PQRS: An Overview of the Physician Quality Reporting

System Don Gettinger, BS, CHTS-IM

Conflict of Interest Disclosures

No Conflicts to Disclose

What is PQRS?

o PQRS is a Medicare program that provides an incentive payment to eligible providers (EPs) who voluntarily report specific clinical quality measures (CQMs) for their qualifying Medicare patients.

o Providers who successfully report data can earn an additional 0.5 % of their total allowable Medicare charges in and 2014.

o In 2016, payment adjustments will be made to providers who choose not to report. This adjustment will be based upon participation in 2014.

Who is Eligible?

Eligible & Able to Participate

Medicare Physicians – • Doctor of Medicine (MD)• Doctor of Osteopathy (DO)• Doctor of Podiatric

Medicine (DPM)• Doctor of Dental Medicine

(DMD)• Doctor of Chiropractic

(DC)

Practitioners – • Physician Assistant (PA)• Nurse Practitioner (NP)• Registered Dietician (RD)• Clinical Social Worker

(CSW)

Therapists – • Physical Therapist (PT)• Occupational Therapist

(OT)• Qualified Speech Therapist

Who is Eligible?

Eligible BUT not able to Participate

Professionals paid under or based upon PFS billing Medicare Carriers/Medicare Administrative Contractors (MACs) who do not bill directly.

Federally Qualified Health Clinics (FQHCs), Rural Health Clinics (RHCs), ambulatory surgery center facilities

Significant Changes for 2014 Reporting

• Last year to receive incentive and avoid 2016 payment adjustment

• Must report nine measures representing three of the six National Quality Strategy domains

• Killing three birds with one stone, PQRS reporting can satisfy requirements for Stage 2 Meaningful Use Clinical Quality Measures (CQMs) and for the 2014 Value-based Modifier

• New reporting methods added

How is the data reported?

o To successfully report and receive the incentive, providers must select and submit at least nine measures.

o Submission of measures can be through claims, registry, a certified EHR or data submission vendor*, or a qualified clinical data registry*.

o Eligible providers may report measures as individual providers or as a group practice (GPRO).

*These methods align with Meaningful Use

Reporting Methods

Claims-Based Reporting Individual EPs only Report on 9 measures across at least three NQS

domains Must report on at least 50% of applicable Medicare

part B fee for service (FFS) patients

Reporting Methods

Registry-Based Reporting Individual or Group Report on 9 measures across at least three NQS

domains Must report on at least 50% of applicable Medicare

part B fee for service (FFS) patients

Reporting Methods

EHR-Based reporting Certified Direct EHR-Based Product or Certified Data

Submission Vendor Individual or Group Report on 9 measures across at least three NQS

domains

Reporting Methods

Qualified Clinical Data Registry-Based Individual EPs only Report on 9 measures across at least three NQS

domains Must report on at least 50% of applicable Medicare

part B fee for service (FFS) patients

The list of QCDRs should be available on the CMS PQRS website by the end of May, 2014

Reporting Methods

Additional Group Reporting methods To Report using the Group Practice Reporting Option

(GPRO) you must register your intent with CMS by September 30, 2014

GPRO Web Interface Must have 25 or more eligible professionals Report on assigned patient sample

Certified Survey Vendor (CG-CHAPS) Optional for groups of 25-99 EPs Required for groups of 100+ EPs

PQRS

EHR INCENTIVE PROGRAM

VALUE-BASED MODIFIER

Reporting Alignment

Step 1 - Am I an eligible professional for both programs?

Check eligibility for the Meaningful Use program http://cms.gov/apps/ehealth-eligibility/ehealth-

eligibility-assessment-tool.aspxCheck eligibility for the PQRS program

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf

MedicareMedicaid

MDDODentists and Oral

SurgeonsPodiatristsOptometristsChiropractors

MDDONPCertified Nurse-MidwifeDentistsPhysician assistant (PA)

who furnishes services in a Federally Qualified Health Center of Rural Health Clinic that is led by a physician assistant

Eligible Providers Meaningful Use

Eligible Providers PQRS & VM

Doctor of MedicineDoctor of OsteopathyDoctor of Podiatric

MedicineDoctor of OptometryDoctor of Oral SurgeryDoctor of Dental

MedicineDoctor of Chiropractic

Nurse PractitionerCertified Nurse MidwifePhysician Assistant

Clinical Nurse SpecialistCertified Registered

Nurse Anesthetist (and Anesthesiologist Assistant)

Clinical Social WorkerClinical PsychologistRegistered DieticianNutrition ProfessionalAudiologistsPhysical TherapistOccupational TherapistQualified Speech-

Language Therapist

MU and PQRS Alignment

9 Clinical Quality Measures that cover at least 3 of the 6 Nation Quality Strategy (NQS) Domains Patient and Family Engagement Patient Safety Care Coordination Population/Public health Efficient Use of Healthcare Resources Clinical Process/Effectiveness

PQRS EHR Based Reporting

Qualified Clinical Data Registry

Submit PQRS measures data directly through the certified electronic health record technology (CEHRT)

Submit PQRS quality measure data extracted from their CEHRT to a qualified EHR Data Submission Vendor

New for 2014The data submitted

to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries.

Choose Reporting Option

Option A Option B

EPs in an ACO (Medicare Shared Savings Program or Pioneer ACO) who satisfy requirements of the Medicare Shared Savings Program using Certified EHR Technology

EPs who satisfy the requirements of PQRS GPRO option using Certified EHR Technology

Group Reporting (GPRO)

Value-based Modifier

Cost data and Quality measures includedPer-claim adjustment Applied at the Group LevelCY 2015 – CMS will apply the VM to groups of

physicians with 100 or more eligible professionals (EPs) based on 2013 performance.

CY 2016 - CMS will apply the VM to groups of physicians with 10 or more EPs based on 2014 performance.

CMS is required to apply the VM to all physicians and groups of physicians starting in 2017.

PQRS Reporters Non-PQRS Reporters

Groups with 10-99 EPs Upward or no VM

based on quality tiering

Groups with 100+ Eps Upward, neutral, or

downward VM based on quality tiering

-2.0% (Automatic VM downward adjustment)

Separate from the PQRS payment adjustment and payment adjustments from other Medicare sponsored programs.

Value-based Modifier

Value-based Modifier

Low QualityAverage Quality

High Quality

Low Cost 0.0% +1.0x%* +2.0x%*

Average Cost-0.5% 0.0% +1.0x%*

High Cost -1.0% -0.5% 0.0%

"x” refers to a payment adjustment factor yet to be determined * higher performing groups serving high-risk beneficiaries (based on average risk scores) are eligible for an additional adjustment of +1.0x%

Why CQMs?

Clinical Quality Measures support achievement of health care goals (Triple Aim) Better Health Better Health Care Lower Cost

Selecting CQMs To Report

3 questions to ask about your practice settingAre there any existing quality

improvement efforts in place?What is the patient population

served?What is my EHR capable of

reporting?

Examples of Measures for Each Domain

• Patient and Family Engagemento PQRS # 377 -Functional Status Assessment for

Complex Chronic Conditionso Percentage of patients aged 65 years and older with

heart failure who completed initial and follow-up patient-reported functional status assessments

Examples of Measures for Each Domain

• Patient Safetyo PQRS # 130 -Documentation of Current Medications in the

Medical Recordo Percentage of visits for patients aged 18 years and older for which

the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

Examples of Measures for Each Domain

• Care Coordinationo PQRS # 374 - Closing the Referral Loop: Receipt of

Specialist Reporto Percentage of patients with referrals, regardless of

age, for which the referring provider receives a report from the provider to whom the patient was referred

Examples of Measures for Each Domain

• Population/Public Healtho PQRS # 226 - Preventive Care and Screening:

Tobacco Use: Screening and Cessation Interventiono Percentage of patients aged 18 years and older who

were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Examples of Measures for Each Domain

• Efficient Use of Healthcare Resourceso PQRS # 312 -Use of Imaging Studies for Low Back

Paino Percentage of patients 18-50 years of age with a

diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis

Examples of Measures for Each Domain

• Clinical Process/Effectivenesso PQRS # 236 - Controlling High Blood Pressureo Percentage of patients 18-85 years of age who had a

diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90mmHg) during the measurement period

Resources

PQRS reporting options and measures www.cms.gov/pqrs

Value-based Modifier information http://

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/index.html

EHR Incentive Program www.cms.gov/ehrincentiveprograms

Institute for Healthcare Improvement http://

www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

Questions?

Don Gettinger, BS, Program Manager812.234-1499 x336dgettinger@inqio.sdps.org

Stacy Colson, RN Clinical Advisor812.234-1499 x314scolson@inqio.sdps.org

Health Care ExcelPopulation Health Team