12/5/2014. What is PQRS? Performance Measurement Committee Practical Theater. Historical concerns with the program (continued)

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1 What is PQRS? Navigating CMS Quality Initiatives: How to Successfully Report and Avoid Payment Adjustments Performance Measurement Committee Practical Theater A federally mandated Medicare Part B quality reporting program Established in 2007 as a voluntary reporting program 2014 Physician Fee Schedule (PFS) Final Rule sets forth current reporting requirements Uses a combination of incentive payments and payment adjustments to promote reporting of quality measures 2014 is the last reporting year offering incentives Applies payment adjustment to eligible professionals who do not satisfactorily report Historical concerns with the program Historical concerns with the program (continued) Lack of meaningful quality measures Many current measures do not accurately reflect the care provided by physicians, especially specialists Despite registered concerns, CMS is removing 50 measures in 2015, including: Back Pain Measures Group Perioperative Care Measures Group Perioperative Care: Timing of Prophylactic Parenteral Antibiotic- Ordering Physician (Individual Measure) Low participation According to CMS PQRS Experience Report, in 2012, only 36% of eligible healthcare providers participated in PQRS. Time and administrative burden Training, process changes and data entry Avoid penalties Year PQRS Incentives (+) for Successful Participation Why should I participate? % No penalty PQRS Penalties (-) for Unsuccessful Participation Why should I participate? (continued) Preparation for future changes in the health care delivery system Continued focus on quality improvement and pay-for-performance models Continued focus on the integration of EHR and Registry systems into healthcare 2015 No bonus -1.5% (based on No bonus -2.0% (based on No bonus -2.0% (based on

2 Why should I participate? (continued) 2014 Registration/Submission Timeline on Physician Compare Public : Physician Compare Website Mandated by the Affordable Care Act and Medicare Improvement for Patients and Providers Act In 2015, CMS will Continue to indicate an eligible professional s status in CMS quality reporting programs Indicate (with a green check mark) those who have earned the 2014 PQRS MOC Incentive Report performance rates for certain measures submitted via 2014 Group Option Report on sub-set of 20 PQRS measures submitted by individuals in 2014 Option Deadline GPRO Must have registered by October 3, Claims February 27, 2015 EHR February 28, 2015 Qualified Registry February 28, 2015 Qualified Clinical Data Registry Last day to submit 2014 CQMs for dual participation in PQRS and the Medicare EHR Incentive Program February 28, 2015 (for dual participation in PQRS and the Medicare EHR Incentive Program ) March 31, 2015 (to be processed only for PQRS) Step 1: Determine eligibility The following are considered eligible professionals (EPs) and are eligible to participate in PQRS: Medicare Physicians Medicare Practitioners Medicare Therapists Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists Physical Therapist Occupational Therapist Qualified Speech-Language Therapist Step 2: Determine Participation as Individual or in a Group For purposes of PQRS, group practice is defined as a single tax identification number (TIN) with 2 or more eligible healthcare professionals. Step 3: Determine how you will report PQRS measures Individual Claims Qualified Registry Qualified Clinical Data Registry (QCDR) CMS Certified (CERT) Direct Electronic Health Record (EHR) Based OR CERT EHR Data Submission Vendor Group Option (GPRO) Web-interface (for groups of 25 or more) Qualified Registry CMS Certified (CERT) Direct Electronic Health Record (EHR) Based OR CERT EHR Data Submission Vendor CAHPS via CMS-certified survey vendor (for groups of 25 or more) Step 3: Determine how you will report PQRS measures: How do I find an EHR or Registry for PQRS reporting? ONC-Certified EHR Product: Registry : Patient-Assessment-Instruments/PQRS/Downloads/2014QualifiedRegistries.pdf 2

3 Step 4: Determine applicable measures based on reporting option 2014 PQRS program 287 individual quality measures and 25 measures groups 2015 PQRS program 255 individual measures and 22 measures groups Step 5: Establish a work Flow and participate Establish an office work flow to ensure that all staff members understand the measures selected for reporting and to allow for efficient and consistent data capture CMS offers trainings on PQRS implementation. For information: Assessment-Instruments/PQRS/CMSSponsoredCalls.html See Navigating CMS Quality Initiatives: PQRS and Value Based Modifier Requirements for measures potentially relevant to spine care for the 2014 program at: ualityinitiatives.pdf. Requirements Submit measures from National Quality Strategy domains Patient and Family Engagement Clinical Patient Processes/ Safety Effectiveness National Quality Strategy Domains Efficient Use Care of Healthcare Coordination Resources Population and Public Health Claims-Based 9 measures NQS domains report each measure for at least 50% of If <9 measures NQS domains apply, report 1-8 measures covering 1-3 NQS domains covering 50% of Medicare Part B FFS Requirements for 2014 Incentive Qualified Registry- Based 9 measures NQS domains report each measure for at least 50% of OR 1 measures group on a 20-patient sample, a majority of which (at least 11/20) must be Qualified Clinical Data Registry 9 measures NQS domains;at least 1 of the measures reported must be an outcomes measure report each measure for at least 50% of CMS Certified (CERT) Direct Electronic Health Record (EHR) Based OR CERT EHR Data Submission Vendor 9 measures of the NQS domains. If an EP's CEHRT does not contain patient data for at least 9 measures domains, then the EP must report the measures for which there is Medicare patient data. An EP must report on at least 1 measure for which there is Medicare patient data. Satisfactorily reportingwill also satisfy the CQM component of the EHR Incentive program 2014 Requirements to Avoid the 2016 Payment Adjustment Meet the requirements for satisfactory reporting under the2014 PQRS incentive program. OR, Report at least 3 measures covering 1 NQS domain for at least 50% of the eligible professional s patients via claims or qualified registry. OR, Participate via a qualified clinical data registry (QCDR) that selects measures for the EP, of which at least 3 measures covering a minimum of 1 NQS domain submission of at least 50% of the EP s applicable Group Practice Option (GPRO) Requirements for 2014 Incentive Groups of All measures included in the Web Interface; Populate data fields for the first 218 consecutively If beneficiaries <218, then report on 100% of If choosing to take part in the PQRS GPRO and choosing to participate in CAHPS for PQRS, must also report all CAHPS summary survey modules via a CMS-certified survey vendor. CMS will bear the cost of administering. Group of 100 or more All measures included in the Web Interface; Populate data fields for the first 411 consecutively If beneficiaries <411, then report on 100% of If choosing to take part in the PQRS GPRO and choosing to participate in CAHPS for PQRS, must also report all CAHPS summary survey modules via a CMScertified survey vendor. CMS will bear the cost of administering. 3

4 Group Practice Option (GPRO) Requirements for 2014 Incentive Qualified Registry-Based 9 measures NQS domains report each measure for at least 50% of CMS Certified (CERT) Direct Electronic Health Record (EHR) Based OR CERT EHR Data Submission Vendor 9 measures of the NQS domains. If a group practice's CEHRT does not contain patient data for at least 9 measures domains, then the group practice must report the measures for which there is Medicare patient data. Group Practice Option (GPRO) 2014 Requirements to Avoid the 2016 Payment Adjustment Meet the requirements for satisfactory reporting under the2014 PQRS incentive program. OR, Report at least 3 measures covering 1 NQS domain for at least 50 percent of the group practice s patients via qualified registry. A group practice must report on at least 1 measure for which there is Medicare patient 2015 Requirements to avoid the 2015 Requirements to avoid the Claims-Based 9 individualmeasures NQS domains for at least 50% of In addition, at least 1 measure must be a cross cutting measure. This will count toward the 9 measure minimum. Qualified Registry-Based 9 individual measures NQS domains for at least 50% of OR Report1 measures group for at least 20 patients, a majority of which must be In addition, EPS submitting individual measures must report on at least 1 cross cutting measure. This will count toward the 9 measure minimum. Reaffirmed that qualified registries are the ONLYway for individuals to report measures groups in 2015 and subsequent years. Qualified Clinical Data Registry (QCDR) 9 individual measures NQS domainsfor at least 50% of Medicare Part B FFS patients Inaddition, at least 2 measuresmust be an outcomes measures. This will count toward the 9 measure minimum. If 2 outcome measures are not available, EPs must report at least 1 outcomes measures and at least 1 resource use, patient experience, or efficiency/appropriate use measure. CMS Certified (CERT) Direct Electronic Health Record (EHR) Based OR CERT EHR Data Submission Vendor 9 measures of the NQS domains An EP must report on at least 1 measure for which there is Medicare patient data. No updates for 2015 Group Practice Option (2-99 EPs) 2015 Requirements to avoid the Qualified Registry-Based 9 measures NQS domains for at least 50% of In addition, EPS submitting individual measures must report on at least 1 cross cutting measure. This will count toward the 9 measure minimum. CMS Certified (CERT) Direct Electronic Health Record (EHR) Based OR CERT EHR Data Submission Vendor 9 measures of the NQS domains An EP must report on at least 1 measure for which there is Medicare patient data. No updatesfor 2015 Group Practice Option (Groups 100+ and Groups 2-99 Choosing to Submit CAHPS Survey Data) 2015 Requirements to avoid the Qualified Registry-Based + CMS Certified CAHPS Survey Vendor CMS Certified (CERT) Direct Electronic Health Record (EHR) Based OR CERT EHR Data Submission Vendor + CMS Certified CAHPS Survey Vendor All CAHPS measures via CMS Certified All CAHPS measures via CMS Certified Survey Vendor at least 6 PQRS Survey Vendor at least 6 PQRS measures covering at least 2 NQS measures covering at least 2 NQS domains. domains. *Of the 6 measures, at least 1 measure must be cross-cutting measure 4

5 Group Practice Option (GPRO) 2015 Requirements to avoid the Groups of Group of 100 or more All measures included in the Web Interface; All measures included in the Web Interface; Populate data fields for the first 218 Populate data fields for the first 411 consecutively If consecutively If beneficiaries <218, then report on 100% of beneficiaries <411, then report on 100% of Must now populate 248 fields in 2015 (increase from 218) report ALL CAHPS Measures via a certified CMS Survey Vendor (optional) Must now populate 248 fields in 2015 (decrease from 411) report ALL CAHPS Measures via a certified CMS Survey Vendor Group Practice Requirements: Consumer Healthcare Provider and Systems (CAHPS) Survey CAHPS surveys ask consumers and patients to report on and evaluate their experiences with health care. For the 2017 payment adjustment (2015 reporting year), reporting of CAHPS is required for group practices of 100 or more reporting via any Group Practice method (in addition to other reporting requirements). For group practices 2-99 that register to participate in the GPRO, CAHPS reporting is optional Beginning in 2015, groups submitting CAHPS data via a CMS-Certified Survey Vendor will bear the cost of survey use (CMS will no longer cover the cost) What are Cross-Cutting Measures? In 2015, Eligible professionals who see at least 1 Medicare patient in a face-to-face encounter and reporting via Claims, Qualified Registry or EHR, MUST report on 1 cross-cutting measure: Tobacco Use and Help with Quitting Among Adolescents Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Medication Reconciliation Care Plan Preventive Care and Screening: Influenza Immunization Pneumonia Vaccination Status for Older Adults Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Documentation of Current Medications in the Medical Record Pain Assessment and Follow-Up Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Functional Outcome Assessment Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Controlling High Blood Pressure Childhood Immunization Status Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Falls: Screening for Fall Risk CAHPS for PQRS Clinician/Group Survey Closing the Referral Loop: Receipt of Specialist Report Diabetes: Hemoglobin A1c Poor Control Value Based : impact-who, what and when Budget neutral program mandated by the Affordable Care Act 2015 (based on 2013 Applied to Group Practices of 100 or more Payment adjustments Neutral (no adjustment) -1% + 1%x* 2016 (based on 2014 Applied to Group Practices of 10 or more Payment adjustments Neutral (no adjustment) -2% + 2%x* * x represents the upward payment adjustment factor 2017(based on 2015 and beyond Applied to ALL eligible individual practitioners and grouppractices Payment adjustments Neutral (no adjustment) Up to -4% Up to+ 4%x* -Paymentadjustment dependent on group size (discussed on next slides) 2017 Modifier: Solo Practitioners and Group Practices of Modifier: Group Practices of 10 or more Solo Practitioners and Group Practices of 2-9 will be held harmless from VM adjustments AS LONG AS THEY SUCCESSFULLY REPORT TO PQRS Non-successful PQRS reporters: receive automatic 2% deduction (in addition to 2% PQRS penalty) Successful PQRS reporters: opportunity to receive incentive up to 2.0x, depending on cost and quality data. Non-successful PQRS reporters: receive automatic 4% deduction (in addition to 2% PQRS penalty) Successful PQRS reporters: opportunity to receive incentive up to 4.0x, depending on cost and quality data 2016 Quality Tiering(based on PY 2014) 2016 Quality Tiering(based on PY 2014) Cost / Quality Low Quality Average Quality High Quality Low Cost 0.0% +1.0x* +2.0x* Average Cost 0.0% 0.0% +1.0x* High Cost 0.0% 0.0% 0.0% Cost / Quality Low Quality Average Quality High Quality Low Cost +0.0% +2.0x* +4.0x* Average Cost -2.0% +0.0% +2.0x* High Cost -4.0% -2.0% +0.0% * x represents the upward payment adjustment factor * x represents the upward payment adjustment factor 5

6 How Will the Value-Modifier Be Calculated? How do EPs participate? Quality Composite + Cost Composite Scores= VM Quality of Care Domain Score: PQRS Measures will be used to calculate the quality domain score. Satisfactory participation in PQRS is necessary to avoid automatic VBM payment adjustments! Measures reported within the National Quality Strategy Domains will be weighted to form a quality composite score. Cost Domain Score: Total per capita costs (plus Medicare Spending Per Beneficiary) Total per capita costs for beneficiaries with specific conditions Group cost measures are adjusted for specialty composition of the group Value Modifier (based on 2014 data) Group practices of 10 or more must have self-nominated by October 3, 2014 via If a group practice does not want to participate in the PQRS GPRO, the group practice can still avoid value-modifier adjustments if at least 50% of individual EPs in their practice successfully report Value Modifier (based on 2015 data) Group practices of 2 or more must self nominate by June 30, 2015 via Individual EPs do not need to self nominate The group s composite scores in each of the domains will then be compared to a national benchmark average. Those outliers falling significantly above or below the benchmark will be subject to an increase or decrease in payment. How will feedback be provided? Comparative performance information will be provided via Quality and Resource Use Reports (QRURs). QRURs will provide insight on how the VBM composite scores will be calculated for each group. QRURs are now available for solo EPs and group practices who participated in the 2013 PQRS program via NASS Working for You NASS working for you NASS has been advocating on members behalf to delay increasing program reporting requirements and penalties. To review NASS comments to CMS on the 2015 Physician Fee Schedule Proposed Rule and other policies affecting performance measurement and quality reporting, go to the NASS website: yimprovement/scientificpolicycomments.aspx. Additional Resources PQRS Centers for Medicare & Medicaid Services Instruments/PQRS/index.html NASS Working for You American Medical Association NASS Working for You QUESTIONS? Physician Feedback Program/ Value Based Centers for Medicare & Medicaid Services Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf Physician Compare Centers for Medicare & Medicaid Services Questions can also be directed to Karie Rosolowski, NASS Senior Manager of Research & Quality Improvement, at [email protected] Physician Compare Website 6