CMS QCDR (Qualified Clinical Data Registry) and Other Ways PPRNet Can Help with Value-Based Payment

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1 CMS QCDR (Qualified Clinical Data Registry) and Other Ways PPRNet Can Help with Value-Based Payment Cara Litvin MD, MS Assistant Professor MUSC Department of Medicine

2 Agenda Provide an update of the current value-based payment landscape in the United States Discuss the future of value-based payment in the US Discuss how PPRNet can help you with valuebased payment now and in the future

3 Cost of U.S. Healthcare Expenditure per Capita 2011 (or nearest year)

4 Quality of U.S. Healthcare The U.S. has the highest rate of deaths amenable to health care Disease burden is higher Hospital admissions for preventable diseases are more frequent Higher rates of medical, medication and lab errors

5 Value-based payment? Strategy used by purchasers to promote quality and value of health care services Goal is to shift from pure volume-based payment to payments that are more closely related to outcomes

6 Transitioning away from fee-for-service Burwell, S: NEJM, March 15,2015 HHS Goals: 85% of all Medicare fee-for-service payments tied to quality or value by 2016 and 90% by % of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50% by the end of strategies: Incentives Improving the way care is delivered (attention to population health, coordination among provides) Accelerate the availability of information to guide decision making

7 Current Value-Based Payment Landscape PCMH MU PQRS VM ACOS

8 PCMH Update Patient-centered specialty practice 2014-New standards issued Increased focus on team-based care Identification of high-needs patients More sustained QI Integration of behavioral health Alignment with MU2

9 1: Enhance Access and Continuity A. *Patient-Centered Appointment Access B. 24/7 Access to Clinical Advice C. Electronic Access 2: Team-Based Care A. Continuity B. Medical Home Responsibilities C. Culturally and Linguistically Appropriate Services (CLAS) D. *The Practice Team 3: Population Health Management A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. *Use Data for Population Management E. Implement Evidence-Based Decision- Support NCQA PCMH 2014 Content and Scoring (6 standards/27 elements) Pts Pts Pts : Plan and Manage Care A. Identify Patients for Care Management B. *Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision-Making 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. *Referral Tracking and Follow-Up C. Coordinate Care Transitions 6: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. *Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology Pts Pts Pts Scoring Levels Level 1: points. Level 2: points. Level 3: points. *Must Pass Elements

10 How can PPRNet help you with PCMH? Apply PPRNet improvement model strategies (regular team meetings, standing orders, train team members to manage patient population and participate in QI activities) Use patient level reports for identifying patients needing services or who could benefit from care management

11 How can PPRNet help you with PCMH? Use practice level reports to Measure and Improve Performance: Must set goals, act to improve, and analyze at least 3 CQMs Must demonstrate improved performance on at least 2 CQMs Must report performance (individual and practice level)

12 Stage 3 MU (Proposed Rule) Single set of 8 objectives for EPs, EHs optional in 2017 and required by 2018 regardless of previous participation 1 year reporting period CQM reporting aligned with PQRS MU Update

13 MU Update Focus on interoperability and patient engagement EHR certification program focused on data portability, adoption of API (application programing interface) functionality (i.e. program to program interface)

14 How can PPRNet help you with MU? PPRNet CQMs are aligned with MU CQMs PPRNet improvement model and QI projects may help you effectively implement CDS to improve care.

15 PPRNet CQMs

16 PQRS Update 2015 Reporting Options: Medicare Part B Claims Qualified PQRS Registry Direct EHR using certified technology Certified EHR technology via data submission vendor Qualified clinical data registry Web interface (for group practices > 25 only) Adjustments to Medicare fee schedule for not reporting: 2015: -1.5% based on 2013 participation 2016: -2% based on 2014 participation 2017: -2% based on 2015 participation (and another -2% thru VM)

17 Qualified Clinical Data Registry (QCDR) A CMS-approved entity that has self-nominated and completed a qualification process that collects clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care delivered to patients. Data submitted not limited Medicare beneficiaries CQMs not limited to PQRS measures Participation satisfies PQRS reporting requirement and avoids negative payment adjustments

18 How can PPRNet help you with PQRS? PPRNet has been approved to be a QCDR for 2015 reporting year!! 30 PPRNet CQMs posted on CMS website Instruments/PQRS/Downloads/2015QCDRPosting.pdf

19 PPRNet QCDR Participating practices must: Extract from their EHR and submit clinical summary data as Consolidated-Clinical Document Architecture (ccda) documents for all patients Designate an easily accessible practice contact; update contact changes immediately Continue on-going report and data scrutiny; notify PPRNet of any reporting errors to assure data and report accuracy

20 How to Sign up for PPRNet QCDR By October 15, each EP requesting that PPRNet submit data on their behalf will: Provide TIN/NPI for each provider via an online registration form Send us a Medicare claims form with NPI and tax documentation to confirm TIN/NPI Sign and send us an updated business associate agreement (BAA)

21 PPRNet QCDR Other January 2016: Requirements Ensure data is submitted for 2015 For each provider, perform an annual manual chart review of a random sample of 12 patient s records to assess agreement of PPRNet data with EHR records. Provide PPRNet with a statement of completion of the record review

22 Value-Based Payment Modifier (VM) Program mandated by the ACA and gradually phased being phased in. Applies to all physicians in 2017 Aligned with PQRS Provides differential payment under the Medicare Physician Fee Schedule (PFS) based on quality of care compared to cost Applies to non-physician EPs in 2018

23 VM Quality and Cost Measures Quality composite score PQRS measures Two composite measures of hospital admissions for ambulatory-sensitive conditions (UTI, PNA, DM2, COPD) One measure of 30 day all cause hospital readmissions Cost composite score based on 6 cost measures Total per capita costs for all attribute beneficiaries Total per capita costs for beneficiaries with specific conditions: DM, CAD, COPD, HF Medicare spending per beneficiary measure Attribution process and risk stratification applied to measures

24 VM Quality Tiering (for up to 9 EPs) Automatic -2% downward adjustment for not reporting Up to +2.0% maximum adjustment No downward adjustments under quality-tiering

25 How does PPRNet help you with the VM? Through your participation in the 2015 PPRNet QCDR, you will AVOID the -2% automatic VM payment adjustment in 2017 Based on your performance (quality and cost measures) you will be eligible for up to +3% VM payment adjustment in 2017

26 Summary of 2017 Medicare Payment Adjustments Downward Adjustments for nonparticipation -3% for MU -2% for PQRS -2% for Value Modifier for up to 9 EPs/ -4% for 10+ Eps -7% to 9% Medicare payments at-risk Upward Adjustments +2% for highest cost/quality tiering and 1% bonus) up to +3%

27 Accountable Care Organizations (ACOs) Update For 2015, 17 measures must be submitted through the GPRO web interface Other measures via the CAHPS survey, claims, EHR incentive program data

28 How does PPRNet help with ACOs? Many PPRNet CQMs are aligned with ACO CQMs

29 THE FUTURE OF VALUE-BASED PAYMENT

30 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Signed into law April 14, 2015 Eliminates the flawed sustainable growth rate formula (and 21% payment cut) Transitions Medicare payment away from fee for service to payment for value Until 2019, Medicare physician payments will increase by 0.5% per year In 2019, physicians can choose between two payment tracks for additional payment adjustments

31 Track 1: MIPS Consolidation of certain current performance programs: EHR Meaningful Use Incentive Program Quality Reporting (PQRS-Physician Quality Reporting System) Value-Based Payments Clinical practice improvement activities New merit-based incentive payment system (MIPS) Composite performance score Negative payment adjustments -4% to -9% by 2022 Positive adjustments for exceptional performance +12 to +27% in 2022

32 Track 2- Alternative Payment Models (APM) APMs include PCMS, any model under the Center for Medicare and Medicaid Innovation Center, ACOs and other demonstration programs Physicians will receive annual bonuses capped at 5% each year (in addition to FFS) if they can show they receive substantial revenue through APM $20 million annually to assist small practices and practices servicing underserved areas participating in an APM

33 The Future of QCDRs MACRA law encourages QCDRs for quality measures QCDR participation will satisfy quality measure reporting component of MIPS

34 PPRNet in the Future Participating in PPRNet QCDR will ensure that you satisfy quality reporting components for incentive programs. PPRNet CQMs will continue to evolve to accurately assess the quality and value of care. Your participation in PPRNet QI activities will position you to receive additional financial incentives for delivering high value care.

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