quality reporting and value-based payment: the physician practice july 31, 2015
TRANSCRIPT
Quality Reporting and Value-Based Payment: The Physician Practice
July 31, 2015
VHQC
Non-profit health quality consulting company since 1984
Virginia and Maryland’s Quality Innovation Network Quality Improvement Organization for CMS
Virginia’s Regional Extension Center as designated by ONC
Provides outreach, education, and comprehensive EHR services to providers and healthcare organizations
1) VHQC Introduction2) Meaningful Use (MU)
a. Timeline Highlightsb. Payment Adjustments & Hardship Exception
3) Physician Quality Reporting System (PQRS)a. Incentive & Adjustmentsb. Reporting Methodsc. PQRS Measure Informationd. Measures Applicability Validation
e. Quality and Resource Use Report (QRUR)4) Value-Based Payment Modifier5) Resources
Agenda
EHR Incentive Program: Meaningful Use
Improved Quality and Outcomes
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health
system
To better align Stages 1 & 2 with Stage 3, CMS proposes:1. Reducing the overall number of objectives to
focus on advanced use of electronic health records (EHRs);
2. Removing measures that have become redundant, duplicative or have reached wide-spread adoption;
3. Realigning the reporting period beginning in 2015, so hospitals would participate on the calendar year instead of the fiscal year; and
4. Allowing a 90 day reporting period in 2015 to accommodate the implementation of these proposed changes in 2015.
Notice of Proposed Rulemakingto Meaningful Use in 2015-2017
Stay Tuned for Changes!
1) First time attesters only: 90-day reporting period
2) Providers beyond their first year of Meaningful Use: FULL CALENDAR YEAR – follow CMS closely for changes
MU Timeline Highlights2015 Reporting Periods
Stay Tuned for Changes!
1) Anticipated to be February 28, 2016 for the 2015 reporting period
2) 2014 was the last year to start Medicare Electronic Health Record (EHR) Incentive Program and receive incentives. First time attesters in 2015 will not receive an incentive, but will avoid the 2017 payment adjustment.
MU Timeline Highlights2015 Reporting Periods
How do meaningful usepayment adjustments work?
-1% 2015 Payment Adjustment Avoided If
Attested to MU for the2013 reporting period OR
Attested to MU for the first time by
October 1, 2014 OR
CMS approved a hardship exception application
specific to 2015 payment adjustment
-2% 2016 Payment Adjustment Avoided If
Attested to MU for the2014 reporting period OR
Attested to MU for the first time by October 1, 2015
OR
CMS approves a hardship exception application
specific to 2016 payment adjustment
-3% 2017 Payment Adjustment Avoided If
Attested to MU for the 2015 reporting period OR
Attested to MU for the first time by October 1, 2016
OR
CMS approves a hardship exception application (form not yet released) specific
to 2017 payment adjustment
Stay Tuned for Changes!
1) Affect Medicare Part B payments
2) Follow the individual provider
3) CMS Payment Adjustment Tip sheet
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipSheetforEP.pdf
Payment Adjustments
1) Hardship exception applications are developed for each payment adjustment year
2) Hardship exception application for 2015 reporting period (to avoid 2017 payment adjustments) not yet released
3) Cannot use old hardship applications from previous years
Hardship Applications
Online tool to help determine a provider’s year and stage of Meaningful Use
http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Participation-Timeline.html
EHR Participation Timeline
Started 2011
2015 MU Attestation• Stage 2• Full calendar
year• $1,960
incentive• Avoids 2017
payment adjustment
Started 20122015 MU Attestation• Stage 2• Full calendar
year• $3,920
incentive• Avoids 2017
payment adjustment
Started 2013In 2015 MU Attestation• Stage 2• Full calendar
year• $7,840
incentive• Avoids 2017
payment adjustment
Started 20142015 MU Attestation• Stage 1• Full calendar
year• $7,840
incentive• Avoids 2017
payment adjustment
MedicareWhat stage am I in?
*Stages shown are not reflective of providers who have skipped program years.
Stay Tuned for Changes!
AIU 2012
2015 MU Attestation• Stage 2• Full calendar year• $8,500 incentive• Avoids 2017
payment adjustment for Medicare Part B claims
AIU 2013
2015 MU Attestation• Stage 1• Full calendar year• $8,500 incentive• Avoids 2017
payment adjustment for Medicare Part B claims
AIU 2014
2015 MU Attestation• Stage 1• Any 90 days• $8,500 incentive• Avoids 2017
payment adjustment for Medicare Part B claims
MedicaidWhat stage am I in?
*Stages shown are not reflective of providers who have skipped program years.
Stay Tuned for Changes!
1) Are provider claims already subject to payment adjustment in 2015?
2) What stage should I be working on in 2015?3) Does staff know if your reporting period has
already started?4) Does staff know how to utilize technology
(EHR and patient portal) in a way that counts for meaningful use reports?
Questions to ask now!
Physician Quality Reporting System Program
1) Individual Eligible Professionals (EPs) and group practices that do not satisfactorily participate and report in the 2015 PQRS program year will be subject to a 2% penalty downward payment adjustment in 2017
2) Penalty applied to all of the EP’s Part B covered professional services under Medicare Physician Fee Schedule (MPFS) during the payment adjustment year
3) EPs are identified by their individual national provider identifier (NPI) and tax identification number (TIN)
Payment Adjustments
PQRS Performance Year
PQRS Payment Year
Negative Adjustment Rate
2013 2015 -1.5%
2014 2016 -2.0%
2015 2017 -2.0%
Reporting Methods
• Select measures and begin reporting by submitting Quality Data Codes on claimsClaims
• Entity that collects clinical data from an EP or Group and submits to CMS on behalf of the EP/Group. Refer to the 2015 Participating Registry Vendors
Qualified Registry
• EP generates files from their EHR – EP uploads to CMS at year endEHR-Direct
• Data electronically shared with DSV – DSV uploads to CMS at year end
EHR-Data Submission Vendor
• CMS approved entity that collects & submits data on behalf of EP-refer to 2015 Participating Qualified Clinical Data Registry
Qualified Clinical Data Registry (QCDR)
• Secured internet-based application available in the PQRS portal to pre-registered usersGPRO Web Interface
• Supplemental to other reporting mechanismsCAHPS – Certified Survey Vendor
Individual Reporting
• EHR Direct Product that is Certified Electronic Health Record Technology (CEHRT)
• EHR Data Submission Vendor that is CEHRT
• Qualified PQRS registry• Qualified Clinical Data
Registry (QCDR)• Medicare Part B Claims
Group Reporting
• EHR Direct Product that is CEHRT
• EHR Data Submission Vendor that is CEHRT
• Qualified PQRS registry• GPRO Web Interface (25+
providers)• Consumer Assessment of
Healthcare Providers and Systems (CAHPS) survey for PQRS-supplemental to other reporting mechanisms
Individual or Group Reporting
GPRO Registration1) Three GPRO group sizes:
a. 100 + EPsb. 25 – 99 EPsc. 2 – 24 EPs
2) Reporting mechanisms & requirements vary depending on the group size at time of registration
3) The reporting mechanism selected during registration will be the only PQRS submission method available to the group and all individual NPIs that bill Medicare under the group’s TIN for PQRS during the reporting year
Group Practice Reporting
Consider important factors when selecting 2015 PQRS measures for reporting:
1. Clinical conditions usually treated2. Types of care typically provided, e.g. preventive,
chronic, acute3. Settings where care is usually delivered, e.g.
office, ED, surgical suite4. Quality Improvement goals for 20155. Other quality reporting programs in use or being
considered6. Review specifications for the selected reporting
option for each measure under consideration
Measure Selection
Review the 2015 PQRS Measures List available in the Measure Codes section of the CMS-PQRS website
1. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
2. Not all measures are available under each PQRS reporting option
3. The GPRO Web interface reporting option has set measures, all of which must be reported
4. Avoid individual measures that do not or may infrequently apply to the services provided
5. PQRS measure set and resulting measure specifications change from year to year
Measure Selection
1) New - 2015 Cross-Cutting Measures Requirement:a. Applies to PQRS
claims and registry reporting options
b. EPs and groups are required to report one cross-cutting measure if they have at least one Medicare patient face-to-face encounter
PQRS Measure #
Cross-Cutting Measure Title
321 CAHPS for PQRS Clinician/Group Survey047 Care Plan
240 Childhood Immunization Status
374Closing the Referral Loop Receipt of Specialist Report
236 Controlling High Blood Pressure001 Diabetes: Hemoglobin A1c Poor Control
130Documentation of Current Medications in the Medical Record
318 Falls: Screening for Fall Risk
182 Functional Outcome Assessment
400Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
046 Medication Reconciliation131 Pain Assessment & Follow-Up
111 Pneumonia Vaccination Status for Older Adults
110Preventative Care & Screening: Influenza Immunization
128Preventive Care & Screening: BMI Screening and Follow-Up Plan
134Preventive Care & Screening: Screening for Clinical Depression & Follow-Up Plan
317Preventive Care & Screening: Screening for High Blood Pressure & Follow-Up Documented
226Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention
402Tobacco Use and Help with Quitting Among Adolescents
Measure Selection
1) 2015 PQRS Implementation Guidea. Provides guidance about how to select measures for
reporting, how to read and understand a measure specification, and outlines the various reporting methods available for 2015 PQRS
b. Details how to implement claims-based reporting of measures to facilitate satisfactory reporting of Quality-Data Codes (QDCs) by EPs
c. Provides decision trees to assist EPs with selecting reporting method
2) 2015 PQRS Measures Lista. Identifies & describes the measures used in PQRS, including
all available reporting methods, PQRS & National Quality Forum (NQF) numbers, National Quality Strategy (NQS) domains, & measure developers
Both resources are available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
Measures & Reporting Resources
1) Satisfactory Claim and Registry-Based Reportinga. Report each measure for at least 50% of the Medicare
Part B FFS patients seen during the reporting period to which the measure applies
b. Report at least 9 measures covering 3 NQS domainsc. Measures with a 0% performance rate would not be
counted2) Measure Applicability Validation (MAV) Process
a. Claims-based MAV: applies to EPs reporting less than 9 measures OR 9 or more measures with less than 3 domains
b. Registry-based MAV: applies to EPs and group practices reporting less than 9 measures OR 9 or more measures with less than 3 domains
Measure Applicability Validation
Value-Based Payment Modifier
1) Aligned with and is based on participation in PQRS2) Assesses both quality of care furnished and the cost of that
care under the Medicare Physician Fee Schedule (PFS)3) Payment adjustment made on a per claim basis to Medicare
payments for items & services furnished 4) Applied at TIN level & applies to all physicians billing under
that TIN5) Phased in:
Value-Based Payment Modifier
Performance Year
VM Payment Adjustment Year
Group Size Affected EPs affected by penalty
CY 2013 CY 2015 Physician Groups ~ 100+ EPs Physician EPs
CY 2014 CY 2016 Physician Groups ~ 10+ EPs Physician EPs
CY 2015 CY 2017 Physician Groups & Solo Practices ~ 2+ EPs
Physician EPs
CY 2016 CY 2018 Physician Groups & Solo Practices ~ 2+ EPs
Physician and Non-Physician EPs
The quality measurement component of the Value Modifier includes three outcome measures that CMS calculates from FFS Medicare claims:1) two composite measures of hospital admissions
for ambulatory care-sensitive conditions a. acute conditions (bacterial pneumonia, urinary
tract infection, dehydration)b. chronic conditions (chronic obstructive
pulmonary disease, heart failure, diabetes)2) one measure of 30-day all-cause hospital
readmissions.3) CAHPS surveys required in some cases
Value Modifier Outcome Measures
The cost measures include:1) Total per capita costs measure (annual payment
standardized and risk-adjusted Part A and Part B costs)
2) Total per capita costs for beneficiaries with four chronic
conditions (chronic obstructive pulmonary disease, heart failure, coronary artery disease, diabetes)3) Medicare spending per beneficiary for all A and B
costs during the 3 days before and 30 days after a Medicare inpatient hospital stay
Value Modifier Cost Measures
Groups of 2-9 Eligible Professionals and Solo Practitioners
PQRS/Value-Based Payment Modifier: What Medicare Professionals Need to Know in 2015 5/18/2015
https://www.youtube.com/watch?v=Ww0oH-FhaYM
Incentives and Payment Adjustments: VM2017 Calculation
30
Cost/Quality Low QualityAverage Quality
High Quality
Low Cost +0.0% +1.0x +2.0x
Average Cost +0.0% +0.0% +1.0x
High Cost +0.0% +0.0% +.0.0%
Groups of 10 or More Eligible Professionals
PQRS/Value-Based Payment Modifier: What Medicare Professionals Need to Know in 2015 5/18/2015 https://www.youtube.com/watch?v=Ww0oH-FhaYM
Incentives and Payment Adjustments: VM2017 Calculation
31
Cost/Quality Low QualityAverage Quality
High Quality
Low Cost +0.0% +2.0x +4.0x
Average Cost -2.0% +0.0% +2.0x
High Cost -4.0% -2.0% +0.0%
1) QRUR - annual reports that provide physicians and physician groups with:a. Comparative information about the quality of care
furnished and the cost of that care to the practice’s Medicare FFS patients – based on PQRS and claims data
b. Beneficiary-specific information to help coordinate and improve the quality and efficiency of care furnished
c. Displays your performance related to the CMS Value-Based Payment Modifier - Value Modifier (VM) program
2) Access report via CMS secure portal - must first sign up for IACS account. Instructions at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html
Quality & Resource Use Report
Summary Incentives and Payment Adjustments
Eligibility for All ProgramsPQRS Value Modifier EHR Incentive Program
Eligible for Incentive
Subject to Payment
Adjustment
Included in Definition of
"Group"Subject to VM
Eligible for Medicare Incentives
Eligible for Medicaid Incentive
Subject to Medicare Payment
Adjustment
Medicare PhysiciansDoctor of Medicine X X X X X X XDoctor of Osteopathy X X X X X X XDoctor of Podiatric Medicine X X X X X XDoctor of Optometry X X X X X XDoctor of Oral Surgery X X X X X X XDoctor of Dental Medicine X X X X X X XDoctor of Chiropractic X X X X X XPractitionersPhysician Assistant X X X X Nurse Practitioner X X X X Clinical Nurse Specialist X X X Certified RN Anesthestist X X X Certified Nurse Midwife X X X X Clinical Social Worker X X X Clinical Psychologist X X X Registered Dietician X X X Nutrition Professional X X X Audiologists X X X TherapistsPhysical X X X Occupational X X X Qualified Speech-Language X X X
1) Incentives for Meaningful Use end in 20152) Medicare eligible professionals who do not
meet the requirements for meaningful use by 2015 and in each subsequent year are subject to payment adjustments to their Medicare reimbursements that start at 1% per year, up to a maximum 5% annual adjustment.
Incentives and Payment Adjustments: MU
35
1) Phased-in approach 2) Two year look back period3) By 2017, all solo practitioners and eligible
professionals in groups of any size will be subject to a 2% downward adjustment if they do not report PQRS data for 2015
4) Failure to report PQRS data automatically results in a downward adjustment in the value modifier for physicians for 2017 in groups with 10 or more eligible professionals
5) Solo practitioners and groups of 2-9 eligible professionals who report PQRS data in 2015 will only receive a neutral or upward adjustment in the value modifier in 2017, since 2015 is their first performance year
Incentives and Payment Adjustments: PQRS
1) Phased-in approach2) Groups of 100 or more eligible professionals are subject to
an upward, neutral or downward adjustment in 2015 based upon performance year 2013
3) Groups of 10 or more eligible professionals are subject to an upward, neutral or downward adjustment in 2016 based upon performance year 2014
4) Solo practitioners and groups of 2-9 are only subject to a neutral or upward adjustment in 2017, since 2015 is their first performance year
5) In any size group, failure to report PQRS will result in an automatic downward adjustment in PQRS and the Value Modifier in 2017 based upon performance year 2015
Incentives and Payment Adjustments: VM
37
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Based on this example: For every $100,000 in Medicare funds, your practice risks losing up to $9,000 in payment adjustments.****Calculation is based on estimate for the 2017 payment year.
The Value Modifier adjustment is dependent upon group size
Payment Adjustment ExamplePerformance Year 2015, Payment Adjustment Year 2017
Meaningful Use
-3%
PQRS
-2%
Value Modifier
-4%
-9% Payment
Adjustment
1) QualityNet Help Desk: a. 866-288-8912 or [email protected] 8:00 am – 8:00 pm EST M-F
b. IACS registration questions
c. IACS login issues
d. PQRS portal password issues
e. PQRS feedback report availability and access
f. PQRS Program questions
2) VM Help Desk:a. 888-734-6433 ~ option 3 or [email protected]
b. Value-Based Payment Modifier Program questions
3) EHR Incentive Program Information Center:a. 888-734-6433 or [email protected]
b. EHR Incentive Program (Meaningful Use)
Help Desk Resources
Stay Connected
Connect with us for the latest, up-to-date information.
@MD_VAQIN www.qin.vhqc.org
Questions
Contact VHQC
Jennifer Chenault-Walker
Manager, Program Operations
804.289.5334
Sandra Gaskins
Improvement Consultant
QIN QIO
804.289.5346
This material was prepared by VHQC, the Medicare Quality Innovation Network Quality Improvement Organization for Maryland and Virginia,
under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
The contents presented do not necessarily reflect CMS policy. VHQC/11SOW/6/17/2015/2177