In this presentation I’ve included hyperlinks to all sorts of resources. So when you get the slide deck and want to drill down into an area of interest you have the resources at your fingertips.
Objectives • Intro to PQRS • Ways to avoid disincentives on PQRS in 2013 • Timeline for incentives/ disincentives (e-
prescribing/ Meaningful Use/ PQRS • Future basis for value based purchasing • PQRS overview and how to report • Meaningful Use quality measures overlap
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Intro to PQRS – I’m not a CMS employee….explain background. I gave a presentation in November on PQRS and this webinar is a follow up with what is new in the program at the front end. I’m still going to go over the back end which is about reporting. You will not offend me if when we get to the ways to report section of this webinar and you would like to jump off the call. REVIEW THE OBJECTIVES I’m going to talk about how to avoid the disincentives on PQRS in 2013 at the beginning. How to report? Will be a big focus for this presentation. There are various avenues to be able to report.
2012 2013 2014 2015 2016 2017 2018 2019 2020
Programs Requiring Provider Reporting for Participation or by Law
Federal
House Bill 128 begins reporting clinic-level
measure results (currently based on
claims data for clinics with five or more
physicians)2
Accountable Care
Organization Formation (Shared
Savings)9,10$$ Continued E-
Prescribing7
$$ (initial penalties)
Meaningful
Use Stage 2$6
Meaningful
Use Stage 36,11$$
Utah Health Insurance Exchange4
Utah Medicaid Accountable Care
Organization3
$=incentive payments $=penalties ---future
Utah
Meaningful
Use Stage 4 (TBD)11
House Bill 128 adds 5 new measures
yearly2
Continued Meaningful
Use Stage 1$6
Continued
PQRS5$
PQRS5 $$
(initial penalties – penalty assessed in 2015 for 2013
reporting)
Meaningful
Use Stage 26,11$$
(initial penalties)
CMS Value Based Purchasing
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Put together by our Medical Director Dr. Woolsey. Explain Slide
These are just some links from the previous slide for reference purposes. Selecthealth at the top is one of the major insurers in Utah and it is starting to publish quality statistics and consumer satisfaction scores for clinics. Medicare has just announced that they have plans in the future to create a “physician compare” website will be available. Transparency efforts are continuing and growing.
• Have any other insurance companies, other than Medicare, that you interact with begun pay for quality programs?
• Yes • No
What is PQRS?
• The Physician Quality Reporting System – Pay-for-reporting program established in 2007 – Combination of incentives and payment
adjustments (dis-incentives) to eligible professionals and selected group practices
– Designed to promote reporting of quality information – feedback reports
• The Physician Quality Reporting System is the basis for the Value-Based Modifier
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The Institute of Medicine (the IOM) came out with a report about waste in healthcare in November 2012 and encouraged an acceleration of new payment models in healthcare. Medicare is not the only insurer making these changes. LOOK FOR THE QUALITY reports – this is the silver liner The Value-Based payment Modifier (VPPM) is a budget-neutral payment modifier to the Medicare physician fee schedule that would affect reimbursement to physicians based on the relative quality and cost of care they furnish. It combines quality measures with a payment adjustment under the Medicare fee schedule. Medicare is not the only insurer going down this road. The main point here is that the sooner you start seeing your reports on the measures you choose the sooner the bugs of documentation, processes, etc. can be worked out to reflect the quality care given. Congress created PQRS, and physicians first reported quality measures on claims for Medicare services in 2007. Doctors and other health professionals have earned millions in bonuses from the program, but in 2015 the incentives will be replaced with penalties for physicians who don't report. The 2015 penalty will be based on PQRS participation in 2013. So if an eligible physician does not report at least one PQRS measure, the minimum threshold for participation this year, his or her pay rates will be cut by 1.5% in two years' time.
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So how are we doing as a country and in Utah? Article in the American Medical News Medicare physician quality reporting: Tale of the tape By Charles Fiegl amednews staff— Posted July 15, 2013 CMS 2011 Reporting Experience report. About 641,000 physicians were eligible for the PQRS program, but only 205,000 went through the process to submit quality data for any measure encounter with a patient in 2011. Of those physicians, only 168,000 met the minimum criteria to earn bonuses, which averaged about $1,260. Oncologists had the highest average bonuses at more than $6,000 and pediatrics had the lowest average bonuses at a couple of hundred dollars. (obviously Pediatrician have a small Medicare population and the incentives are based on gross Medicare claims) Specialists struggle to some degree to find measures – they are growing. The different national specialty groups are working to find and develop new measures for their groups. There are lots of measures for primary care. The highest specialists participation in 2011 was emergency medicine, pathology, and anesthesiology (between 55 and 70% participation in) PCPs were around 30%. The lowest was psychiatry at 3%. Physicians in small states also lag when it comes to participating in PQRS. Four of the five states with the lowest rates of participation also are the least populated. The AMA perspective – alignment of the different programs “Further aligning reporting requirements across and within the multiple federal performance programs will help improve patient access to care and minimize the aggregate financial and administrative blows to physician practices as they grapple with rising practice costs” the AMA stated in a June 14 letter to Dept. of Health and Human Services Secretary Kathleen Sebelius.
Who Can Participate?
• Medicare Eligible Professionals (EPs) include physicians, practitioners, and therapists
• For details on participants see http://www.cms.gov/PQRS/Downloads/EligibleProfessionals.pdf
• Professionals must meet the minimum number or percentage of Medicare Part B Fee-for-Service patients for the measures they choose
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Medicare Eligible Professionals (EPs) include physicians, practitioners, and therapists For details on participants see http://www.cms.gov/PQRS/Downloads/EligibleProfessionals.pdf – This is the official website to determine eligibility. Professionals must meet the minimum number or percentage of Medicare Part B Fee-for-Service patients for the measures they choose
Penalties are two years later….so for calendar year 2012….you will be dinged in 2014 2013 is a critical year for Medicare eligible professionals for these three programs – CMS adopted the concept of a “two-year look back period” for payment adjustments CQMs and PQRS measures are mandated to merge. Did you report the eRx measure’s numerator code at least 25 times in 2013? Group 25-99: 625 times Group 100+: 2500 times
PQRS Program Progression
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Highlight increases in measures and different reporting oprionts 2013 – 264 measures with 26 measure groups
Poll
Have you reported on PQRS in past years by any method? – Claims method? – EHR – Direct? – EHR – Data Submission Vendor ? – External Registry ? – GPRO ?
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Have you reported on PQRS in past years by any method? Claims method? EHR – Direct? EHR – Data Submission Vendor ? External Registry ? GPRO ?
Incentives and Payment Adjustments
• Federal legislation authorized incentive payments through 2014
• Payment Adjustments (Dis-incentives) are proposed for 2015 and beyond (-1.5% in 2015 and -2.0% in 2016 and beyond). The 2015 dis-incentive is based on the 2013 calendar year. Report in 2013 to avoid dis-incentive!!!
• Additional incentive of 0.5% by working with a Maintenance of Certification entity
• 2013 - 0.5% incentive • 2014 - 0.5% incentive
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These incentives are based on a percentage of the providers gross Medicare claims. Speak to the slide.
3. Report one measure or one measures group for any Medicare patient (avoid penalty only).
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Speak to the slide 1.Report traditional PQRS for incentive. - emphasis this. 2.Elect to be analyzed under the administrative claims-based reporting mechanism (avoid penalty only). 3.Report one measure or one measures group for any Medicare patient (avoid penalty only).
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This is a CMS slide that gives a decision tree for Eligible professional on how to avoid the payment adjustment. - Ways of reporting in number one - Options 2 and 3 – no incentive payment involved. Groups participating through another CMS program (such as the Medicare Shared Savings Program) need to check the program’s requirements for information on how to simultaneously report under PQRS and the respective program and avoid the payment adjustment.
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Slide for group practices. Very similar.
Administrative Claims-Based Reporting (New)
• Quick way to avoid the 2015 penalty – New for 2013 – only for the adjustment purposes
• Elect to be analyzed under the administrative claims-based reporting mechanism
• Details on how to select this reporting option will be made available in 2013
• Pros: Little effort just sign up by Oct 2013. • Cons: No say in your data. Option for this year
only. No incentive payment.
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Unlike the traditional claims-based reporting option, an eligible professional or group practice would not be required to submit quality-data codes (QDCs) on claims to CMS for analysis. Rather, CMS will analyze every eligible professional’s or CMS-selected group practice’s patients’ Medicare claims to determine whether the eligible professional or group practice has performed any of the clinical quality actions indicated in the proposed PQRS quality measures. (table 63) ONLY available to use for reporting for the 2015 and 2016 PQRS payment adjustments Available for use by all eligible professionals and CMS-selected group practices using the GPRO Eligible professionals and group practices MUST elect to use this reporting mechanism
Instructions for registering for Administrative Claims
STEP 1: Registration for CMS IACS account and define role at https://applications.cms.hhs.gov/ STEP 2: Beginning July 15th, go to https://portal.cms.gov/ and select the PV PQRS option, near the bottom of the page to register. Closes October 15, 2013 For additional information, please go to http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html
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Elect to participate in the CMS-calculated administrative claims-based reporting mechanism July 15, 2013 through October 15, 2013 – The window for this process is currently open. Give warning about Roles and IACS STEP 1: Prior to signing up for your PQRS reporting mechanism, individuals will need to register for a CMS IACS account if they do not already have an IACS account, or add the appropriate IACS role if they already have an existing account Registration for IACS begins June 3, 2013 at https://applications.cms.hhs.gov/ STEP 2: Beginning July 15th, go to https://portal.cms.gov/ and select the PV PQRS option, near the bottom of the page to register For additional information, please go to http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html
Best snow on the earth. We have half a dozen ski resorts a half hour from Salt Lake
What is the Value Based Modifier
• Assesses quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule.
• Phase-in complete by 2017 • VM is based on participation in Physician
Quality Reporting System
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Speak to the slide •VM assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule. •Begin phase-in of VM in 2015, phase-in complete by 2017. •Implementation of the VM is based on participation in Physician Quality Reporting System •For CY 2015, we will apply the VM to groups of physicians with 100 or more eligible professionals (EPs).
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This is the decision tree version of explaining it •Each group receives two composite scores (quality of care; cost of care), based on the group’s standardized performance (e.g. how far away from the national mean) •This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers. *Eligible for an additional +1.0x if : −Reporting quality measures via the web based interface or registries AND −Average beneficiary risk score in the top 25% of all beneficiary risk scores
Quality-Tiering Approach
Two composite scores (quality of care; cost of care), based on the group’s standardized performance (e.g. how far away from the national mean).
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READ THESE NOTES •Each group receives two composite scores (quality of care; cost of care), based on the group’s standardized performance (e.g. how far away from the national mean). •This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers. This is the table version – The x in the table is the payment adjustment factor (x). In order to ensure budget neutrality the value of X will change based on how many providers fall in the high cost/low quality category. So for example if after determining the aggregate projected amount of the downward payment adjustments, CMS could calculate that the payment adjustment factor was 0.75% so those in the high quality low cost table would receive 2 * 0.75% or 1.5% The payment algorithm also accounts for treating high-risk beneficiaries. Beneficiary risk score will be weighed into this also. −Average beneficiary risk score in the top 25% of all beneficiary risk scores
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Timeline….phased in by 2017 for everyone.
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End of our value based modifier section. Moab – slick rock area for outdoor enthusiasts
Reporting • Five main methods to report PQRS measures:
– Claims Based Reporting – External Registry – EHR Data Submission Vendor Reporting – Direct EHR Based Reporting – Group Practice Reporting Option
• Validation steps required with all methods • Six- (Jul-Dec) or 12- (Jan-Dec) month time
periods are used based on reporting method
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I highlighted these two because Medicare is really making a push to encourage providers to report in these two methods for various reasons.
Method #1 – Claims Based Reporting (Individual EP)
• CPT and G-Codes are added to Medicare claims that include clinical information on a subset of patients
• Medicare does the measure calculation and sends a feedback report and incentive check annually
• Providers must report on at least 3 measures of over 250
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Oldest way of reporting. Some clinics make this work really well If your just getting going in PQRS probably not the best option unless it is your only option. Report at least 3 measures, OR, if less than 3 measures apply to the eligible professional, report 1-2 measures*; AND report each measure for at least 50 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate will not be counted. *Subject to the Measure-Applicability Validation (MAV) process. Claims based reporting – CPT and G-Codes are added to Medicare claims that include clinical information on a subset of patients. Medicare does the measure calculation and sends a feedback report and incentive check annually?. EPs must report on at least 3 measures.
• Provider submits data on 3 measures electronically to a registry.
• The external certified registry then captures, stores, calculates, and submits to Medicare the measure related data.
• Registries must be certified with Medicare and starting in 2012 cannot be EHR vendor.
• Select from over 250 measures.
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This was the second way of reporting. Numbers of measures have grown substantially. Popular with providers and clinics Cost involved Certified Registry - the EP submits data on three measures electronically to a registry. The certified registry then captures, stores, calculates, and submits to Medicare the measure related data. Registries must be certified with Medicare. Report at least 3 measures, AND report each measure for at least 80 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate will not be counted. Registry-based reporting of at least three PQRS measures for 80% or more of the applicable Medicare Part B FFS patients Registry-based reporting of at least one measures group for 30 or more applicable Medicare Part B FFS patients Registry-based reporting of at least one measures group for 80% or more of applicable Medicare Part B FFS patients (with a minimum of 15 patients) To report PQRS data for services furnished July 1 through December 31, 2012 use the following option: Registry-based reporting of one measures group for 80% or more of applicable Medicare Part B FFS patients (with a minimum of 8 patients) Certified Registry - the EP submits data on three measures electronically to a registry. The certified registry then captures, stores, calculates, and submits to Medicare the measure related data. Registries must be certified with Medicare.
Method #3 – EHR Data Submission Vendor Reporting (Individual EP)
• New in 2012 • Similar to registry reporting only done by EHR
vendor • The vendor captures, stores, calculates, and
submits to Medicare the measure related data
• Select from over 50 measures • Report on 80% of applicable Medicare Part B
FFs patients
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-Medicare is really promoting the EHR based reporting. Which are methods 3 and 4. -Cost involved with DSV reporting An EHR data submission vendor (DSV) is a vendor that collects an eligible professional’s clinical quality data (at least the numerator data) directly from the eligible professional’s EHR. DSVs will be responsible for submitting Physician Quality Reporting System measures data from an Eligible Professional’s EHR system to CMS in a CMS-specified format(s) on behalf of the eligible professional for the respective program year. EHR-based reporting (Direct EHR or Data Submission Vendor) of at least three PQRS measures for 80% or more of the applicable Medicare Part B FFs patients Beginning in 2014: All direct EHR products and EHR data submission vendor’s products must be certified by the Office of the National Coordinator as CEHRT.
Not going to spend time on this slide but this decision tree talks about based on where your data is coming from what type of PQRS reporting should be done (EHR direct, DSV, Registry) – slide from 2012
PQRS Data Submission Vendor and
Registry in Utah – Central Utah Informatics
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There is entities similar to this throughout Utah.
Method #4 – Direct EHR Based Reporting (Individual EP)
• Provider chooses 3 measures to report • Provider must be using a qualified EHR to
report to Medicare patient level data • Report on 80% of applicable Medicare Part B
FFs patients • List of qualified EHR products is published on
the Medicare website
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Highlight – Aprima, Vitera, and e-MDs Beginning in 2014: ◊ All direct EHR products and EHR data submission vendor’s products must be certified by the Office of the National Coordinator as CEHRT. ◊ Expand use of the EHR-based reporting mechanism to group practices participating in the GPRO Qualified electronic health record (EHR) product – The EP chooses three measures to report on. The EP must be using a qualified EHR to report to CMS data patient level data. CMS calculates measure level reports for the provider. The provider gets a report and incentive after completing the process. A list of qualified EHR products for 2011 can be found here.
• MCMP was a Medicare pilot for four years in states of UT, AR, MA, CA from 2007-2011
• Combination of claims and clinical data • Participants received a free waiver on PQRS • The GPRO option is very similar to MCMP.
GPRO uses the same software tool as MCMP. • More measures in GPRO than there were in
MCMP.
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Speak to the slide
Method #5 – Group Practice Reporting Option (GPRO)
• Began in 2010 • “Group Practice” – one TIN with 2 or more
NPIs • Web Interface option involves claims and
clinical data on a larger measure set • New Registry option (3 measures) in 2013
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Speak to the slide
GPRO • Groups with 2-24 Eligible Professionals – New
Registry option only
• Groups with 25-99 Eligible Professionals – Registry or Web Interface option
• Groups with 100+ Eligible Professionals – Registry or Web Interface (higher number of patients to report on)
GPRO Benefits of Participating as a Group Practice:
• Centralized reporting, reduced need to track individual providers efforts
• Incentive-eligible groups will receive a larger incentive because it is based on the TIN-level
• Individual providers who have difficulty with reporting requirement for individuals will be eligible
GPRO
Web Interface option • Claims databases compiled by Medicare
and sent to clinic. The database is then completed either electronically or manually and sent back to Medicare. Once a year.
• Software Similar to MCMP P4P pilot which ended 2011
How to sign-up for 2013 PQRS GPRO? • Self-nominate via the Communication
Support Page (Portal) between December 1, 2012–January 31, 2013
• The second timeframe to elect to report as a PQRS GPRO is right now summer 2013–to October 15 2013.
GPRO
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Practices 25-99
GPRO – Registry (New) • Registry Reporting – A registry is an entity
that captures and stores clinically related data and submits on behalf of providers. Must find a suitable registry.
• Pros: May be seamless to the provider and retrospective data collection possible
• Cons: Availability and may have associated cost
• Report on 3 measures at a minimum (from the larger set) on 80% of patients
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Speak to the slide
Meaningful Use Quality Measures/PQRS pilot program
• EHR-based reporting (Alignment with Medicare EHR Incentive Program) of all three Medicare EHR Incentive Program core measures OR up to 3 Medicare EHR Incentive Program alternate core measures AND 3 additional measures for the Medicare EHR Incentive Program
• Pilot at this Stage – will be implemented 2014
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Speak to the slide
PQRS Summary
• 5 Different Ways to Report • Get involved to avoid dis-incentives and
prepare for value-based purchasing • Contact your EHR vendor to find out which
options they have available • Contact the QualityNet helpdesk • GET STARTED!!
Salt Lake City – downtown (lone peak in the background)
Q&As
This material was prepared by HealthInsight, the Medicare Quality Improvement Organization for Nevada and Utah, 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
