In this third article of our series, we cover acronyms and abbreviations pertaining to quality measures espoused and promulgated by the Centers for Medicare & Medicaid Services (CMS), specifically the Physician Quality Reporting System (PQRS). Because CMS has driven many of these initiatives through Medicare, we begin with a brief discussion of that federal health insurance program.
Although Medicare is not an acronym, it is appropriate to describe the basis of Medicare in this context. Medicare was instituted in the United States in 1966, and it is the most dominant payer in the healthcare system. Many of the other healthcare insurance providers take their cues from Medicare. Medicare covers adults in the United States older than age 65 years who have paid into the system. It also provides coverage for those with end-stage renal disease and amyotrophic lateral sclerosis.
Medicare is divided into four parts:
- Part A is dedicated to paying for inpatient hospital and hospice treatment. It is funded by the Hospital Insurance (HI) Trust, which is funded by payroll taxes, income tax paid on Social Security benefits, interest paid on the trust fund investments, and Medicare Part A premiums.
- Part B is the fund that pays for physician services. It also pays for outpatient services such as radiology, outpatient procedures, and durable medical equipment (DME). Part B and Part D are funded by the Supplementary Medical Insurance (SMI) Trust, which is funded by Congressional authorization, interest on the trust fund investments, and premiums paid by enrollees.
- Part C is also known as "Medicare Advantage." This is very similar to regular Medicare, but it is a capitated program. Health maintenance organizations (HMOs) and many health insurers have offered Medicare Advantage programs. Approximately one-fourth of patients on Medicare have elected to be in the Medicare Advantage program. Many Medicare Advantage plans have been shown to have lower costs and premiums than fee-for-service Medicare, but there remains a debate as to whether this is due to better management, advantageous risk profiles, or lower contract prices with providers.
- Part D is the portion of Medicare that covers prescription drugs.
PQRS: Physician Quality Reporting System
PQRS is a CMS initiative founded in 2006 as the Physician Quality Reporting Initiative (PQRI). PQRS previously offered incentive payments to physicians if they voluntarily participated in the program. Since passage of the Affordable Care Act, failure to participate in PQRS now results in physician payment penalties.
To successfully qualify for PQRS, an eligible provider (EP) must attest to nine different Performance Measures in three different National Quality Strategy (NQS) Domains for 2016. Physicians who fail to either attest to PQRS (or an alternative pathway) will receive a penalty in their Medicare payments 2 years later. With the passage of the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), PQRS will be rolled into the Merit-Based Incentive Payment System (MIPS) with the Value-Based Payment Modifier and the Medicare Electronic Health Record (EHR) incentive.
EP: Eligible Professional
Personally, we detest being called a provider; we are board-certified orthopaedic surgeons! However, in the context of PQRS, EPs are anyone who CMS believes should be reporting quality data—not just physicians. For PQRS, EPs include physicians (MD and DO), nurse practitioners, physician assistants, and physical and occupational therapists.
PM: Performance Measure
PMs are the metrics that physicians use to attest to their quality through PQRS. A PM defines the patient population and the measure description. There are different types of PMs. Process measures reward practices that can demonstrate optimal treatment. Outcomes PMs are more favored than process PMs because they better reflect the quality of care rendered. Efficiency PMs aim to decrease unnecessary spending and increase value in healthcare.
For example, PQRS Measure 352 is "Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet." The measure description is "Percentage of patients regardless of age or gender undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet." This is an outcome measure that is within the Patient Safety NQS domain.
The AAOS is working to develop PMs that are more specific to the practice of orthopaedic surgery. The PMs are often derived from clinical practice guidelines and patient-reported outcome measures.
NQS: National Quality Strategy
The NQS was formed by the Agency for Healthcare Research and Quality (AHRQ) in 2011. The three aims of the NQS are as follows:
- Better Care: Improve the overall quality by making health care more patient-centered, reliable, accessible, and safe.
- Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health, in addition to delivering higher-quality care.
- Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
PQRS PMs are classified according to the following six NQS domains:
- Person and Caregiver-Centered Experience Outcomes
- Patient Safety
- Communication and Care Coordination
- Community, Population, and Public Health
- Efficiency and Cost Reduction Use of Healthcare Resources
- Effective Clinical Care
CPG: Clinical Practice Guideline
The AAOS has developed CPGs to help orthopaedic surgeons quickly distill the body of knowledge on a certain topic to a reasonable amount of information. Different subgroups determine the inclusion criteria and the final conclusions, and the literature is systematically reviewed to determine which recommendations can be made regarding diagnosis and treatment of orthopaedic conditions. A CPG may be the starting point that is used to develop PMs. CPGs should not be confused with appropriate use criteria (AUC).
AUC: Appropriate Use Criteria
AUC are different from CPGs in that the AUC make recommendations as to when the literature supports the use of certain procedures in patient treatment. The AAOS has developed many AUC, and uses the RAND/UCLA Appropriateness Method in AUC development. The AUC developers review the available literature and make recommendations if "the expected health benefits exceed the expected health risks by a wide margin."
PROM: Patient-Reported Outcomes Measure
PROMs derive from validated surveys that patients complete at different stages in the treatment of their illness or injury. These instruments may be used to gauge a patient’s recovery. Although PROMs have not been used as PMs, they can be used to generate an outcomes PM. There are many different types of PROM available, including the following:
- HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems
- HOOS: Hip Disability and Osteoarthritis Outcome Score
- KOOS: Knee Injury and Osteoarthritis Outcome Score
- PROMIS: Patient-Reported Outcomes Measurement Information Systems
- VR-12: Veterans Rand 12 Item Health Survey
NSQIP: (American College of Surgeons) National Surgical Quality Improvement Program
NSQIP is a surgical outcomes-based initiative launched by the American College of Surgeons (ACS) to improve surgical care in the private practice sector. NSQIP is a registry that provides surgeons’ data, tools, and training to improve their practice. NSQIP is validated and risk-adjusted. Although NSQIP has not been extensively adopted in orthopaedic surgery, there are certainly opportunities for the profession to consider.
NQF: National Quality Forum
NQF is an organization that is dedicated to reviewing performance metrics, ensuring that they are validated, reproducible, and meaningful. Medicare prefers to use NQF-endorsed measures in their bundled payment initiatives because it demonstrates that a full review of the metric has been performed.
Douglas W. Lundy, MD, MBA, is member of the AAOS Council on Advocacy and the editorial board of AAOS Now. He is copresident of Resurgens Orthopaedics in Atlanta. Thomas C. Barber, MD, is the chair of the AAOS Council on Advocacy and a total joint surgeon in Oakland, Calif.
- http://www.ahrq.gov/workingforquality/about.htm#aims (accessed 5/6/16).
- http://www.aaos.org/Quality/Appropriate_Use_Criteria_(AUC)/Appropriate_Use_Criteria/ (accessed 5/6/16)