CMS PQRS and VBPM Incentive/Penalty Programs. Devin Detwiler Manager Quality Improvement Telligen

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1 CMS PQRS and VBPM Incentive/Penalty Programs Devin Detwiler Manager Quality Improvement Telligen

2 Free Resource to you Join our Network Engage providers and stakeholders in improvement initiatives through Learning and Action Networks including: Learning Events Spreading successful improvements/best Practices Discussion forums - encourage peer sharing Resource library Recorded events Videos/Webinars 2

3 Join our Network! Cardiovascular Health and Million Hearts Meaningful Use PQRS Physician Quality Reporting System Value Based Payment Modifier Providers, ASCs, IPFs, Hosp Everyone with Diabetes Counts Hospital Healthcare-Associated Infections Nursing Home Quality Improvement Hospital Readmissions/Care Transition/Community Organizing Medication Safety 3

4 PQRS Incentives None PQRS Incentive Payments 2015: 0% Additional.5% for Maintenance of Certification 4

5 Penalties Payment Adjustments PQRS Payment Adjustments 2016: -2.0% Based on 2014 reporting If you did not report PQRS in 2014 you will see a 2% cut in Medicare Part B Reimbursement on every line item charge/payment on your EOB) 2017: -2.0% 2018: -2.0% 5

6 2% Penalty Cost to MCB total payment on allowable charges 6 MC Part B 2% Penalty Allowable Charges $50,000 $1,000 $75,000 $1,500 $100,000 $2,000 $125,000 $2500 $150,000 $3,000 $175,000 $3,500 $200,000 $4,000

7 Eligible professionals who MUST participate in Physician Quality Reporting* Physicians MD, DO, Doctor of Podiatric Medicine, Doctor of Optometry, Doctor of Dental Surgery, Doctor of Dental Medicine, Doctor of Chiropractic Practitioners Therapists PA, NP, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant), Certified Nurse Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional, Audiologists Physical Therapist, Occupational Therapist, Qualified Speech- Language Therapist *if they bill Medicare under their own NPI 7

8 Eligible professionals who MUST participate in Physician Quality Reporting in 2016 Beginning 2018 (reporting year 2016), the payment adjustments will also apply to non-physician EPs who are solo practitioners or are in groups of 2 or more EPs. 8

9 Reassigned Benefits to Critical Access Hospitals In 2015 professionals who have reassigned benefits to Critical Access Hospitals and bill professional services at a facility level such as CAH Method II Billing may participate in PQRS using any reporting method 9

10 2015 PQRS Reporting Requirements 9 individual measures in 3 Domains OR 1 Diagnostic Measure Group 10

11 What is a Domain? 1. Patient and Family Engagement 2. Patient Safety 3. Care Coordination 4. Population/Public Health 5. Efficient Use of Healthcare Resources 6. Clinical Processes/Effectiveness *Each measure listed has domain in 4th column 11

12 Clinical Quality Measures that qualify for both PQRS and Meaningful Use Clinical Quality Measures count as both #46 Medication Reconciliation Domain: Patient Safety #128 Adult BMI Assessment and Counseling Domain: Community/Population Health #130 List Current Meds Include sig for OTC Domain: Patient Safety #226 Tobacco Use and Cessation Counseling Domain: Community/Population Health 12

13 Measurement Requirement at least ONE of these Cross Cutting Measures PQRS Number Description PQRS Number Description 1 HbA1c Control 226 Tobacco Use & Plan 46 Med Rec 236 Controlling High Blood Pressure 47 Care Plan 240 Childhood Immunizations 110 Influenza 317 HTN Screening & Plan 128 Pneumovax 318 Fall Risk Screening 130 BMI and Plan 321 CAHPS 131 Current Medications 374 Receipt of Specialist Report 134 Pain Assessment & Plan 182 Functional Outcome 13 Assessment & Plan 400 Hepatitis C Screening 402 Tobacco Use & Plan in Adolescents

14 PQRS Reporting Requirements Full Year of Data Required OR Diagnostic Measure Group on 20 MCB Patients 14

15 Using CHAPS for 3 PQRS Measures Complete CAHPS Survey to receive credit for 3 PQRS Measures Must still report 6 additional measures from 2 domains 15

16 What information is collected from CAHPS Getting timely care, appointments, and information How well providers Communicate Patient s rating of provider Access to specialists Health promotion & education Shared decision making Health status/functional status Courteous and helpful office staff Care coordination Between visit communication Helping patient to take medication as directed Stewardship of patient resources Reference: for more information on the CG CAHPS survey modules 16

17 2015 PQRS Data Submission Deadline March 31 Annually 17

18 PQRS Reporting Claims 2. Qualified Registry 3. Clinical Quality Registry* 4. EHR Direct 5. CEHRT using Data Submission Vendor *MU Registry Qualification??? 18

19 2015 Changes Continued Reporting Option Claims Measures Registry Measures EHR Measures GPRO Web Interface Measures Groups

20 Claims Based Reporting Medicare providers submit claims (via CMS-1500 Form) for reimbursement on payable services rendered to Part B beneficiaries Eligible professionals use their individual NPI to submit for services on Medicare Part B beneficiaries Standardized reporting codes Provider documents Quality Data Codes (QDC) on claim 20

21 How to Start Claims-Based Reporting Select measures most applicable to your practice (see Measures List and Measures Specifications Manual) No registration is required, simply bill as you normally would on the CMS-1500 form (or electronic equivalent) Add the applicable code for the measures you have selected, Medicare Part B claims If you are using an EHR, speak to vendor about functionality around claims submission 21

22 Claims Based Example Pneumonia Vaccination Example PQRS #111 DENOMINATOR: Patients 65 years of age and older with a visit during the measurement period (E&M code) NUMERATOR: CPT II Code 4040F: Pneumococcal vaccine administered or previously received OR CPT II Code 4040F8P: Pneumococcal vaccine was not administered or previously received, reason not otherwise specified 22

23 Claims Based PQRS Coding 2 23

24 3 rd Party Registry Reporting What is a registry? o Entity that captures and stores clinically related data o Submits on behalf of providers (cost $250-$500) o Some offer data mining tools (additional charge) PQRS Participating registries are updated annually Data on applicable beneficiaries is reported to registry via secure portal manually, data mining software, or through EHR vendor 24

25 Clinical Data Registry New Qualified Clinical Data Registry These specialty societies can report up to 20 non-pqrs measures as approved A QCDR is different from a qualified registry in that it is not limited to measures within PQRS - Measures used by boards or specialty societies, and -Measures used in regional quality collaborations -CG CAHPS-Clinician & Group Consumer Assessment of Healthcare Providers and Systems 25

26 Clinical Data Registry Examples of Clinical Registries Asthma Anesthesia Cardiology Metabolic and Bariatric Radiology Urological Surgery Rheumatology Osteoporosis Gastroenterology Renal Surgery Thoracic Surgeons Oncology Wound Care 26

27 EHR Direct Reporting Report on 9 PQRS quality measures for 2015 calendar year using qualified EHR Vendors emds, Aprima, Success EHS, Vitera, Practice submits measures to CMS via secure portal IACS (Individual Authorized Access to the CMS Computer Services) 27

28 Data Submission Vendor EHRs that are 2014 CEHRT must have the capability to do CQM reporting for MU and PQRS NextGen, Greenway, ecw, Athena, Allscripts PQRS measures are pulled from the EHR - they are not pulled from claims data or the PMS (billing system) 28

29 What if I can t find 9 Applicable Measures? MAV Measure-Applicability Validation Eligible Professionals or Groups who satisfactorily report on fewer than 9 PQRS measures and/or fewer than 3 domains will be subject to the MAV Process The MAV Process determines if additional measures or measures in other domains should have been submitted to be considered for incentive eligibility All EPs and Groups that have submitted PQRS via claims or registry could be subject to MAV 29

30 Individual vs Group PQRS Reporting PQRS Group Practice Reporting Option (GPRO) A group practice under 2014 PQRS consists of a physician group practice, as defined by a single Tax Identification Number (TIN), with 2 or more individual EPs, as identified by individual National Provider Identifier or NPI 30

31 GPRO PQRS Reporting 2015 Practices must register to participate in PQRS through the GPRO Registration will be held April 1 - June 30, 2015 Registration is completed through the Physician Value (PV)-PQRS registration system: Payment/PhysicianFeedbackProgram/Self-Nomination- Registration.html 31

32 PQRS Group Practice Reporting Option (GPRO) Determine Reporting Method Group practices will need to determine the best reporting method for the group. Groups 2+ Qualified Registry 3 rd party (not clinical) Electronic Health Record (EHR) Direct Reporting Data Submission Vendor GPRO Web Interface Reporting (all 19 measures) 32

33 PQRS Group Practice Reporting Option (GPRO) One TIN/Individual EP NPIs Agree to have the results on performance of their PQRS measures publicly posted on the Physician Compare Website Once you sign up as a group you cannot change your mind 33

34 PQRS and Maintenance of Certification Additional 0.5% Incentive Payment Satisfactory PQRS Submission AND More Frequent participation and reports to MoC program Information on the survey of patient s experience, MoC methods, measures and data for practice assessment 34

35 VBPM Quality Tier Approach in 2014 In 2015 each group receives two composite scores (quality of care and 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 +1.0% Incentive 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 35

36 Composite Score VBPM Program Composite Quality Score based on reported PQRS data Composite Cost Score Total Cost for the Medicare Beneficiary under Part A and Part B programs Composite Risk Score Assigned Patient Panel with risk scoring (above the 75% qualifies for additional incentive payments) 36

37 Composite Score VBPM Program Total per capita costs for beneficiaries with 4 chronic conditions: Chronic Obstructive Pulmonary Disease (COPD) Heart Failure Coronary Artery Disease Diabetes All Cause 30 Day Hospital Readmission 37

38 The Value Based Payment Modifier 38

39 2015 VBPM Quality-Tier Approach 10+ Providers 2015 Reporting Year/2017 Adjustment Applied Quality/Cost Low Cost Average Cost High Cost High Quality +2.0% +1.0% +0.0% Average Quality +1.0% +0.0% -0.5% Low Quality +0.0% -0.5% -1.0% 3 39

40 2015 VBPM Quality-Tier Approach All Providers 2017 Based on 2015 Data Quality/Cost Low Cost Avg Cost High Cost High Quality +2%* +1%* 0 Average Quality +1%* 0 0 Low Quality

41 Incentive/Penalty Value Based Payment Modifier All Providers 2018 Based on 2016 Data Quality/Cost Low Cost Avg Cost High Cost High Quality +2%* +1%* 0 Average Quality +1%* 0 -.5% Low Quality 0 -.5% -1% 41

42 Incentive/Penalty Value Based Payment Modifier All Providers 2019 Based on 2017 Data Quality/Cost Low Cost Avg Cost High Cost High Quality +2%* +1%* 0 Average Quality +1%* 0-1% Low Quality 0-1% -2% *Eligible for an additional +1.0x if reporting clinical data for quality measures AND average beneficiary risk score in the top 25 percent of all beneficiary risk scores. 42

43 QUALITY AND RESOURCE USE REPORT QRUR Report to see your Value Based Payment Modifier Score. Will detail each of the measures and how you scored. Will come out in September of each year and include a providers patient panel. 85% will receive no adjustment. 15% will either receive an incentive OR a penalty 4 43

44 Physician Compare Website and Resources Website URL: Data on Physician Compare comes from PECOS Specialty is as reported on your Medicare Enrollment Form Physician Compare support team Physician Compare information and updates Assessment-Instruments/physician-compare-initiative/ 44

45 Bringing it all together MU, PQRS, VBPM Chronic Care Mgmt - $42 Reimbursement for 2 chronic conditions MU Stage 2 - Generate at least 1 patient list by specific condition. Use secure messaging to patients. Patient Education. 5 Clinical Decision Support Tools in EHR for stage 2 related to 4+ clinical quality measures Clinical Data Registries also count for MU Stage 2? MU Stage 2 - Patient Reminders use this to improve clinical quality measure. Use patient portal 45

46 Will you join us? Thank You for your time! Devin Detwiler For more information or to sign up for the program! 46 This material was prepared by Telligen, the Medicare Quality Improvement Organization for Colorado, 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. 11SOW-CO-B1-09/14-004