Emergency Medicine Advocacy Handbook

Ch. 12 - Data Registries: Impact on Quality and Reimbursement

Luke Knapp, MD; Chet Schrader, MD, FACEP

Modern health care’s drive toward increased quality and value has seen an emphasis placed on data and analytics, with a goal of affecting overall population health. To achieve these aims, the creation of large data sets to track metrics, evaluate health, and drive change has been required. The explosion of large databases and a desire to use this metadata has the potential to effectuate profound change.

Health care legislation and CMS measures continue to emphasize quality over quantity, and multiple data registries have been implemented to help satisfy reporting measures as well as increase quality of care.

Clinical Data Registries

CMS is mandated to implement a quality payment incentive program.¹ The PQRS was most recently used for reporting data through the end of 2016, when it converted to MIPS under the QPP.2 Of note, 2015 was the first year clinicians were subject to negative payment adjustments for not satisfactorily reporting quality measure data. To achieve this aim, CMS allows for data processing via Qualified Clinical Data Registries (QCDRs), CMS-approved entities that collect and submit clinical data. While QCDRs are used to satisfy MIPS reporting data, they also have a wider scope as they are allowed to submit data on up to 30 non-MIPS CMS measures.³

Clinical Emergency Data Registry

To allow emergency physicians to keep up with changes in quality measures and ensure they are fairly reimbursed for their services, ACEP created a system called the Clinical Emergency Data Registry (CEDR) to measure and report health care quality and outcomes. CMS has approved CEDR as a QCDR that satisfies MIPS reporting and potentially other quality reporting requirements.

CEDR measures and reports quality metrics, such as ED utilization of CT scans, 3-day return rates to the ED, and time to tPA; however, it also provides physicians with information to identify outcomes and trends in emergency care. Additionally, CEDR gives physicians feedback on their performances and compares the individual physician to his/her peers at a national level.

CEDR collects all this information from an ED’s electronic medical record system, administrative data system, or the practice management system so that the individual physician or physician group does not have to develop a separate system to collect this complex information. CEDR also allows for a simpler, single date capture to satisfy multiple quality measure reporting requirements by CMS.⁴

Implementing CEDR

ACEP implemented CEDR over an 11-month span in 2015. To join CEDR, potential participants complete a questionnaire that includes information on the group and EDs they serve. Once this is completed, both parties fill out a Participation Agreement, including a Business Associate Agreement and Data Use Agreement in compliance with HIPAA. After everyone agrees, the Registry Practice Connector software can be installed. The software is designed to be as unobtrusive as possible and should require read-only credentials to the Revenue Cycle Management system and/or EHR used by the physician’s group. Data then can be extracted in a secure manner. A Client Account Manager (CAM) will work with a group administrator to assess data mapping as well as obtain performance reports and create an easily accessible dashboard that allows group participants to see their quality measure performance.⁴

Advantages of CEDR

By creating its own database, ACEP has provided a quality measurement device made by emergency physicians geared to work best for emergency physicians. Its goal is to be user-friendly, provide quality data on patients from all payers, have meaningful measures, and pose a minimal data entry burden while still meeting CMS and other reporting requirements. CEDR also affords national, comparative data that allows clinicians and groups to identify quality measures that need improvement. The CEDR also benefits government policy-makers and health care leaders by supplying invaluable data to help guide future health care policy on a population level.4 Hopefully with the large volume of data that is gathered, emergency physician can advocate for informed and evidence based health policy and respond to external threats with the information available.

All Payer Claims Databases

To comply with national and state payment reform initiatives, as well as respond to a push for increased transparency in health care and analysis of utilization and cost of health care, states have increasingly over the past decade begun to establish state-sponsored all-payer claims database (APCD) systems.⁵

State-sponsored APCDs collect eligibility and claims data from private insurers, public insurers (including CHIP, Medicare, and Medicaid), dental insurers, and prescription drug plans. The database looks at the charges for specific diagnosis codes and procedure codes, as well as the payment the physician received. The goal of APCDs is to provide policymakers statewide information from all payers about the costs, quality, and utilization patterns for health care in their state to help guide health reform efforts. This same data may eventually be used by patients and health care purchasers to compare prices and quality between various providers and make more informed decisions about cost-effective care.⁶

As of 2018, 18 states had established APCDs, and many more were engaged in the process of implementing an APCD. It is estimated that half of all states will have an APCD or similar database by 2022, with each database containing information on roughly two-thirds of that state’s population.⁷ Some APCDs include legislatively mandated reporting by insurers, while others are voluntary and thus less detailed.

There is ongoing debate about how APCDs can best enhance health care price transparency goals. Some states are utilizing public websites that display health care costs based on retrospective data. There exist wide variations in how the APCDs are being utilized amongst states. While many of these efforts are still young, there remains significant work for many of these databases to achieve their goals.

One challenge the states have encountered is accurately tracking providers, as it has been expensive and complex to use taxonomy codes (such as the NPI), state licenses, and physician names.8 However, if APCDs are to be used to track provider pricing, quality, or efficiency, accurate provider tracking will be essential. There is concern that in the future, information in the APCD could be used by insurance companies to set reimbursement rates for physicians based on their knowledge of reimbursements by other insurers, and that this shared information could drive down reimbursement in an anticompetitive way. However, this does not appear to have happened yet in existing markets with APCDs.6

As with all data presented to the public, concerns about accuracy and adjustment for patient populations remain. Doing large meta-data analyses and assigning health care outcomes only to the health care systems or providers in a certain geographic region can ignore variations in social determinants of health, access to care, and other non-medical health factors that influence outcomes. While these data limitations exist for APCDs, they exist in all large data registries and require careful monitoring and engagement to ensure the most accurate data is reported.

Transforming Clinical Practice Initiative

Under the ACA, CMS has initiated numerous programs to improve the efficiency of health care resources. One method to strengthen the quality of patient care and spend health care dollars more judiciously is the Transforming Clinical Practice Initiative (TCPI). The TCPI’s primary goal is to help clinicians achieve large-scale practice transformation across the country. The TCPI will assist more than 140,000 clinicians by supporting practice transformation tools over the next 4 years. It is one of the federal government’s largest investments in transforming health care on a large scale.⁹

Emergency Quality Network

ACEP has developed the Emergency Quality Network (E-QUAL), one of many CMS-approved networks under the TCPI. E-QUAL launched in 2015 with the goal of enrolling more than 24,000 emergency clinicians from 2,000+ EDs over a 4-year period. As of July 2017, more than 27,464 ED clinicians from 863+ ED practices were enrolled.9 E-QUAL has a dual mission to engage EDs and clinicians in multiple clinical initiatives while serving as a resource to the CMSsupported TCPI.

E-QUAL has 4 clinical initiatives with clinician and group enrollment. These initiatives have data available from phases 1 and 2. The initiatives are as follows: improving outcomes for patients with sepsis, reducing avoidable imaging in low risk patients, improving the value of ED chest pain evaluation, and improving strategies for opioid prescribing. Clinicians and ED groups can enroll in the E-QUAL Network by completing a quality improvement readiness assessment survey and then submitting NPIs and group Tax ID Number through ACEP’s website. After enrollment, clinicians can choose which learning collaboratives they want to participate in; each learning collaborative has different enrollment deadlines for the different phases.

By participating in E-QUAL and its learning collaboratives, EDs can use performance benchmarks and other tools to improve patient care. Each learning collaborative supplies online learning activities, CME activities, monthly webinars, and other educational material. At the end of each phase, data and summary reports are supplied to all participants. This allows ED groups and clinicians to gauge where they stand on a national level, as well as identify metrics that need improvement or increased efficiency. EDs can also use this metric data to exhibit their high-quality care to health care payers. E-QUAL data will function similarly to CEDR/QCDR data in regards to quality improvement efforts implemented at a local level.

Not only will participation help improve patient care and health care efficiency, it will also help clinicians and groups receive proper compensation. It is important to note that participation in E-QUAL satisfies the Improvement Activity under MIPS, which is scheduled to have progressive payment adjustments as each year passes. By 2022, payments adjustments will be as large as +/- 9% based on numerous factors. CMS bases this reimbursement component strictly on participation, while other components of MIPS are based on actual quality metric scores not associated with E-QUAL (see above).¹⁰

Health care legislation and CMS measures continue to emphasize quality over quantity. Multiple data registries have been implemented to help satisfy reporting measures as well as increase quality of care. Effective advocacy includes:

• Understanding the role of QCDRs and ACEP’s CEDR that allows physicians to meet their MIPS reporting requirements and get meaningful feedback.
• Monitoring and engaging with state-sponsored APCDs as they will likely guide future quality measures and have an impact on reimbursement.
• Participating in E-QUAL’s quality improvement projects that seek to improve quality and cost efficiency while also satisfying CMS reimbursement measures.