Group Practice Reporting Option (GPRO) Tool and Accountable Care Organizations (ACO)

The CMS proposed regulations on Accountable Care Organizations (ACO)s was released on March 31, 2011. These rules give a glimpse of how the government is planning to coordinate the electronic health record (EHR) meaningful use incentive program with its plans for ACOs. In an article published in the New England Journal of Medicine, Donald Berwick, MD, administrator of the Centers for Medicare and Medicaid Services, said the creation of ACOs is one of the first delivery-reform initiatives that will be implemented under the health reform passed a year ago. But this program also builds on some existing incentive programs and tools for quality reporting.

The Physician Quality Reporting Initiative (PQRI) established a financial incentive for eligible healthcare professionals to participate in a voluntary quality reporting program. By reporting on a minimum of 3 measures on a specified group of patients, a physician can earn a bonus payment of 1% on all of their Medicare billing for one year. In 2011, CMS renamed PQRI the Physician Quality Reporting System (PQRS). For 2011, there are 194 quality measures and 14 measures groups in the PQRS, which can be reported to CMS by physicians and other caregivers in hospitals or physician practices. Last years rule for the Medicare Physician Fee Schedule had an impact on both PQRI and eRX Incentive programs. The recently released proposed rule on Accountable Care Organizations will make use of the same reporting tools that PQRS uses. The CMS website for the PQRS is here: https://www.cms.gov/PQRS/01_Overview.asp

Beginning with 2011 Physician Quality Reporting, a group practice consisting of a single Taxpayer Identification Number (TIN) with 2-199 individual eligible professionals or individual national provider identifiers (NPIs) can submit data on quality measures to qualify for an incentive payment. If it is determined that the group practice satisfactorily reports data on Physician Quality Reporting measures, the practice will be eligible for an incentive payment equal to one percent of the practice's total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges.

The GPRO II reporting mechanism is via claims. If the group does not have an applicable measures group to report via claims, the practice can report that measures group via a qualified registry. The reporting requirements for GPRO II are determined on a tiered basis depending on the group's size. Groups selected to participate in GPRO II will use the Physician Quality Reporting System Measure Specifications Manual for Claims and Registry Reporting of Individual Measures and the Physician Quality Reporting System Measures Groups Specifications Manual for the respective reporting year.

In the first year of the new ACO program announced by CMS ACOs will use a new ACO GPRO tool based on the data collection tool currently used in the PQRS. In subsequent program years through additional rulemaking, we would expect to refine and expand the ACO measures to enhance our ability to assess the quality of care furnished by ACOs participating in the Shared Savings Program and expand measures reporting mechanisms to include those that are directly EHR-based. The tool would allow ACOs to submit clinical information from EHRs, registries, and administrative data sources required for measurement reporting. One very interesting section of the proposed rule on ACOs is:

In July 2010, HHS published final rules for the EHR Incentive Programs. Included within the final regulations were certain clinical quality measures for which eligible professionals and eligible hospitals are responsible. We have noted in Table 1, the proposed Shared Savings Program quality measures currently included in the EHR Incentive Programs and will continue to further align the measures between the two programs. Given that we have proposed in Section II.E.6 that at least 50 percent of an ACO's PCPs are "meaningful EHR users" as that term is defined in 42 CFR 495.4 by the start of the second Shared Savings Program performance year in order to continue participation in the Shared Savings Program, our intent is to develop the capability of the GPRO web-based tool to interface with EHR technology, such that EHR data could directly populate the ACO GPRO tool with the required quality data. As we intend to further align both the Shared Savings Program and EHR incentive program through subsequent rulemaking, we anticipate that certified EHR technology (including certified EHR modules capable of reporting clinical quality measures) will be an additional measures reporting mechanism used by ACOs under the Shared Savings Program for future program years.

Obviously, there will continue to be alignment, not only between the reporting requirements for ACOs and the EHR Incentive Program requirements for meaningful use, but also the Standards and Certifications Criteria for EHRs in the succeeding phases of the program. I imagine that the interface between the EHR and the ACO GPRO tool will become a very important part of healthcare innovation for the future...


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