included in the VM calculation. We are in a period of transition

8 Page 6 of 6 during which more providers are using EHRs and starting to share data. However, until we have a robust and tested data exchange, it is important to have a supplemental process that allow practices to review and correct information extracted from the EHR, especially when that information is used for performance and public reporting programs. EHR Measures Finally, the practices we spoke to reiterated the importance of having a stable set of measures that have been tested and validated for the EHR. We realize that CMS has to balance this requirement with the need to keep specifications current, but the constant flurry and changing of measures makes it difficult to implement appropriate systems of measurement.