Report from the AQUA Registry

A Review of 2020 MIPS Reporting Through the AQUA Registry

By Ilma Imamovic, MA, AQUA Registry Project Coordinator, and et. al.

The AQUA Registry is a “one-stop shop” for urologic care providers to satisfy the Centers for Medicare and Medicaid Services’ (CMS) Quality Payment Program (QPP) requirements for the Merit-based Incentive Payment System (MIPS). AQUA Registry members, participating at the “Total MIPS Solution” level, are able to report on quality measures and attest for the Promoting Interoperability (PI) and Improvement Activities (IA) categories.

Additionally, the AQUA Registry successfully reported for MIPS, for over 500 urologic providers, during the 2020 MIPS performance year. CMS has approved the AQUA Registry to report on behalf of its participants as a Qualified Clinical Data Registry (QCDR) for six consecutive years.

Techniques for Measure Development

By Karen Johnson, PhD, Director, Quality and Measurement, and et. al.

In keeping with the American Urological Association’s mission of promoting the highest standards of urological clinical care through education, research and the formulation of health care policy, the Science & Quality Division of the AUA is dedicated to the development and maintenance of evidence-based, urology-specific performance measures. Ideally, AQUA participants will use these measures as tools in their quality improvement efforts. Some of these measure also can be used in the CMS MIPS program.

AUA's measurement aims include the following:

1. To develop measures that address a performance gap and are meaningful and relevant to patients, urologists and other decision-makers
2. To focus on outcomes and promote quality improvement, efficiency and effectiveness in urologic care
3. To reduce the administrative burden associated with data collection

AUA aspires to the meet the National Quality Forum’s measure evaluation criteria when developing and maintaining its measures:

1. Importance to measure and report: measures address a known problem in quality (e.g., less-than-optimal performance), with clinical evidence that supports a link to desired patient outcomes
2. Scientific acceptability: measure specifications are precise and unambiguous, and produce consistent (reliable) and credible (valid) results about care quality when implemented
3. Feasibility: measures can be implemented as specified, while minimizing burden associated with data collection and implementation
4. Usability and use: measure results can be used for both quality improvement and accountability, where benefits of the measure outweigh unintended negative consequences
5. Related and competing measures: minimizes duplication of measurement efforts and aligns specifications with similar measures to the extent possible

The AUA relies on input from the Measure Evaluation Panel (MEP) to guide our measurement efforts. Members of this panel have expertise and experience in measure development and implementation. More importantly, they bring a variety of perspectives needed when developing and implementing urologic-specific healthcare performance measures, including knowledge in relevant clinical areas, informatics, healthcare policy, health systems and other payer models, and patient experience. AUA staff and the MEP welcomes input from AQUA participants. We are particularly interested in feedback regarding measure specifications and any difficulties in understanding or applying them, and in how our measures are used in specific quality improvement efforts. You can contact AUA’s quality and measurement staff with questions or feedback at quality@AUAnet.org.

Four AQUA Measures Receive CMS Benchmarks

By Kimberly Ross, MPH, AQUA Registry Operations Manager, and et. al.

The AQUA Registry is a "one-stop-shop" for urologic care providers to satisfy Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) requirements for the Merit-based Incentive Payment System (MIPS). Participants selecting the “Total MIPS Solution” level are able to report on quality measures and attest for the Promoting Interoperability (PI) and Improvement Activities (IA) categories. A major benefit of using the AQUA Registry for MIPS reporting is the opportunity to track and report on urology-specific measures. Over the past few years, the AUA and other urology-focused registries developed new measures to create additional value to the reporting process for urologic providers. The challenge with all new measures is to establish benchmarks, which means these measures must meet the reporting minimum requirements set by CMS. A measure must be used by a minimum of 20 providers for at least 20 cases each within a given 12-month reporting period within the same calendar year to receive the designation of a CMS benchmark. Measures without CMS benchmarks receive a 3-point base value, whereas measures with established benchmarks are worth a score of anywhere between 3 and 10 points.

For the 2021 MIPS performance year, the AQUA Registry supports a total of 53 quality measures, including nine registry-developed measures of which four measures have received historical benchmark status from CMS. These measures include AQUA14, AQUA15, AQUA18 and AQUA26, and could gain the eligible professional up to 10 points each in the 2021 reporting year.

Policy Updates

Measure Benchmarks for Users - Deciles

By Ilma Imamovic, MA, AQUA Registry Project Coordinator, and et. al.

Under the Quality reporting program, participants are scored on how complete their reporting is, compared to other participants, through a series of benchmarks established by CMS. A benchmark is generated by reviewing historical performance data from two years prior (e.g., 2021 benchmarks are based on 2019 data). Additionally, a measure must meet the following criteria to establish a benchmark:

• A minimum of 20 eligible clinicians (ECs), or groups, must report on the measure.
• The reporting ECs, or groups, must meet data completeness and case minimum requirements.

CMS has created a matrix of deciles where measure benchmarks are separated into performance groupings that correspond with the number of points a clinician will receive. An EC’s performance will be compared to the benchmark, and points will be assigned based on a sliding scale. The below table displays the 2021 urology-specific, or Non-QPP, AQUA Registry measures that have received benchmarks, along with their respective deciles:

To better understand decile scoring, let’s suppose Dr. Smith submits data yielding a performance rate of 50% on AQUA18 (Non-Muscle Invasive Bladder Cancer: Early Surveillance Cystoscopy, Within 4 Months of Initial Diagnosis). Decile 8 ranges from 45.32% – 58.53%, so Dr. Smith will receive 8 points because 50% falls in the eighth decile.

In the case of inverse measures, such as AQUA14 and AQUA26, the lower the performance rate the more points the EC will receive. For instance, the 10th decile for AQUA26 (Benign Prostate Hyperplasia (BPH): Inappropriate Lab & Imaging Services for Patients with BPH) corresponds with a performance score of 0%. In other words, an EC earning a 0% for this measure will receive the full 10 point value. If you view the deciles in descending order, you will notice the decile point values lessen the higher your performance rate is for this measure. This is true for all inverse measures.

Additionally, it’s important to note that measures with benchmarks are worth a maximum of 10 points, whereas measures without a benchmark receive a 3 point floor. In general, if a clinician submits data for a measure, they will receive a minimum of 3 points—which is why the first and second deciles are not shown in the table above. If you have any questions about the above measures of decile scoring, please contact the AQUA Registry Team at AQUA@AUAnet.org.

What Should You Do If You Notice an Inaccurate Measure?

By Ilma Imamovic, MA, AQUA Registry Project Coordinator, and et. al.

We strive to provide AQUA Registry participants with the most accurate data possible. However, sometimes the data do not appear as expected on the dashboard. Provided below are the steps you should take when you encounter this situation.

• Contact your CAMS representative or submit a service desk ticket. Details on reporting a service ticket can be found in the Pegasus Help Center, which is accessed through a link on the upper right-hand corner of your dashboard. Enter the “Get Started Here” section to view the information in the “About Service Desk” area. There is also an accompanying video to walk you through the process.
• The service desk request should highlight any issues you encounter, including specific information such as which measure is causing concern, the discrepancy area (in the denominator or numerator) and the list of patients (Note: To enter PHI details in the ticket, check the “Select to Add PHI” checkbox).
• Enter one service request ticket per measure.
• A representative from FIGmd or the AQUA Registry Team will contact you within 3 business days to schedule a review call with your practice.

Registry Insights

How to Interpret Measure Specifications

By Karen Johnson, PhD, Director, Quality and Measurement

As defined by the National Quality Forum, measure specifications are the technical instructions for how to build and calculate a healthcare performance measure. At a minimum, measure specifications identify the “who, what, where, when, and how” of the measure. Some of the components included in most measure specifications include the target population, numerator, exclusions, exceptions, source(s) of data, type of provider(s) assessed, setting of care, and calculation algorithm. Specifications for more complex measures also may include a sampling methodology, risk-adjustment methodology, stratification scheme, scoring instructions, and/or attribution rules, and possibly, other components. Regardless of the complexity of a measure, its specifications should be complete, precise, and unambiguous, so that those collecting data and calculating the measure can do so in a consistent (i.e., repeatable or reliable) way.

Take QPP measure #236 as an example: This measure (entitled “Controlling High Blood Pressure”) assesses the percentage of hypertensive patients whose blood pressure (BP) was adequately controlled. Although this is a relatively simple measure, the specifications are quite extensive. Note the following:

The target population reflects, broadly, those who should be included in the measure: for this measure, patients ages 18-85 with hypertension. A closer look at the specifications provides additional detail on how to identify these patients (e.g., using age at date of encounter, the CPT codes that define an eligible encounter, and the ICD-10 code that defines a diagnosis of hypertension).

The denominator used in the measure reflects a more nuanced definition of those who should be included in the measure. It takes those patients in the target population and subtracts those listed as denominator exclusions (those on hospice, those with ESRD, etc., along with the specific codes that identify these excluded patients). The assumption is there are clinical and/or practical reasons why it is not useful or reasonable to hold providers accountable for the BP of these patients, and thus they are excluded from the measure.

The numerator of the measure indicates what is being measured. It includes those patients in the denominator whose blood pressure (BP) was under adequate control, defined for this measure as having a systolic BP < 140 mmHg and a diastolic BP < 90 mmHg. Note that these thresholds should be evidence-based.

Other instructions included in these specifications tell the user how to handle various scenarios that might occur (e.g., which BP to use if there are multiple BPs listed or if no BP is listed, which telehealth visits can be counted). Finally, the specifications explain “the math” used to calculate the measure results once the patients in the numerator and denominator are identified.

Not every measure will include all the components noted above (e.g., measure #236 is not risk-adjusted and is not collected via sample, so these components are not needed). Regardless, measure specifications should be expansive enough, and precise enough, so that different users know exactly how to calculate the measure. This is the first step in ensuring correct interpretation and legitimate comparison of measure results.

Tips & Tricks

How to Use the AQUA Registry to Attest to the Promoting Interoperability (PI) and Improvement Activities (IA) Categories of the MIPS Requirements.

PI and IA are 2 of the 4 categories required by MIPS and together account for 40% of the overall 2021 MIPS composite score.

• A score calculator where eligible providers can input numerator/denominator data.
• An attestation module where providers are able to attest to the required measures.
• The ability to earn 10 points toward the Public Health and Clinical Data Exchange objective. Clinicians must attest “yes” for “Clinical Data Registry Reporting” AND one additional measure under this objective.

(Note: Participation in the AQUA Registry alone is not sufficient to meet this category; eligible providers must use their certified EHR, in conjunction with the AQUA Registry, to meet the required measures.)

• An attestation module which allows providers the ability to attest to a series of weighted activities, geared towards improving clinical practice and care delivery.
• The ability to select from any one of CMS’ 100+ improvement activity measures.
• The ability to attest to certain high weight activities, only available to providers participating with a QCDR.

(Note: Contact the AQUA Registry Team to learn more about specific IA measures that AQUA can support.)

Important Dates