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Physician Performance Measurement

A Nephrologist’s Guide to National Initiatives

Performance Measurement, the systematic collection of outcome, process, structural, access, or patient experience indicator of data over time, has a growing impact on the practice of nephrology. In the past, measures have been used predominantly for quality assurance, quality improvement, and public accountability. Increasingly, however, private and public payers are using performance measures as preconditions for determinants of payment, including pay for reporting and pay for performance. In addition, payers are also instituting nonpayment for specific complications experienced by patients or reduced payments for non-participation in programs such as MIPS.

To provide a greater understanding of performance measurement activities affecting nephrology practitioners, RPA has created and maintains this portal to assist you in navigating how multiple performance measurement efforts interrelate and how you can comply with the various requirements in real time. The following information has been compiled for easy access and reference:

  • What are the measures that apply to the kidney patient population?
  • Why are the measures important?
  • Where are the measures housed and maintained/updated?
  • What do nephrology practitioners need to know to utilize the measures?

 

* A Clinical performance measure (CPM) is a mechanism for assessing the degree to which a provider competently and safely delivers clinical services that are appropriate for the patient in the optimal time period. In other words, CPMs estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.

Outcome and process measures are usually calculated in rates (e.g., numerator of people with the outcome or who received the process of care divided by a denominator of people who were eligible for achieving the outcome or receiving the process of care times 100).

Instructions for Use

Performance measurement activities fall into the following main categories: measure development, measure endorsement and adoption, and measure implementation. Each component will include a description of the activity, its status, RPA’s role in its development or implementation, and guidance on how to comply. In order to ensure this document remains up to date, much of this information is provided with links to the source materials.

PERFORMANCE MEASUREMENT ACTIVITIES AFFECTING NEPHROLOGY PRACTITIONERS

Measure Development

A measure is developed through a defined process by an organization such as the Centers for Medicare and Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI), RPA, and others. The RPA endorses the requirements for practice guidelines and performance measures set forth by the AHRQ. Measures may be directed at the physician-level or facility-level.

Project Name

ESRD Clinical Performance Measures (CPM) Project

Description

Balanced Budget Act (BBA) required CMS to develop and implement a method to measure and report the quality of renal dialysis services provided under the Medicare program. To implement this legislation, Centers for Medicare and Medicaid Services (CMS) funded the development of CPMs based on KDOQI guidelines. These are being rolled out in phases.

 

Status

April 2008 – CMS Phase III developed 26 new facility level CPMs in order to further monitor the quality of care being delivered to ESRD patients.

March 2010, Phase IV – contracted with Arbor Research Collaborative For Health (Arbor Research) and University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to develop Quality Measures for ESRD for Anemia Management/Iron Targets, Mineral and Bone Disorder, Hemodialysis Vascular Access Related Infections, Pediatric Hemodialysis Adequacy,Pediatric Anemia, and Fluid Weight Management. As part of the measure development process, Technical Expert Panels (TEPs) were formed to provide expertise and input. TEPs also defined target values for existing ESRD measures. These measures were submitted to National Quality Forum (NQF) in Sept 2010.

 

RPA's Role

Little involvement on an organizational level. A few RPA members were involved in the Clinical Technical Expert Panels.

 

Resources Available/ Participation Information

 

2008 CPMs
Status of CMS measures submitted to NQF in Sept 2010

Project Name


Physician Consortium for Performance Improvement (PCPI)

Description


Multiple stakeholder community for the advancement of measurement science, quality improvement and clinical registries.
Status

The Kidney Disease Workgroup developed 6 ESRD (adult) measures, 6 CKD measures, and 2 ESRD (pediatric) measures. Adult ESRD and CKD measures were pilot tested in four nephrology practices. Testing was completed and the report was generated in February 2009.

The workgroup was reconvened Oct 2010 to review/revise the existing CKD and ESRD measures and consider development of new measures based on RPA’s shared decision-making clinical practice guideline that was published in October 2010. These measures were submitted to NQF in June 2011 in response to a “call for renal measures”.

RPA's Role

RPA served as the lead organization for the Kidney Disease Workgroup.

RPA is a voting member of PCPI and frequently consults with content experts. RPA is now the measure steward of the kidney measures developed by the Workgroup. These measures are including in the RPA Kidney Quality Improvement Registry. 

Resources Available/ Participation Information

 

PCPI Measures

Project Name

 

Kidney Care Partners

Description

Kidney Care Partners is a coalition of patient advocates, dialysis professionals, care providers and manufacturers working together to improve quality of care for individuals with Chronic Kidney Disease.

Status

KCP Measures workgroup convenes regularly to make recommendations about whether KCP should support or oppose proposed facility-level measures The Kidney Care Quality Alliance (KCQA), funded by KCP, develops quality measures for used in the dialysis setting.

RPA's Role

RPA content experts participate in KCP including the measures workgroup and serve on KCQA.

Resources Available/ Participation Information

KCP Overview



Measure Review - Endorsement
and Adoption


Review, revision and endorsement of measures based on evidence. This process that usually entails field testing of the measures prior to consideration for endorsement. RPA recognizes the National Quality Forum (NQF) as the designated entities who endorse measures.

Project Name

 

National Quality Forum (NQF)

Description

Reviews, revises and endorses proposed measures developed by others. Serves as CMS’ preferred measure endorsement entity for public value based purchasing programs.

Status

Ongoing – maintains a clearinghouse of measures that have been endorsed.

RPA's Role

RPA was granted membership in NQF 12/2005. RPA is a voting member and provides feedback on proposed measures related to kidney care. RPA submitted measures during the 2015 call for renal measures and maintains measures in the NQF clearinghouse.

Resources Available/ Participation Information

 

List of NQF-endorsed measures
RPA Appeal of Measure 2496 - Standardized Readmission Ratio (SRR) for Dialysis (2014)

 



Measure Implementation

Use of, facilitation of use, of measures and subsequent reporting on/grading of measure use.



Project Name

Quality Payment Program

Description

An outcome of the MACRA in 2015, the Quality Payment Program replaced existing programs such as PQRS, Meaningful Use and the Value-Based Modifier.

Status

 

Launched in 2017. Providers may participate in the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

MIPS includes 4 components:

  • Quality Reporting (formerly PQRS)
  • Advancing Care Information (formerly Meaningful Use)
  • Improvement Activities (new)
  • Cost (formerly Value-based Modifier; not counted for 2017)

 

RPA's Role

CKD & ESRD measures in program were developed by RPA/PCPI.

Incentives or Adjustments


Eligible professionals who do not successfully participate in 2017 will face a 4% adjustment in 2019. Successful participation may result in an incentive payment.

Resources Available/ Participation Information

 

Learn about the QPP
QPP Education and Tools
RPA webinar on MACRA
Determine whether you need to submit MIPS data



Project Name


Dialysis Facility Compare Five Star Rating System

Description

DFC Five Star Ratings System is CMS’ effort to provide patients in dialysis facilities with an easy to understand summary of the quality data reported on the DFC website. Rather than compel patients to try and compare facilities by looking at numerous individual quality measures, the Five-Star system is an attempt to aggregate that information. It uses a forced bell curve.

Status

The DFC Five Star Ratings System went live January 22, 2015. It is expected that it will be updated annually.

RPA's Role

 

RPA submitted comments to CMS in August 2014 regarding the absence of meaningful public review and comment process, assignment of the Star Ratings, use of the Standardized Ratio measures, and potential disruptions in continuity of kidney patient care.

Incentives or Adjustments


N/A

Resources Available/ Participation Information


RPA FAQ on the Five Star Rating System
CMS presentation (July 2014)



Project Name

Medicare and Medicaid EHR Incentive Program - "Meaningful Use"

Description

Established by the American Recovery and Reinvestment Act (ARRA) of 2009, to acknowledge the necessity of implementing widespread use of electronic health records (EHRs) and the fact that doing so would be prohibitively expensive for most medical practices. To address the necessity and cost-prohibitive concerns regarding EHR implementation, ARRA made a $19 billion investment intended to assist physicians and hospitals in purchasing EHR systems.

Status
In 2017, MU was replaced by MACRA.
RPA's Role

RPA submitted comments to CMS on the Stage 1 proposed rule on issues such as insurance eligibility and claims requirements, computerized provider order entry (CPOE), clinical quality measures, patient-system interaction, privacy and security audit requirements, and laboratory results management. Some of these issues were addressed in the final rule. RPA also submitted comments on the proposed Stage 2 rule.

Incentives or Adjustments

EPs who did not participate in MU in 2016 nor claim a hardship exception by July 1, 2017 will be subject to a 2% payment adjustment in 2018.

Resources Available/ Participation Information

Getting Started with Meaningful Use (CMS Guide)
CMS supporting documentation for MU audits
CMS Interactive Timeline
CMS eCQM library and resources
Hardship Exception



Project Name

Physician Compare Web Site

Description

Required by Section 10331 of the Affordable Care Act, the Physician Compare Web site will contain information on physicians enrolled in Medicare and other eligible professionals who participate in Physicians Quality Reporting System (PQRS) [formerly PQRI] and e-prescribing (eRx).

Status

Section 10331 of the Affordable Care Act required CMS to implement a plan to make information on physician performance publicly available through the Physician Compare Web site no later than January 1, 2013.

CMS must submit a Report to Congress on the Physician Compare Web site by January 15, 2015. CMS is authorized to establish a demonstration program by January 1, 2019, to provide financial incentives to Medicare beneficiaries who are furnished services by high quality physicians. CMS held a town hall on Oct 27, 2010 to solicit input from stakeholders.

RPA's Role

AMA submitted comments to CMS on the proposed rule.

Incentives or Adjustments

N/A

Resources Available/ Participation Information

Physician Compare Background Paper

 



Project Name

CMS Quality Incentive Program (QIP)

Description

Implements a quality incentive program (QIP) for Medicare outpatient ESRD providers and facilities with paymentconsequences beginning January 1, 2012. The ESRD QIP would reduce ESRD payments by up to 2% for dialysis providers and facilities that fail to meet or exceed a total performance score for performance standards established with respect to certain specified measures.

Status

The final rule was issued December 27, 2010.

RPA's Role

RPA submitted comments on the proposed rule in Sept 2010.

Incentives or Adjustments

Facilities that do not meet or exceed performance standards will be subject to a payment reduction up to 2 percent. ESRD QIP payment adjustments will apply to payments under the ESRD PPS for outpatient maintenance dialysis items and services furnished to Medicare patients by ESRD facilities between Jan. 1, 2015 and Dec. 31, 2017.

Resources Available/ Participation Information

QIP Final Rule
CMS Overview of ESRD Quality Improvement



Project Name

Maintenance of Certification - ABIM

Description

Maintenance of Certification promotes lifelong learning and the enhancement of the clinical judgment and skills essential for high quality patient care.

At the time of application, be previously certified in internal medicine by ABIM; Satisfactorily complete the requisite graduate medical education fellowship training; Demonstrate clinical competence in the care of patients; Meet the licensure and procedural requirements; and Pass the Certification Exam in Nephrology.

Status

Internists and subspecialists certified in or after 1990 renew their certificates through ABIM's Maintenance of Certification program. Candidates must be credentialed, pass a secure examination, and earn a total of 100 points of self-evaluation in medical knowledge and practice performance.

The Affordable Care Act (ACA) requires a mechanism whereby an eligible professional may provide data on quality measures through a maintenance of certification program (MOC) operated the American Board of Medical Specialties (ABMS) or an equivalent program - for nephrologists this is the American Board of Internal Medicine (ABIM).

Beginning in 2018, nephrologists will have the option to take a 2-year Knowledge Check In every 2 years or they may continue to take the 10 year exam. 

RPA's Role

Ongoing monitoring and collaboration with ABIM. 
RPA's Kidney Quality Improvement Registry will also allow physicians to use their data for MOC reporting.

Incentives or Adjustments

None.

Resources Available/ Participation Information

Overview of Maintenance of Certification
ABIM Announcement about Changes to Nephrology Exam
Practice Performance Modules
Nephrology Blueprint
ASN Nephrology Self-Assessment Program (NephSAP)
MOC Guide for Nephrologists

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