Quality in Gastroenterology: Understand What is Being ...s3.gi.org/meetings/bp2014/14ACG_Best_Practices_0012.pdf · Quality in Gastroenterology: Understand What is Being Asked of

Irving M. Pike, MD, FACG, FASGE

Quality in Gastroenterology: Understand What is Being Asked of You

January 24, 2014Irving M. Pike, MD, FACG, FASGE

[email protected]

Who is Interested in Your Quality

• You• CMS• An ACO?• Your Patients

Maybe some-- perceived or real quality?• Private Insurers

Just a few examples around the country

ACG Board of Governors/ASGE Best Practices Course - Las Vegas, NV Copyright 2014 American College of Gastroenterology

1


Who Pays for Quality

• Commercial Insurance companies?• Government Insurers?• Patients?• Our practices?

Commercial Insurers Focus on Quality

• HEDIS• NCQA• STAR


2


Common GI Measure for All Payors

CRC- One or more screenings for colorectal cancerAppropriate screenings are defined by any one of the criteria pp p g y ybelow:1. FOBT during the measurement year (guaiac or immuno)2. Flex Sig during the measurement year or the 4 years prior3. Colonoscopy during the measurement year or the 9 years

prior

All i 50 75 h h h h d lAll patients 50-75 except those who have had colectomy or CRC

Payment for Quality 2014

• Scattering of models (Major Commercial Ins Co.)• Quality to Play (North Carolina Blue Cross Blue• Quality to Play (North Carolina Blue Cross Blue

Shield)• PQRS0.5% 2013 or potential 1.5% fee cut in 20150.5% 2014 or potential 2% additional fee cut in

20162016No upside in 2015 but avoids a 2% additional fee

cut in 2017


3


PQRS 2014: Overview of PQRS Reporting Options and Requirements

Beginning 2014, CMS will group PQRS measures into National Quality Strategy “domains” and will require Medicare providers to report 9 PQRS measures across these various domains. The domains: Person and Caregiver-Centered Experience and

Outcomes; Patient Safety; Communication and Care Coordination; Community/Population Health; Efficiency and Cost Reduction; and Effective Clinical Care.

New Reporting Option: Clinical Quality Data Registry (QCDR) A QCDR is a CMS-approved entity that allows registries to select their

own measures to satisfy PQRS reporting requirements.own measures to satisfy PQRS reporting requirements. GIQuIC is currently going through the application process to be

deemed a QCDR for 2014 reporting. EPs reporting PQRS measures via a registry have a 90% success rate of

satisfactorily reporting PQRS measures as opposed to a 50% success rate reporting PQRS measure via Medicare claims forms.

PQRS 2014Reporting Mechanism To earn the 2014 PQRS Incentive

(.5%)To Avoid the 2016 Payment Cut (2%)

Qualified Clinical DataRegistry:

M l d b h Q lifi d

Report at least 9 measures for 50% of applicable patients covering at least 3 NQS domains.

Report at least 3 measures covering at least 1 NQS domain.

Measures selected by the Qualified Clinical Data Registry The eligible professional must

report on at least 1 outcome measure.

Medicare Claims Form:

Individual PQRS Measures Only (no measure groups)

Report at least 9 measures for 50% of applicable Medicare FFS patients covering at least 3 NQS domains

Report at least 3 PQRS measures.

PQRS Qualified Registry: Report at least 9 measures for 50% Report at least 3 measures Individual PQRS Measures; and GPRO (practice of 2+)

of applicable Medicare FFS patients covering at least 3 NQS domains

covering at least 1 of the NQS domains.

PQRS Qualified Registry:

PQRS Measures Groups

Report at least 1 measures group.

At least 20 patients, a majority of which must be Medicare Part B FFS patients.

Report at least 3 measures covering at least 1 of the NQS domains.

Visit the ACG website for more information on 2014 PQRS reporting options and requirements


4


Commercial Ins Tennessee P4PGIQuICBaseline value (1st 100,000 cases)Compliance

GIA contract Goal Compliance with National Guidelines

GIA with GIQuIC 1st 3 mosCompliance with National

GIA with GIQuIC 2nd

3 mosCompliance with p

with National Guidelines

Guidelines National Guidelines

Normal Screen Colon AVG Risk 10 yr F/U

64% 69% 77% 73%

<3 adenoma non-high risk, Screening

57% 60% 57% 69%

Screening Colon 5 yr F/U

Adenoma Detection Rate

M >25%F> 15 %Combined >20%

M=39%F=39%Combined=39%

M=35%F=35%Combined =31%

ACG Abstract 2013 A P4P program changes physician recommendations for colonoscopy follow up intervals. Overholt, Reynolds. et al.

BCBS of North Carolina

•Beginning in 2013 participating in a GI specific registry counts for a significant

P

g g p p g p g y gportion of the quality metrics required for a standard BCBSNC tiered benefit product. •And this tiering benefit design has been expanded from one of BCBSNC largest clients to affect tiering efforts for other clients as well.

Personal communication with Dr. Eugenie Komives, VP, Sr. Medical Director BCBS N.C.


5


What to Measure?

• Colonoscopy and Colorectal Cancer P tiPrevention

• EGD Measures• IBD• Hepatitis C• Patient Experience• Endo Unit Measures

Priority Quality Indicators for Colonoscopy

1. Adenoma Detection Rate2. Use of recommended screening and

surveillance intervals3. Cecal intubation rate including photo

documentation


6


Priority Quality Indicators for EGD1. Frequency with which (unless contraindicated)

endoscopic treatment is given to ulcers with endoscopic treatment is given to ulcers with active bleeding or non-bleeding visible vessels

2. Frequency with which patients diagnosed with gastric or duodenal ulcers have documented plans to test for H. pylori infection

3. Frequency with which appropriate prophylactic antibiotics are given in patients with cirrhosisantibiotics are given in patients with cirrhosis with acute upper GI bleeding who undergo EGD

4. Frequency of proton pump inhibitor use for suspected peptic ulcer bleeding

Collecting Data for Quality Measurement


7


Collecting Data for Quality Measurement

GI Quality Improvement Consortium, LTD (GIQuIC)

• A non-profit organization jointly owned by the ACG and ASGE with a purpose of keeping gastroenterologists at the helm of quality activity as it relates to our specialty

• Allows for direct Endo Report Writer and EMR entry into a web-based registry as well as having a manual entry option

• Provides immediate feedback with respect toProvides immediate feedback with respect to benchmarking of accepted quality measures

• Provides an opportunity for customized reports to provide physician or unit-based information or as a source of data for clinical research


8


Access LoginAccess Loginwww.giquicregistry.org

Portal PagePortal Page


9


UploaderUploader InterfaceInterface

Hyperlink to file format template

Reports Selection PageReports Selection Page


10


Time Period, Measure Reports,Time Period, Measure Reports,Filters, and Display OptionsFilters, and Display Options

• Time Period can be chosen with Daily, Monthly, Quarterly, and Annual intervals, or data can be aggregated

• Measure reports can be run for a single physician, an entire facility, and compared to the entire study

• Filters can be placed on that data based specific fields on the form.• Each report can be run with separate formats and with different comparison

groups• Each set of measures can be run with Display Options.


11


GIQuICGIQuIC Measure Measure ReportsReports

Adenoma DetectionRate (male and female combined)

My Site (red) compared to the entire study (blue)


Adenoma DetectionRate (male and female combined)



12


ADR Correlation with Colon Cancer Protection314,872colonoscopies

n Early Cancer> 6mos<3 yrs

n Delayed Cancer> 3 yrs

189 36189 364

ADR, Quintiles (CI 95%) (CI 95%)

<19.05% 48 1.00 (reference) 103

1.00 (reference)

19.06%-23.85% 36 0.94 (0.63, 1.42) 73 0.94 (.68, 1.30)

23.86%-28.04% 46 1.09 (0.76, 1.57) 59 0.75 (0.58, 0.96)

28.41%-33.50% 44 0.67 (0.39, 1.14) 88 0.67 (0.50, 0.90)

>35.51% 15 0.40 (0.23, 0.69) 41 0.62 (0.39, 0.97)

Corley DA, Marks AR, Zhao W, Lee JK, Quesenberry C, et al. Physician adenoma detection rate variability and subsequent colorectal cancer risk following a negative colonoscopy. Gastroenterology 2013;144:S2-3.


Adenoma DetectionRate (male only)



13



Adenoma DetectionRate (female only)



PhotodocumentationPhotodocumentationof the Cecum/CecalIntubation

My Site compared to the entire study

This may represent f l dfailure to provide photodocumentationand not failure to reach the cecum.


14


100%

Follow-Up Recommendations: Screening Procedure, Age 50 and older

Adequate Preps, Average Risk, No Pathology Findings

65.80%

40%

50%

60%

70%

80%

90%

age

of C

ases

1.08%

22.26%

4.86% 5.06%

0%

10%

20%

30%

40%

3 5 10 Other NoneYears

Perc

enta

GIQuIC Data August 2013

100%

Follow-Up Recommendations: Screening Procedure, Age 50 and older

Adequate Preps, Average Risk, 1-2 tubular adenomas found

60.43%

40%

50%

60%

70%

80%

90%

tage

of C

ases

1.97% 1.55%

20.39%

1.39%

7.62% 5.69%

0%

10%

20%

30%

40%

1 2 3 5 10 Other NoneYears

Perc

ent

GIQuIC Data August 2013


15


Current Data

• Over 470,000 colonoscopies with 5-6,000 new colonoscopies per weekcolonoscopies per week (From July 2010-Oct 2012: 100,000 colonoscopies added,

in October 2013: 350,000 total colonoscopies in registry)

• Over 200 organizations, over 1,600 physicians• Registration continues and there is lag time

before procedure submission due to software updates and training

• Significant clinical research project recently approved

Growth Rate- 2011-2013

1200

1400

1600

1800

Physicians

0

200

400

600

800

1000

1200

50

100

150

200

250

Organizations

500000

Cases

0

050000

100000150000200000250000300000350000400000450000

May

July

Sept

Nov Jan

Mar

May

July

Sept

Nov Jan

Mar

May

July

Sept

Nov


16


ACOs as Payors

• The three priority measures with respect to

Quality-Affordability-Patient Experience

The three priority measures with respect to colonoscopy come into play: adenoma detection rate, cecal intubation, screening and surveillance intervals

• Anesthesia vs moderate sedation• Appropriate utilization of Colonoscopy• Site of Service• Open Access

Is There a Quality Agenda?

When will the pay for quality switch go on?

Will you be ready to hi th li htshine the light on your

level of quality?


17

Documents

Quality in Gastroenterology: Understand What is Being ...s3.gi.org/meetings/bp2014/14ACG_Best_Practices_0012.pdf · Quality in Gastroenterology: Understand What is Being Asked of