Navigating CMS Incentive Programs for Eligible Professionals Why It Matters and What You Need to Know. Dr. Paul Mulhausen, CMO

Transcription

1 Navigating CMS Incentive Programs for Eligible Professionals Why It Matters and What You Need to Know Dr. Paul Mulhausen, CMO

2 Objectives Better understand CMS Incentive Programs and payment adjustments Learn how to report once for Meaningful Use and PQRS Understand the PQRS/Value-Based Modifier Program relationship Learn how to improve performance for population health (cardiac, immunizations, diabetes, readmissions) through incentive programs such as PQRS 2

3 The QIO Program s Approach to Clinical Quality 3 Goals Make care safer Strengthen person and family engagement Promote effective communication and coordination of care Promote effective prevention and treatment Promote best practices for healthy living Make care more affordable 4

4 Join the Telligen QIN-QIO Network The Telligen QIN-QIO network offers NO COST expertise and support at local, regional and national levels We believe the quality of healthcare can be transformed to better serve the people of all communities How we serve our participants: Assess and understand unique needs and opportunities Provide opportunities to connect with Align improvement efforts Leverage expertise and relationships Facilitate connections, sharing and learning Bring you access to tools, resource, metrics, evidence based, collaboration, best practice, peer support, education 4

5 HHS Press Release January 26, 2015 Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value Percent of FFS Medicare Tied to Quality 85% 90% Percent of FFS Medicare Tied to Alternate Models 20% 30% 50% 5

6 CMS Quality Strategy: Make care affordable Paying providers based on the quality and efficiency of care delivered Developing and promulgating clinical guidelines and quality standards Improving data systems by establishing health information exchanges for administrative simplification Making healthcare costs and quality more transparent to consumers and providers, enabling them to make better choices and decisions. 6

7 Quality Reporting and Incentive Programs Promote higher quality of care Promote more efficient health care Promote quality and cost transparency for patients and consumers 7

8 Current CMS Quality Programs Electronic Health Record Incentive Program* (Meaningful Use) Physician Quality Reporting System* Physician Value Based Payment Modifier* Hospital Value Based Purchasing Home Health Quality Initiative Nursing Home Quality Initiative ESRD Quality Incentive Program 8 * Discussed in this webinar

9 Payment Taxonomy and Alternative Payment Models Fee for Service No Link to Quality Fee for Service Link to Quality Alternative payment built on fee-for service Population Based Payment Payments based on volume and not linked to quality or efficiency A portion of payments vary based on the quality or efficiency of care delivery Some payment is linked to the effective management of a population or an episode of care Payment is not directly triggered by service delivery. Limited in Medicare fee-forservice Majority of Medicare payments are now linked to quality Hospital Value Based Purchasing Physician Value Based Modifier Readmissions/Ho spital Acquired Conditions ACOs Medical Homes Bundled Payment CPCI Comprehensive ESRD Eligible Pioneer ACO in years 3-5 9

10 The Medicare Access and CHIP Reauthorization Act Repealed the Sustainable Growth Rate (SGR) formula. Introduced MIPS: Merit-based Incentive Payment System MIPS will combine PQRS, Value-Based Modifier (VM) program, and EHR Incentive Program ( Meaningful Use ) into a single quality payment system. MIPS Assessment Categories include Quality, Resource Use, EHR Meaningful Use, and Clinical Practice Improvement Activities. The MIPS incentives will go into effect in The EHR Incentive program, PQRS, and VM will continue under current law through

11 PQRS and the Value Based Payment Modifier programs CMS Incentives and Penalties Value Based Payment Modifier July 9, 2015 Devin Detwiler, MBA, MSHA, CHTS, Program Specialist 11

12 Physician Quality Reporting System Eligible Professional (EP): a provider must deliver services that are payable under the Medicare Part B Fee Schedule. Started in 2007 for providers to qualify for INCENTIVES by reporting clinical quality measures information on their Medicare Part B patients In 2015 it is no longer an incentive program but a payment adjustment penalty program for Medicare Part B providers who do not report clinical quality measures to CMS (incentives were paid thru 2014) 12

13 Value Based Payment Modifier VBPM NOW the VALUES of those clinical measures (PQRS Data) are benchmarked across the nation to similar practicing providers (as listed in PECOS) and a cost and quality value is assigned to the provider/practice Applied to practices of 100+ in 2013 Applied to practices of 10+ in 2014 Applied to all BILLING providers in 2015 for payment year 2017 Applied to all RENDERING providers in 2017 for payment year

14 CMS Penalty and Incentive Programs 2015 and beyond No PQRS reporting 2% Penalty No PQRS data to apply to the VBPM program additional 2% Penalty No Meaningful Use Reporting 3% penalty 2019 Merit Based Incentive Payment System (MIPS) /-4% to +/-12% /-7% to +/-20% /-5% to +/-15% /-9% to +/-27% Alternate Payment Model Track 5% bonus on PFS (Physician Fee Schedule) and incentives for high performers 14

15 Penalties Payment Adjustments PQRS Payment Adjustments 2016: -2.0% Based on 2014 reporting 2017: -2.0% Based on 2015 reporting Many providers were made aware of this program in January of 2015 when they received the penalty letters from CMS (negative 1.5% payment adjustment notification for 2013) 15

16 Penalty in 2017 for 2015 reporting based on MCB total payment on allowable charges MC Part B Allowable Charges 2% Penalty $50,000 $1,000 $75,000 $1,500 $100,000 $2,000 $125,000 $2,500 $150,000 $3,000 $175,000 $3,500 $200,000 $4,000 16

17 Eligible professionals who MUSTparticipate 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 17

18 To Avoid 2% Penalty in 2017 for 2015 Data 9 measures reported to CMS (over 300 to choose from!) 1 Cross-Cutting Measure included 3 National Quality Strategy domains covered 18

19 PQRS Reporting Requirements Full Year of Data Required PQRS Data Submission Deadline -March 31 Annually The only exception is Report at least 1 Diagnostic Measure Group on at least 20 Medicare Part B patients reported using a registry. (If you do not have 20 MCB patients you can report on 11 of them and include 9 other patients) 19

20 PQRS Reporting Claims 2. Qualified Registry 3. Clinical Quality Registry* 4. EHR Direct 5. CEHRT using Data Submission Vendor *Could count as an MU Stage 2 Menu Registry 20

21 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 21

22 The Value Based Payment Modifier 22

23 VBPM Quality Composite Score Total cost from Part A and Part B Total per capita costs for beneficiaries with: Chronic Obstructive Pulmonary Disease (COPD) Heart Failure Coronary Artery Disease Diabetes Beneficiary Average Risk Score Performance Measures PQRS Measures reported Hospitalizations due to Pneumonia, UTI, Dehydration, Diabetes, COPD, Asthma and Heart Failure All Cause Hospital Readmissions 23

24 VBPM Cost Comparison Information Per Capita Cost E&M Services by you/group E&M Services by Other Procedures by you/group Procedures by Other Inpatient Hospital Services Outpatient Hospital Services ED Services with NO Admit Ancillary Services Post-Acute Services Other Services (ambulance, DME, etc) 24

25 Quality and Resources Use Report QRUR Quality Review Utilization Report Report to see your Value Based Payment Modifier Score. Will detail each of the measures and how you scored. Data from the first 6 months of 2014 are now available

26 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% All 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% +0.0% Low Quality +0.0% +0.0% +0.0%

27 27 Quality Tier Under the Value Modifier 2019 for reporting year 2017

28 QRUR Access You can access a Quality and Resource Use Report (QRUR) on behalf of a group or solo practitioner at QRURs are provided for each Medicare-enrolled Taxpayer Identification Number (TIN). You or one person from your group will need to obtain an Individuals Authorized Access to the CMS Computer Services (IACS) account with the correct role first. 28

29 Physician Compare Websites and Resources Physician Compare URL Data on Physician Compare comes from PECOS Physician Compare support team Physician Compare information and updates 29

30 Meaningful Use Proposed Modifications to Meaningful Use in How Eligible Professionals (EP) can report once July 9, 2015 Temaka Williams, MPH, MBA, HIT Advisor 30

31 Meaningful Use Defined Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health and Maintain privacy and security of patient health information. These objectives are evolving in three stages over five years Stage 1 Data capture and sharing Stage 2 Advance clinical processes Stage 3 Improved outcomes 31

32 Meaningful Use Penalty To avoid 3% Penalty in 2017 for 2015 Data the modifications to Meaningful Use suggest the following: 9 Objectives 2 Public Health Measures 9 CQMs across 3 of 6 National Quality Strategy domains for a 90 day period 32

33 MU Certified EHR MU measures CQMs PQRS PQRS data Physician compare VBMP Outcome and cost measures from claims Quality and cost composite score QRUR reports Payment adjustments 33

34 Report Once for 2015 Medicare Quality Reporting Programs The reporting period for 2015 PQRS is 12 months; The Medicare EHR Incentive Program s reporting period is proposed to be changed to a 90- day period and aligned with the calendar year. Eligible Professionals Choose PQRS Electronic Reporting Using an EHR OR Qualified Clinical Data Registry Report on 9 CQM s covering at least 3 of the National Quality Strategy Domains for 12 months (1/1/ /31/2015). Note: You will still be required to report the other meaningful use objectives and public health measures through the Medicare EHR Incentive Programs. 34

35 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 35

36 QIN-QIO Strategic Initiatives Improve Cardiac Health Improve Diabetes Care Meaningful Use of HIT Reduce Healthcare-Associated Infections Reduce Healthcare-Acquired Conditions Reduce Immunization Health Disparities Improve Care Coordination Quality Reporting & Value-Based Incentives 36

37 Upcoming Events July 29 th : QRUR and Migration of IACS Services to EIDM August 19 th : A Deep Dive into the Final Rule Modifications to Meaningful Use September 16 th : Patient Portal: Provider Success Stories 37

38 Eligible Professional Website and Resources EHR Incentive Program -Modifications to Meaningful Use in 2015 Through Guidance/Legislation/EHRIncentivePrograms/Downloads/Modific ations_mu_rule.pdf 38

39 Contacts Telligen Linda Brewer Sr. Quality Improvement Facilitator Telligen Devin Detwiler Program Specialist Telligen Paul Mulhausen, MD Chief Medical Officer Telligen Temaka Williams HIT Advisor This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, 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. 39