What can the TMF Health Quality Institute do for you?

By Jonathan Nelson

Do you remember what you were doing two years ago today? What patients did you see that day? What about the day before? How well were you coordinating care for your chronically ill patients? Here’s a scary question: how much do you know about the care your patients were receiving from physicians and other providers outside of your practice?

In the steady march from “volume to value” in how we pay for health care services, what happened two years ago is increasingly important to the amount you get paid for Medicare services you provide today. Since the passage of the Affordable Care Act, the Centers for Medicare and Medicaid Services have launched a series of payment experiments using both incentives and penalties in hopes of bending the health care cost curve and improving the quality of care patients receive. Along the way, they have invented a jumble of acronyms and a maze of initiatives, each seemingly designed to be more confusing than the last. And now with the passage of MACRA — the Medicare Access and CHIP Reauthorization Act of 2015 — the stakes have been raised yet again.

Under MACRA, physicians will either choose to participate in the Merit-Based Incentive Payment System or they will practice in an Alternative Payment Model. MIPS will be a combination of the Physician Quality Reporting System, the Value-Based Payment Modifier Program, and Meaningful Use, while APMs will offer Medicare an avenue for paying physicians in advanced delivery models like accountable care organizations and patient-centered medical homes.

Whichever path you take, you’ll have to be able to report your quality and resource use data effectively and efficiently, and you’ll have to understand how services your patients receive from other providers will affect your value scores. Unfortunately you don’t have long to get good at reporting this information or to implement quality improvement initiatives. Payment bonuses and penalties under MIPS and APMs start in 2019, but they will be based on 2017 performance data.

Lucky for you there’s an organization in Texas dedicated to helping physicians and other providers succeed in the various CMS measurement programs and demonstrate their level of quality. TMF Health Quality Institute is the CMS Quality Improvement Organization for Texas and in 2014, it became the Quality Innovation Network QIO for Texas, Arkansas, Missouri, Oklahoma, and Puerto Rico. They work with hundreds of practices across the region, providing technical assistance, consultation, and education on a variety of quality improvement initiatives like behavioral health, diabetes, cardiovascular health, and immunizations.

“Our job is to help any practice that accepts Medicare to improve their quality,” says Russell Kohl, MD, medical director for practice transformation at TMF Health Quality Institute. The company runs projects with hospitals, nursing homes, and other health care venues, but Kohl says physician practices are a top priority for TMF. “We try to focus as much as possible on the actual individual doctor’s office, and the great thing about it is all the stuff we provide is completely free.”

That’s right. Free.

TMF is a not-for-profit company that receives funding directly from CMS to help physicians improve the quality of their care and properly meet federal quality reporting obligations that affect physicians’ future payments.

It’s those future payments that have Kohl and his colleagues concerned. Take the Physician Quality Reporting System, or PQRS, for example. CMS initiated the program by offering positive payment adjustments for participating physicians but in 2015, CMS started issuing negative payment adjustments to physicians who didn’t satisfactorily report on services provided back in 2013. That trend is going to continue and the penalties get steeper in the new Medicare payment model.

“If a practice sits back and doesn’t try to figure out how to do things really well, what they are likely to end up with is a situation where 2019 hits, they take a significant cut to their finances, and they start trying to do the work then. Well we know that to really go in and try to optimize the way a practice works, that takes time. It’s not something you just change overnight.”

A family physician from Oklahoma, Kohl was the chief medical officer for AAFP’s TransforMED before joining TMF, so he’s seen practice transformation up close. “If they are not starting until 2019 or 2020, they are looking at not being in a position to be successful until 2022 or 2023, and they are going to be dealing with things like 10 percent penalties on their payments each year from 2020 on.”
By signing up to join TMF’s Value-Based Improvement and Outcomes Network, physicians can interact with experts and peers who can help them understand and meet the CMS goals of the physician value-based payment and quality reporting programs. Recently a major focus for the network has been showing physicians how to access and interpret the quality and cost information CMS provides in the quality and resource use reports, or QRURs. Although these dense reports indicate how physicians will fare under Medicare’s value-based payment model, many physicians don’t even know they exist.

“The QRURs can initially appear daunting,” says Suzie Buhr, BSN, RN, CPHQ, a quality improvement consultant with TMF. She says many large practices with ample resources are using the reports successfully but that’s not the case for everyone. “Our education focuses largely on the smaller practices that don’t necessarily have all the manpower. This is very new to them and they don’t really have an understanding of it yet. We are available to help walk them through the report.”

In the Value-Based Improvement and Outcomes Network, TMF consultants help physicians understand and analyze their QRURs, then they help put that information to good use. The consultants can work inside the practice to identify gaps in quality and reporting procedures and help implement strategies to close those gaps. Physicians and their office staff also have access to a broad spectrum of educational materials, including online information exchanges, webinars, videos, conferences, how-to instruction manuals, and more.
Kohl says often TMF consultants can identify process changes inside a practice’s daily workflow that improve quality and reporting with little disruption and without “killing the doctors.”

“Most of the time, if more work is being piled on the doctor, it’s because they don’t really understand how the workflow of the practice should go,” he says. “So a lot of what we do is actually taking work away from the doctor that doesn’t require a medical degree to be done, building processes in the practice so the right person can do it at the right time, and freeing up some of that time for the doctor to either just stop and take a breath for a minute in the day or to have the time to do the stuff they really need to be doing.”
In fact, TMF consultants often work with practice administrators rather than physicians to implement quality improvement and reporting strategies. That’s how it went for the Youens and Duchicela Clinic in Weimar. In 2011 the practice contacted TMF for help with PQRS. The consultants worked mainly with the practice IT manager, Amanda Ritzen, to identify quality measures they could report and optimize templates in the practice’s electronic health record so they could collect the right data.

“It wasn’t necessarily too much of an extra step for us because we were doing these things already,” she says. “It was more or less a couple of extra clicks to make sure that those templates captured those codes so we could report on them after the first of the year.”
She says the program runs smoothly with the physicians’ current workflow. “Everyone has a busy schedule with lots of things to manage, but the good thing about TMF is they assign one or two people to work with you and they work around your schedule.”

To gain access to TMF’s Value-Based Improvement and Outcomes tools and resources, go to www.TMFQIN.org and join the Value-Based Improvement and Outcomes network.

Behavioral health

The Value-Based Improvement and Outcomes Network is only one of TMF’s Learning and Action Networks. Others cover EHR care management, population health management, diabetes, cardiovascular health, immunizations, Meaningful Use, and more. In April, TMF launched a new initiative to improve integration of behavioral health into primary care. The TMF QIN-QIO has engaged with more than 200 practices in each of its four states plus Puerto Rico to increase screening for depression and alcohol use disorder. A psychiatrist in Frisco, Clifford Moy, MD, leads the project as TMF’s medical director for behavioral health.

“In the Medicare beneficiary population, behavioral health disorders have been identified as a significant comorbid set of conditions that adversely affect other medical conditions such as diabetes, hypertension, COPD, and generally result in poorer outcomes,” he says. “The hope is with this project, by increasing screening, identification, and treatment, we can improve the overall health outcomes for the Medicare population. We believe this needs to occur in the primary care setting where care can be better coordinated.”

Moy says a number of factors have led to low screening rates for depression and alcohol use disorder in the primary care setting but that now, a number of validated screening tools are available that can be administered to patients or completed by patients outside of the clinic.

“This is really going to be a game changing process if we can make this work and identify these patients so they can get treatment.”

Behavioral health screening services are billable under Medicare Part B and they also serve as reportable quality measures under Medicare’s value-based care programs. Moy says putting systems in place to ensure these services are provided to Medicare patients in primary care practices is good for patients and their doctors. “We believe that improving the overall health of a physician’s panel of patients is going to improve the physician’s financial outlook as well. This is something we believe is a win-win. Patients will have better health, they’ll get treatment, and physician practices will see better patient outcomes and the health of their practices should improve, employed or not employed.”

“A lot of what we do is actually taking work away from the doctor that doesn’t require a medical degree to be done, building processes in the practice so the right person can do it at the right time, and freeing up some of that time for the doctor to either just stop and take a breath for a minute in the day or to have the time to do the stuff they really need to be doing.”—Russell Kohl, MD

To gain access to TMF’s behavioral health tools and resources and to benefit from what they learn over the course of this project, go to www.TMFQIN.org and join the behavioral health network.

Joining this network or any of their other networks is the first step to taking advantage of what TMF has to offer. As one of 14 QIN-QIOs across the country, TMF has access to a massive amount of information and case studies on how to improve quality in a multitude of practice settings, and as the CMS contractor for quality improvement, they are empowered to help physicians succeed. By joining their networks, you can engage their resources at the level you wish, using as much or as little of their services as you like.

“With everything going on in health care right now, there are all sorts of people who have gone into the business of practice transformation, or practice consulting,” Kohl says. “Some of them are great organizations with long track records and know exactly what they are doing. Others are people who just spotted that this is a great time to be a consultant in health care. ‘I can make a lot of money and be gone by the time it’s over.’”

He says if you consider the history of TMF, you don’t have to worry about what you’re going to get. “It was started by Texas physicians specifically to improve quality. We still have that relationship. We are working with Medicare on a daily basis to try and give practices the things they need to be successful.”