History and Overview of the National Quality Strategy

Level of accountability

Name

Description

Examples of GI measures in program

Health system

Medicare Shared Savings Program

Measures ACO care coordination

CG-CAHPS

Medicare Advantage 5 Star Quality Rating System

Health plan quality incentive program

Rate of CRC screening among plan members

Medicaid Adult Core Measure Set

Basic quality metrics for Medicaid patients

Flu shots, BMI, CG-CAHPS, monitoring of persistent medications

Quality Rating System for Qualified Health Plans for Insurance Exchanges

Monitors health plans for meeting ACA standards

CAHPS, Access to specialists, cultural competency, CRC screening, weight management

Clinician performance

PQRS

1.5–2 % reduction in Medicare payments beginning 2015

CAHPS, CRC screening, polyp surveillance interval normal exam, surveillance interval in patients with prior adenoma. Adenoma detection rate added in 2014 (not NQF endorsed as yet)

Meaningful Use

Penalties begin in 2015 and will continue

Stage 1, 2, and 3 with increasing standards for communication

Physician Compare

Public reporting website on individual physicians—2014

Process and experience patient outcomes, Meaningful Use, PQRS participation

VBM

Pay for performance—2017 for all. Composite of quality (NQF endorsed) and cost measures

CAHPS, CRC screening, polyp surveillance interval normal exam, surveillance interval in patients with prior adenoma. Adenoma detection rate not currently endorsed

Hospital performance

Hospital Compare

Public reporting and pay for performance

GI as part of a larger group

PQRS Physician Quality Reporting System, VBM value-based modifier, ACO accountable care organizations, ACA Affordable Care Act, NQF National Quality Forum, GI gastroenterology, CG-CAHPS Consumer Assessment of Healthcare Providers and Systems (CAHPS ®) Clinician & Group, CRC colonoscopy and colorectal cancer, BMI body mass index

Table 1.1 includes examples of gastroenterology (GI)-related measures that might be useful to practices or implemented at a health system or ACO level and used to assess quality in a GI practice. Additional measures under consideration within this process include rate of repeat colonoscopy for poor preps, appropriate age for CRC screening colonoscopy, and several measures related to bundled payment for a colonoscopy episode. Recently, the American Gastroenterological Association Institute (AGA) published a framework to develop a colonoscopy bundle and CMS has expressed interest in testing payments tied to such a bundle [14].

There is new information about PQRS as it relates to GI as of 2014. Of note, the adenoma detection rate is included in the 2014 PQRS but as yet is not endorsed by NQF. CMS is going to retire a number of claims-based measures (such as those related to hepatitis C) in order to encourage more use of a qualified registry. It is also increasing the number of measures that need to be reported from three to nine in many cases. As of 2014, CMS is offering a new “qualified clinical data registry” (QCDR) reporting option requiring nine measures across three NQF domains and including at least one outcomes measure. These specific measures can contain a combination of PQRS and non-PQRS measures. CMS announced recently that there are two registries pertinent to gastroenterologists that will be “qualified”. These include the Digestive Health Outcomes Registry (DHRP) maintained by the AGA and the GI Quality Improvement Consortium (GIQuIC) a registry maintained by the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy (ASGE). Reporting through a QCDR into PQRS can only be done at an individual level and must include more than 50 % of eligible Medicare patients seen by a provider.

In summary, the following are current colonoscopy- related measures that are either endorsed or under consideration for use in a qualified registry (as a non-PQRS inclusion):

Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps—Avoidance of Inappropriate Use (PQRS 185 NQF 0659)
Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (PQRS 320/NQF 0658)
Screening Colonoscopy Adenoma Detection Rate (PQRS 343)
Colonoscopy Assessment (Procedure adequacy)—Assessment of Bowel Preparation (non-PQRS measure)
Colonoscopy Assessment (Cecum reached)—Cecal Intubation/ Depth of Intubation (non-PQRS measure)
Unnecessary Screening Colonoscopy in Older Adults (non-PQRS measure)

Building a QI Program in Your Practice

Physicians who decide to build a QI program within their practices should understand clearly that performance is to be measured by their peers, compared to optimal practices, opportunities for improvement will be identified, and they will be held accountable for actively participating in these initiatives. When improvement opportunities are found, practices can follow the Donabedian Model described above to alter processes or structure and improve health outcomes. Several basic references are provided to help kick-start a QI program [15–18].

Variation in colonoscopy quality and outcomes exists and will likely continue until process and outcome measures for all colonoscopy examinations are either mandated (see later discussion) or become a routine part of practice for both gastroenterologists and nongastroenterologists who perform screening colonoscopy . The current FFS system of reimbursement, where payment is disconnected from health outcomes, will likely end in the near future. Current systems of credentialing occur at a facility level (a situation with inherent economic conflicts of interest) so factors other than quality and patient-centered health outcomes continue to be powerful influences in the community. Recent CMS efforts to begin identifying outliers within ambulatory surgical centers will continue and increase in intensity.

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