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Quality Feature — October 2014

Tex Med. 2014;110(10):43-46).

By Amy Lynn Sorrel
Associate Editor 

Austin internist Ghassan F. Salman, MD, knows physician practices like his are under increasing pressure to adapt to rapid changes in the health care system and in patient needs. But he wants Texas physicians to know they can call on a trusted partner to help: TMF Health Quality Institute

The Austin-based health care consulting firm remains the statewide quality improvement organization for Texas after winning another multiyear contract with the Centers for Medicare & Medicaid Services. One of TMF's top jobs is to help physicians, hospitals, and other entities improve quality right at home with hands-on technical assistance to bolster clinical processes and health care outcomes and to home in on federal quality reporting obligations that will affect all physician payments by 2017, many next year. 

Because Medicare funds the contract to further national quality improvement efforts, physicians can take advantage of services that could otherwise add up to $10,000, for no additional cost. 

That's an opportunity no physician should pass up, says Dr. Salman, a member of the Texas Medical Association's Council on Health Care Quality and the TMF Board of Trustees.

"We [physicians] are going through a very difficult time as health care professionals. TMF can be a friend, a colleague to you during this time of change to make it easier on you to do your daily practice so your patients get the best out of their care, and physicians can still do what they are trained to do," the chief executive officer of the multispecialty Austin Diagnostic Clinic said. While those pressures are real, Dr. Salman also cautions that "physicians should not be looking at quality improvement as a policy from the White House, or a law from Congress, or a political goal from a certain party. Quality improvement is impartial. Quality improvement has the patient at the center. And as physicians, we should be working on quality improvement all the time." 

Clinical Transformation 

Under the new Medicare contract, TMF went from being the statewide quality improvement organization for Texas since 1984 to what CMS now calls a broader quality innovation network quality improvement organization for a multistate region that also includes Arkansas, Missouri, Oklahoma, and Puerto Rico. 

Having partnered with TMF in the past on some of the quality improvement tools and public health programs like Be Wise — ImmunizeSM that TMA offers, the association expressed "strong support" for TMF's bid to remain the statewide quality improvement organization of Texas.

"With established relationships at the local and state levels, TMF has a long history of understanding our state and focusing on quality of care, which reduces medical costs and improves patient outcomes in the long run," then-TMA President Stephen L. Brotherton, MD, wrote to Medicare officials.

Through a team of experts that includes physicians, nurses, clinicians, biostatisticians, and other industry professionals, TMF offers what Quality Innovation Network Program Manager Christine Allen, RN, describes as "all-encompassing" quality improvement consulting services to transform practices. 

"We recognize that [quality] measures won't improve and costs won't go down unless there is some clinical transformation," she said. "And all of our work is data-driven, because you can't manage what you can't measure."

Specifically, Medicare charges TMF with helping physicians successfully report to the Physician Quality Reporting System (PQRS) and to the new Medicare value-based payment system set to take effect in 2015 for larger practices and by 2017 for all physicians, and their meaningful use of electronic health records (EHRs). (See "Countdown to Value-Based Payments.") For more information about Medicare's quality reporting initiatives, visit the TMA website

Ms. Allen says physicians' reporting obligations become more important as the current financial incentives for participating in federal quality reporting programs shift to penalties for nonparticipation. (See "Penalties Add Up," May 2013 Texas Medicine, pages 35-39.) Once the value-based payment modifier kicks in, Medicare will scale all payments based on practices' quality and cost performance. 

TMF works with practices on communication, team-based care, patient engagement, clinical decision support systems, pulling data from EHRs, and assessing clinical processes and outcomes to identify areas for improvement. The organization also helps practices stay up to date with the constantly changing Medicare quality reporting requirements.

With a growing list of reportable PQRS measures, for example — now in excess of 300 — "what we do is focus on those measures that are appropriate for each individual practice or physician," Ms. Allen said. The Medicare contract also targets several quality measures aimed at improving cardiac health, reducing disparities in cardiac and diabetes care, and cutting down on infections in hospitals and adverse events in nursing homes. 

TMF has helped hundreds of practices successfully report to PQRS over the past five years, including transitioning practices to reporting quality information electronically.

Dr. Salman says that while TMF got its start performing primarily auditing duties on behalf of Medicare and Medicaid, the organization has taken that expertise and evolved into a broader quality improvement organization. 

"TMF is a leader in quality measurement and quality improvement. They not only understand how to measure quality, but also advise physicians on what they need to put in place to achieve a certain goal. I don't know of another company in Texas that can do this," Dr. Salman said. Rather than just focusing on auditing of poor performers, “quality improvement has a completely different approach: We look to move the whole curve and the average of everybody up. The way to do that is to not look at what's wrong, but to look at daily practices and processes we need to change to improve the overall quality of care. We ask about specific steps physicians or staff can take to identify opportunities for improvement, then we help doctors do the right thing at the right time." 

Closing Gaps

That's exactly what TMF did for Port Arthur family physician Tracie D. Updike, MD. 

Now, she collects information on various preventive measures she and her staff can easily assess and act on as soon as patients walk in the door. A new tracking tool reminds Dr. Updike to discuss mammograms with her female patients, prostate exams with her male patients, and colonoscopy screenings with everyone older than 45. When she sees diabetic patients, a foot diagram on the tool cues her to check their feet.

Oftentimes, some of her diabetic patients would show up with heavy work boots, reluctant to take them off, "so I was missing my diabetics before. Now, everybody takes off their shoes and socks, and I look at everybody," she said. "I have my tracking measures in my hand or on my desk when I walk into the patient's room. Now, I don't even want to see a patient without them."

Dr. Updike has since expanded the tool to include reminders to discuss end-of-life issues such as living wills with older patients and to test their mobility. 

Hers was one of dozens of physician practices to receive the first Texas Physician Practice Quality Improvement Award in 2013 for the changes she made. The award, cosponsored by TMF, TMA, and the Texas Osteopathic Medical Association, recognizes high-performing practices for investing in quality improvement through health information technology, patient education, early detection and disease management, public reporting of data, and top performance on nationally recognized clinical outcomes measures. 

To learn more about the award and to apply, visit the TMF website

The changes not only helped Dr. Updike enhance patient care but also translated into financial rewards. Standardizing the way her practice collects and reports quality data made it easier to report to PQRS through her EHR system and earn bonuses for doing so. 

"It was not an easy transition to PQRS, but I saw the light in 2008, and I got in gear in 2009. And this is not going to go away. It's only going to get more intense, and TMF was able to tweak things I was already doing and help me see a clearer path," she said. 

Sustainable Solutions

TMF provides most of its services through so-called "learning and action networks," which TMF organizes not only to educate and provide technical assistance to physicians on specific topics, but also to connect physicians with other practices that are working on similar issues.

Physicians can dial into free, web-based learning sessions on PQRS or meaningful use, for example, and ask questions. TMF has hosted virtual demonstrations with EHR vendors and has offered a series of webinars that break down performance improvement into easy steps practices can follow and use to set goals. 

Dr. Updike recently attended a discussion with several clinics to learn from their strategies to improve patient compliance and adherence.

TMF still conducts in-office consulting, but Ms. Allen says the virtual networks offer a convenient option for practices to learn and connect and help TMF reach more physicians across the state. 

"Part of the contract with Medicare is to make things sustainable. So if the contract ever goes away, we can do that by networking through practices," she said. "And, hopefully, the idea of helping practices start on a small scale encourages them to use what they learn and expand their knowledge to another measure or process that needs to be improved."

Dr. Updike says she's applied the principles she's learned through the Medicare quality improvement programs to commercial programs. "I don't just do this for my Medicare patients. I do this for all my patients."

Beyond the Medicare contract, TMF offers services to help physicians complete their applications for the Bridges to Excellence (BTE) performance improvement program, for example. (See "Recognition and Reward," September 2013 Texas Medicine, pages 59-62.) TMF also works with physicians, hospitals, pharmacies, and other entities on a medication safety program to reduce adverse drug events and is looking to partner with state agencies like the Texas Department of State Health Services on additional quality improvement projects. 

Dr. Updike signed on to BTE and other commercial incentive programs and earned financial bonuses from several private insurers. When one of those carriers came to her office requesting patient records, "it didn't take but 10 minutes," she said, because of the processes she already had in place. "And they just sent me $75 per patient."

Dr. Updike's improved performance also has emboldened her to challenge the two-star rating one insurance company gave her. "I want them to come and take a look."

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Join TMF and Start Improving Quality Now!

Joining TMF Health Quality Institute's quality innovation networks is free and easy. The networks serve as information hubs for physicians to learn and share best practices on a variety of Medicare quality improvement initiatives. Here's how to get started:   

  • Visit to learn about the various network projects.
  • Choose from among the following networks that interest you:
  • Cardiovascular health and the Million Hearts campaign;
  • Health for life, an Everyone with Diabetes Counts initiative;
  • Health care-associated infections;
  • Meaningful use;
  • Medication safety;
  • Nursing home quality improvement;
  • Quality reporting and incentive programs; and
  • Readmissions.
  • Set up an account to participate in the network and access webinars, technical assistance, peer discussion groups, and quality improvement tools and resources. 

For more information about TMF, visit the TMF website. 


Countdown to Value-Based Payments  

The countdown is on for the launch of the value-based payment modifier beginning next year, when Medicare will start calculating physician payments based on quality and cost performance. As incentives in federal quality reporting programs now shift to penalties for nonparticipation, Texas Medical Association officials urge all physicians to prepare now to avoid the financial toll.

The value-based modifier will automatically adjust physicians' Medicare payments based on their performance in the Physician Quality Reporting System (PQRS). Depending on how doctors stack up against their peers, Medicare will increase, decrease, or keep payments the same.  

  • Physicians in group practices of 100 or more will be subject to the modifier in 2015, based on their 2013 PQRS performance.
  • Physicians in group practices of 10 to 99 will be subject to the modifier in 2016, based on their 2014 PQRS performance. 
  • All physicians will be affected by the value modifier by 2017. 

Physicians who did not report to PQRS in 2013 will see their 2015 Medicare payments cut by 1.5 percent.  

While it's too late to avoid the 2015 penalty, physicians still can act to avoid a double whammy in 2016: Failure to report in 2014 will result in a 2-percent pay cut in 2016 under PQRS for all physicians, plus another 2-percent penalty in the value-based modifier program for group practices with 10 to 99 physicians. 

Confused? Check out the chart "How Does PQRS Participation Affect the Value-Based Payment Modifier?

TMA officials offer the following tips to avoid future penalties:   

  • For group practices that missed the Sept. 30 deadline to register to report quality measures as a group under the Group Practice Reporting Option for the value-based modifier program, Medicare will calculate a group quality score if at least 50 percent of eligible professionals within the group report PQRS measures individually. Also, individual physicians can still avoid the PQRS penalty by reporting individually. 
  • Practices that adopted electronic health records (EHRs) should check with their vendor to see if their system is capable of reporting their PQRS data to Medicare. The option is often free and minimizes staff time to review charts and reenter patient information. 
  • No EHR? TMA recommends reporting via a registry, which has proven more successful than claims reporting. Medicare vets the registries to ensure they provide the required PQRS data elements, accurately calculate measures reporting and performance, and properly transmit the required information. TMA members get a discounted rate for choosing one of TMA's endorsed, cost-effective qualified registries: PQRSwizard and Covisint PQRS (use the discount code TMAPQRS14). 
  • If you haven't already completed your reporting using claims, TMA officials warn it's likely too late in the year to meet Medicare's 2014 reporting requirements via the claims-reporting option. Instead, they recommend reporting via registry or EHRs. 

For an overview of the 2014 PQRS reporting requirements, check out TMA's on-demand webinar. TMA members get a discounted rate and continuing medical education credits. 

For more information about Medicare's quality reporting initiatives, visit the TMA website.   

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Last Updated On

April 19, 2018

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