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PQRS 101: Meeting Requirements, Avoiding Penalties

Raymond MarianoManager Small Group Sales

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Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at:http://downloads.cms.gov/files/TR2013.pdf;

Projected Medicare Fee-for-service Payment Cuts per the ACA

2014 2015 2016 2017 2018 2019 2020

Projected number of Medicare beneficiaries

54M 56M 57M 59M 61M 63M 64M

-14B -21B -25B -32B -42B -53B -64B

Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf

2018: 90% of Medicare

payments tied to quality.

2020: 75% of commercial plans will be value-based.

Jan 2015. http://www.hhs.gov/news/press/2015pres/01/20150126a.html

FFS versus FFV

Eliminates incentive to increase volume Eliminates incentive to provide high-cost services over equally effective low-cost servicesQuality-based incentives Shared risk Emphasizes the role of primary care providers Encourages coordination of care

Fees billed per units of serviceIncome maximized through volumeNo penalty for poor quality Providers lose money if they reduce unnecessary services

Volume

Driven Health

Care

Value Driven Health

Care Co

stQualit

y

Fee-for-service Value-based payments

Physician Quality Reporting System

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The Evolution of PQRS

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

74 measures

119 measures

119 measures

175 measures

198 measures

225 measures

260 measures

287 measure

s

+2.0% +1.0

% +0.5%

+0.5%

+0.5%

-1.5%-2.0%

BONUS PENALTY2016 participation affects penalty in

2018.

254 measure

s

280 measure

s

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PQRS Meaningful UseMEDICARE PHYSICIANSDoctor of Medicine X XDoctor of Osteopathy X XDoctor of Podiatric Medicine X XDoctor of Optometry X XDoctor of Oral Surgery X XDoctor of Dental Medicine X XDoctor of Chiropractic X XPRACTITIONERSPhysician Assistant XNurse Practitioner XClinical Nurse Specialist XCertified Registered Nurse Anesthetist XCertified Nurse Midwife XClinical Social Worker XClinical Psychologist XRegistered Dietician XNutrition Professional XAudiologists XTHERAPISTSPhysical Therapist XOccupational Therapist XQualified Speech-Language Therapist X

PQRS and MU eligible providers

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• Federally Qualified Health Centers (FQHCs)• Patient Centered Medical Homes (PCMH)• Hospitals• Independent Labs• Rural Health Clinics• Ambulance providers• Ambulatory Surgical Centers (ASCs)

Who is not eligible for PQRS?

In the Medicare EHR Incentive Program so providers demonstrate meaningful use of the capabilities of theirEHRs to achieve benchmarks.

1To calculate the 2018 Value Modifier based on quality of care and cost data to select those eligible for payment adjustments.2It will be publicly posted on the Physician Comparewebsite allowing patients and other practices to view performances of all.3

How is 2016 PQRS data used?

The Evolution of Meaningful Use

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Stage 1:Data capture and sharing

Stage 2:

Advanced processes

Stage 3:

Improved outcomes

In the Medicare EHR Incentive Program so providers demonstrate meaningful use of the capabilities of theirEHRs to achieve benchmarks.

1To calculate the 2018 Value Modifier based on quality of care and cost data to select those eligible for payment adjustments.2It will be publicly posted on the Physician Comparewebsite allowing patients and other practices to view performances of all.3

How is 2016 PQRS data used?

Value Modifier uses reported PQRS data to rate practices on cost & quality

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(above average) COST (below average)

QUAL

ITY

0% +2% +4% -2% 0% +2% -4% -2% 0%

Rewards and penalties are based on how practices perform relative to the nation

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(above average) COST (below average)

QUAL

ITY

In the Medicare EHR Incentive Program so providers demonstrate meaningful use of the capabilities of theirEHRs to achieve benchmarks.

1To calculate the 2018 Value Modifier based on quality of care and cost data to select those eligible for payment adjustments.2It will be publicly posted on the Physician Comparewebsite allowing patients and other practices to view performances of all.3

How is 2016 PQRS data used?

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PQRS and MU Program Comparison

PQRS versus MU Upcoming Medicare Penalties

Program 2016 2017 2018

Physician Quality Reporting System (PQRS)

-2% -2% -2%

Value Based Modifier Program (VM) -2%** -2%*** or

-4%**** -4%

Meaningful Use/EHR Incentive Program -2% -3% -4%

Penalty -6% -7% or-9%

At least-10%

* -2% in 2015 only applies to providers who failed Meaningful Use and eRx thresholds** -2% applies to practices with 100+ EPs only*** -2% is only for practices with 1-9 EPs**** -4% only applies to practices with 10+ EPs

20out of23

measures

MUPQRS

9out of280

measures

PQRS versus MU Reporting Measures

Report first.

Then, performance against your

peers.

Measure against

thresholds.

MUPQRS

PQRS versus MU Measurement style

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PQRS40%

MU30%

of eligible providers faced a payment reduction in 2015

for not reporting in 2013.

were penalized in 2015 for not

meeting requirements in 2013 and 2014.

National Penalty ResultsPQRS versus MU

2007PQRI starts

2011Meaningf

ul Use Stage 1

2014Meaningf

ul Use Stage 2

2019Start

MIPS or APM

2015Meaningf

ul Use penalties

begin

2015ICD-10

2015PQRS

penalties begin

2017VM

applies to all HCPs

2016VM applies to groups of 10 or

more EPs based on

2014 performan

ce

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MU PQRS VMMIPS2019

2022

Fully implemented with a much

greater range of adjustments

-4% penalty+12%

incentive

MIPS takes over and replaces

penalties from current programs

-9% penalty+27%

incentive

athenahealth’sFull Value Program

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PQRS Success with athenahealth

1 For enrollment, we look at our network data to determine the best 9 measures for each specialty.

2 Once enrolled, our rules engine tracks the performance of each HCP and adjusts enrollment based on performance.

3Our software provides real-time visibility into performance to ensure you are on track.

We navigate regulatory change so you don’t have to

Meaningful Use Stage 2 attestation

% of HCPs avoiding PQRS penalties in 2015

NATIONAL AVERAGE

33%ATHENAHEALTH

CLIENTS

98.2%NATIONAL AVERAGE

60%ATHENAHEALTH

CLIENTS

93.6%

Ask a few key questions ofyour EHR vendor

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Is your vendor able to deploy the 2016 Certified Edition to all clients at once?1How is your vendor monitoring your PQRS and MU performance?2Does the vendor provide MU/PQRS support and training as part of the regular pricing without additional fees?3Do they provide the required interfaces for free and without interruption? How many connections? When will they be available? 4

Thank You