The ability to measure and report on the quality of care nephrologists provide is increasingly important. The physician quality reporting system (PQRS), the value-based modifier (VBM), and the soon-to-be enacted merit-based incentive payment system (MIPS) are now, or will shortly, impact the fee-for-service revenue of nephrology practices. When combined with the alternative payment models and the various government programs publicly reporting both provider quality and other financial data, it is clear that generating relative value units (RVUs) and having reason ably satisfied patients is no longer enough to be considered a successful nephrologist.
But how to measure the value of the care provided by nephrologists is not as clear-cut. We deal with highly complex, multi-organ dysfunction patients. Patients with chronic kidney disease are typically older and at the end of life; end-stage renal disease (ESRD) patients account for a disproportionately high quantity of Medicare dollars, on a per capita basis. However, nephrologists are often subject ed to non-specific and unhelpful metrics of quality and cost that are not relevant to their practices.
The question becomes, “How do we level the playing field for nephrologists, both now and in the future?”
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Until recently, quality measures were developed through organizations such as the American Medical Association Physician Consortium for Performance Improvement (AMA PCPI), reviewed and approved by the National Quality Forum (NQF). Specialty societies, with the financial and admin istrative support of the AMA PCPI, developed these measures, at significant cost (both personnel and financial) to shepherd them through the entire process as an “approved” and “tested” measures. In recent years, the AMA PCPI has discontinued its role as a measure developer due to the excessive costs, devolving this responsibility to its member specialty societies, such as the Renal Physicians Association (RPA).
The RPA has a long history of experience in performance measure development and has worked as part of and with the AMA PCPI as well as the NQF in developing, testing, reviewing, and endorsing renal measures. But without the AMA PCPI, specialty societies, like RPA, must now both help members measure quality and develop the measures they are to use.
A registry to measure quality of renal care
The RPA is doing that with its Kidney Quality Improvement Registry, a national initiative designed to measure and improve the quality of renal care. It is a web based subscription service that allows providers to upload and analyze patient-specific clinical data, generate reports, and use that data for both demonstrating quality and improving clinical performance. The registry will feature a practice-based data network that longitudinally links nephrologists across the renal community and includes real-time benchmarks, gap analysis, and reporting to stay ahead of the payment reform curve.
At its heart is the database of patients and associated clinical data measuring various aspects of the care a patient has received, i.e., the registry data is entered at the individual provider level, but may be aggregated for practice-level analysis. A series of peer comparison tools are also built into the registry.
Though there are numerous ways to get data into the registry, the ideal and increasingly common means is a direct connection between a provider’s electronic health record (EHR) system and the registry itself. Data may be uploaded daily, weekly or monthly, and includes certain patient identifiers as well as ICD-10 based diagnoses, discrete lab values, and other metrics of clinical status and care, such as the presence of diabetes or heart failure, for example. The Kidney Quality Improvement
Registry can import data from multiple sources, such as the dialysis facility, in addition to practice data.
Once sufficient data is uploaded, it may be used in a variety of ways. Patient and disease tracking is the most straightforward use. Data is dis played in a dashboard and a user can drill down to greater detail.
For each measure that has been populated with data, both benchmarking and gap analysis are available, If multiple members of the same practice are participating, they can compare performance against each other as well as individually against the group as a whole. Most importantly, when gaps are identified, i.e., patients whose data demonstrates they are not meeting the stated threshold or goal of the measure, the registry provides links to educational materials and tools for improvement. Furthermore, the registry dashboard will note when interventions were accessed, allowing users to see whether they made an impact on quality scores.
Key features that make this registry even more valuable are the various ways this data can be used:
- The registry allows for ongoing monitoring of a vari ety of PQRS eligible measures prior to submission to CMS. This helps providers and practices ensure that when the deadline for submission approaches their data represents the best of their quality performance.
- The registry gives practices the means to easily report quality data back to its providers, including a provider’s performance trended over time as well as a comparison of a provider’s performance to others in the practice or a subset of the practice. For example, the Registry can compare quality performance between office location A vs. location B. Thus, practices may more easily incorporate value-based outcomes into compensation packages for their providers.
- Practice level reporting allows for the demonstration of ongoing efforts and improvements in organizational quality-an increasingly important component of negotiating contracts and relationships with risk bearing entities such as HMOs, ACOs, and other participants in Shared Savings programs.
- At the provider level, the same data collected may be used to help meet the requirements of various maintenance of certification (MOC) or licensure (MOL) performance improvement programs.
Since the Registry is the only nephrology-specific, eMS approved qualified clinical data registry the RPA can develop its own metrics outside of the existing PQRS measure library and have those measures count toward PQRS participation. (Society-developed QCDR measures do not need to go through the NQF review and endorsement process, though they must be approved by CMS.) To be sure, many of the measures are the same as those found under the PQRS program. However, as a CMS-approved QCDR, the RPA has an increasing number of its own nephrology specific measures. Participating providers who collect and report on these RPA developed measures will have that data count for their PQRS data submission. These non-PQRS measures can only be used to satisfy the PQRS reporting requirements when reported through the RPA Registry. For the 2015 reporting year, RPA’s Registry includes 28 standard PQRS measures and lO non-PQRS measures. The non PQRS measures include the following:
- Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) therapy (RPA measure)
- Adequacy of volume management for ESRD patients on hemodialysis (RPA measure)
- ESRD patients receiving dialysis: Hemoglobin level<9g/ dL (RPA measure)
- Arteriovenous fistula referral and placement, prior to dialysis (RPA measure)
- Transplant referral (RPA measure)
- Documentation of advance care planning discussions (RPA measure)
- Advance directives completed (RPA measure)
- Referral to hospice (RPA measure)
- Advance care planning-Pediatric kidney disease (RPA measure)
- NHSN bloodstream infection in hemodialysis outpatients (CDC measure)
The most immediate impact of this registry is providing users the opportunity to collect, manage and report data for a set of measures more relevant to renal care. In the future, this registry will allow the RPA to develop and evolve quality measures, creating a comprehensive renal specific repository of data that may be used for a variety of purposes and monitored in a continuous fashion.
In addition to data collected for the purpose of measure reporting, the registry also allows for an expanding amount of other patient data, not directly associated with a mea sure or metric. Questions such as whether a patient has had a transplant, types of pre-dialysis education provided, end-of-life planning, transfusion data, prior episodes of acute kidney injury, and other experiential/demographic data points are optionally collected when patients are added to the registry. This allows for more granular tracking and provides data points for future measure development. As with any online database containing patient information, the RPA requires a business services agreement with the practice. Data is housed in a secure online environment akin to online banking, web-based electronic health records, or other high-security online environments typically encountered on a daily basis.
It is important for providers and practices to begin working with registry level data. Submitting data to a quali fied clinical data registry currently satisfies Meaningful Use Stage II menu set items. In the future, with the rollout of MIPS and the increasing focus on sharing risk, registry data will be used as a benchmark for both publicly-reported per formance (the physician compare program will be linked to provider-level QCDR data) and modifications to reim bursement. It is important to remember that PQRS data is the basis for the value based modifier now and MIPS related quality data after 2018.
The RPA has launched and is evolving a unique and versatile nephrology-specific data collection and analyt ics tool. In collaboration with the American Society of Diagnostic and Interventional Nephrology, vascular access measures will be added to the registry for 2016. The registry and the analytics platform is a tier of software operating above your practice management system and EHR and, if data can be obtained, it can span all the locations in which nephrologists provide care.