Pay for Performance Solutions A wholly owned subsidiary of
Company Overview Balanced Improvement for Health Systems and Physician Practices Products and Services to Integrate People, Processes, and Technology 12/4/2014 Copyright Mingle Analytics 2
Nobody knows PQRS the way we do Dr. Dan Mingle, MD, MS Family Physician and Educator Knows the business & practice of medicine Reporting PQRS since 2008 Principle Architect for nine registries Feature in Healthcare Informatics magazine Kash Basavappa Thirty years in healthcare and healthcare informatics Recipient of multiple awards as Chief Information Officer Directed development of commercial healthcare information technology products Working with Dr. Mingle since 2000 Assisted By PQRS Consultants providing Client Support Account Management Project Management Data Analysts Development Staff Gay De Hart Ten years in healthcare Practice Manager Business Writer Grant Writer Working with Dr. Mingle since 2011 Scott Larsen 27 years in Information Technology 6 years in healthcare informatics Web Applications, Software as a Service Security Infrastructures Building environments that scale 12/4/2014 Copyright Mingle Analytics 3
Review of the 2015 Medicare Final Rule Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015 12/4/2014 Copyright Mingle Analytics 4
Federal Register Document 2014-26183 Filed 10/31/2014 Publication Date: 11/13/2014 12/4/2014 Copyright Mingle Analytics 5
Focus on the Sections J. Physician Compare Website K. Physician Payment, Efficiency, and Quality Improvements Physician Quality Reporting System N. Value-Based Payment Modifier and Physician Feedback Program 12/4/2014 Copyright Mingle Analytics 6
Logistics Ask Questions Anytime Type your questions into the GoToWebinar dialog box Email questions to us after the Webinar We will distribute a link to the slides and a recording of the Webinar 12/4/2014 Copyright Mingle Analytics 7
Pause to check Any problems hearing or seeing the presentation? Before moving on to: PHYSICIAN COMPARE 12/4/2014 Copyright Mingle Analytics 8
Physician Compare Website Required by the Affordable Care Act 2010 To the extent that scientifically sound measures are developed and are available, we are required to include, to the extent practicable, the following types of measures for public reporting: Measures collected under PQRS Assessment of patient health outcomes and functional status of patients Assessment of the continuity and coordination of care and care transitions Assessment of efficiency Assessment of patient experience and patient, caregiver, and family engagement Assessment of the safety, effectiveness, and timeliness of care Other information as determined appropriate by the Secretary 12/4/2014 Copyright Mingle Analytics 9
Physician Compare Resources Website URL: http://www.medicare.gov/physiciancompare Data on Physician Compare comes from PECOS https://pecos.cms.hhs.gov/pecos/login.do Specialty is as reported on your Medicare Enrollment Form Physician Compare support team PhysicianCompare@Westat.com Physician Compare information and updates http://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/physician-compare-initiative/ 12/4/2014 Copyright Mingle Analytics 10
Physician Compare Milestones SrvYear Publish Method To be Reported 2009 2010 Reg, Claims Site launch in December 2010 listing PQRS Participants 2012 2013 Web, EHR, Reg, Claims Checkmarks for PQRS, erx, EHR 2012 2014 Web 5 DM and CAD Measure Performance 2013 2014 Web, EHR, Reg, Claims Add Checkmarks for MOC, CV Prevention MG 2013 2014 Web 6 DM and 2 CAD Measure Performance 2013 2014 Web 5 CG-CAHPS summary Measure Performance for groups 100 (6 for ACO) 2014 2015 Web, GPRO-EHR, GPRO-Reg, Administrative Claims All Web, 13 EHR, and 16 Registry Measure Performance 2014 2015 Web, Survey Vendor 12 CAHPS for PQRS Summary measure Performance (6 for ACO) 2014 2015 Ind-EHR, Ind-Reg, Claims Performance for 20 measures that align with Web Measures 2014 2015 Reg Performance for Measures from CV Prevention MG 12/4/2014 Copyright Mingle Analytics 11
12/4/2014 Copyright Mingle Analytics 12
Physician Compare 2015 2015 Reporting Year Publish in 2016 Groups 2 participating in GPRO Shared Savings Program (SSP) ACO All Groups 2 and SSP Individual Reporting by Reg, EHR, Claims, QCDR All PQRS Measures by all Methods All Measures (Web) 12 CAHPS for PQRS Summary Scores All PQRS Measures by all Methods Prerequisites 20 Patient Minimum Sample Measures beyond Year 1 of Distribution Measures deemed to be statistically comparable Statistically valid and reliable Understood by Consumers Practices given 30d Preview Period 12/4/2014 Copyright Mingle Analytics 13
Pause for Questions about Physician Compare Before moving on to: PHYSICIAN QUALITY REPORTING SYSTEM 12/4/2014 Copyright Mingle Analytics 14
Remember Medicare s Naming Conventions Incentive Is Named for the Service Year Your 2014 Incentive (The Last Incentive) Is based on your 2014 Year of Patient Services That you report in 2015 Is paid in 2015 Adjustment (Penalty) Is Named for the Adjustment Year Your 2016 Adjustment Is based on your 2014 Year of Patient Service That you report in 2015 The Adjustment is taken out of payments for 2016 Patient Services 12/4/2014 Copyright Mingle Analytics 15
2017 PQRS and VBM Program Years VBM Naming conventions match PQRS Adjustment Naming Conventions Quality Tiering adjustments apply to payments for claims for patient services provided in the program year This 2015 Final Rule applies primarily to: Patient Services Provided in 2015 PQRS Reporting Completed in 2016 Adjustments to Payments made for services provided in 2017 12/4/2014 Copyright Mingle Analytics 16
3.0% 2.0% 1.0% 0.0% Service Year -1.0% No More Incentive Adjustment stable at 2% First Adjustments Showing up 0.5% We Are (almost) Here 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018-2.0% -3.0% -2% Incentive Adjustment Earned Adjustment Applied Adjustment will be Avoided 12/4/2014 Copyright Mingle Analytics 17
MOC There is still a 0.5% Incentive When PQRS is combined with a Specialty Specific Maintenance of Certification Program (MOC) 12/4/2014 Copyright Mingle Analytics 18
Individual Claims 2015 Reporting Options Available Methods are Unchanged Group Web Interface Tool Registry GPRO Registry Measure Groups Qualified Clinical Data Registry EHR GPRO EHR Certified Survey Vendor 12/4/2014 Copyright Mingle Analytics 19
Claims Measures De-emphasized Measure Selection Reduced for 2015 Will be eliminated at a later date TBD Cited reason: high failure rate 12/4/2014 Copyright Mingle Analytics 20
Submission Deadline March 31 annually 12/4/2014 Copyright Mingle Analytics 21
GPRO Election Deadline June 30 Annually Elect GPRO and Commit to Method 12/4/2014 Copyright Mingle Analytics 22
Reporting Basics Unchanged 9 measures 3 Domains 50 % of eligible Medicare patients Any measure with 0% performance will not be counted 12/4/2014 Copyright Mingle Analytics 23
Not enough Measures? Measure Applicability Validation (MAV) is back for Claims and Registry Reporting New for EHR Reporting: If the CEHRT does not contain data for 9 measures in 3 domains Report all measures for which Medicare Patient Data exists Must have 1 measure 12/4/2014 Copyright Mingle Analytics 24
Cross-Cutting Measures Groups and EPs with at least 1 face to face encounter must submit 1 measure from the cross-cutting set 12/4/2014 Copyright Mingle Analytics 25
Cross-Cutting Measures # Topic Mthd 1 Hemoglobin A1c control C,R,E 46 Medication Reconciliation C,R 47 Care Plan C,R 110 Influenza C,R,E 111 Pneumovax C,R,E 128 BMI and Plan C,R,E 130 Current Medications C,R,E 131 Pain Assessment and Plan C,R 134 Screen for Depression and Plan C,R,E 182 Functional Outcome Assessment and Plan C,R # Topic Mthd 226 Tobacco Use and Plan C,R,E 236 Controlling High Blood Pressure C,R,E 240 Childhood Immunization Status E 317 Screen for HTN and Plan C,R,E 318 Screen for Fall Risk E 321 CAHPS for PQRS Survey S 374 Receipt of Specialist Report E 400 Hepatitis C Screening R 402 Tobacco Use and Plan in Adolescents R,MG 12/4/2014 Copyright Mingle Analytics 26
Consumer Assessment of Healthcare Providers and Systems CG-CAHPS Survey 1. Renamed CAHPS for PQRS 2. CMS no longer Pays for Survey 3. Required for All GPRO submissions for groups 100 Optional in all other cases 12/4/2014 Copyright Mingle Analytics 27
Critical Access Hospitals When hospitals use billing method II, EP who assign billing to the CAH previously unable to participate Hospital must include individual NPI on Claim to Qualify for reporting 2014: Able to participate in all methods other than claims 2015: Able to participate in all methods including claims 12/4/2014 Copyright Mingle Analytics 28
Advice to Critical Access Hospitals (Method 2 UB Billing) Get involved with lobbying efforts for 2014 Reporting (2016 Adjustment Program Year) Relief Regional Medicare Representative Federal Legislators 2015 Get the rendering Provider NPI on the UB Form Choose the GPRO Option by June 30 (if appropriate) 12/4/2014 Copyright Mingle Analytics 29
Measure Groups Requirements Only through Registry Submit 1 measure group 20 Patients 11 Medicare Patients If any measure has 0% performance the Measure Group will not be counted 12/4/2014 Copyright Mingle Analytics 30
Measure Group Changes Discontinued Measure Groups Perioperative care Back pain Cardiovascular prevention Ischemic Vascular Disease (IVD) New Measure Groups Acute Otitis Externa Sinusitis New Measures added to bring Measure count per measure group 6 12/4/2014 Copyright Mingle Analytics 31
Qualified Clinical Data Registry Report 50 % of eligible patients (NOTE: All Patients are Eligible, not just Medicare) Must include 1 outcome measure Must Include one additional measure of the type: Outcome resource use patient experience of care efficiency/appropriate use Safety QCDR May support up to 30 non-pqrs measures Must post data to QCDR Website by April 30 12/4/2014 Copyright Mingle Analytics 32
Web Interface Tool Only applicable to GPRO submissions for 25 Providers Must have one measure with Medicare Patient Data Groups 100 Providers must also submit CAHPS for PQRS Measures reduced 22 17 For all size practices 25 Providers: Report on first consecutive 248 eligible patients for each measure Or all patients if < 248 12/4/2014 Copyright Mingle Analytics 33
Individual and GPRO Measure Changes 49 Measures Discontinued 20 New Measures 23 Measure Domains Recategorized 12/4/2014 Copyright Mingle Analytics 34
Reasons for Measure Retirement 1. Consistent and Universal near-100% Performance 2. Preference for Outcome instead of Process Measures 3. Failure to Identify a Measure Steward 12/4/2014 Copyright Mingle Analytics 35
20 Timing of Prophylactic Antibiotic, Order 28 ASA on Arrival for acute AMI 30 Timing of Prophylactic Antibiotics, Administration 31 VTE Prophylaxis in Stroke 35 Screening for Dysphagia in Stroke 36 Rehabilitation Services Ordered in Stroke 45 Discontinuation of Prophylactic Antibiotics 49 Characterizing Urinary Incontinence 55 EKG for Syncope 56 Vital Signs in CAP 59 Empiric Antibiotics in CAP 64 Assessment of Asthma Control 83 Confirmation of Hepatitis C Viremia 106 Depression Diagnosis and Severity 123 Hemoglobin levels in ESA 142 Assess use of OTC in Osteoarthritis 148 Back Pain, Initial Visit Discontinued Measures 149 Back Pain, Physical Exam 150 Back Pain, Advice for Normal Activity 151 Back Pain, Advice against bed rest 157 Cancer Staging prior to Thoracic Surgery 159 AIDS, CD4+ count 169 CABG, APA at Discharge 170 CABG, BB at Discharge 171 CABG, Lipid Tx at Discharge 197 CAD, Lipid Control 198 HF, LVEF Assessment 228 HF, LVF Testing 231 Tobacco Use Screening 232 Tobacco Use Intervention 233 Performance Status prior to Thoracic Surgery 234 PFT prior to lung resection 245 Wound Surface Culture 246 Wet to Dry Dressings 247 Substance abuse Tx Options 12/4/2014 Copyright Mingle Analytics 36 248 Screening for Depression in Substance Abuse 266 Seizure type and frequency 267 Epilepsy, documentation of etiology 269 IBD Characterization 272 Flu shots in IBD 273 Pneumovax in IBD 296 HTN, lipid profile 297 HTN, Proteinuria 298 HTN, Serum Creatinine 299 HTN, Diabetes Screening 300 HTN, BP Control 301 HTN, LDL Control 302 HTN, lifestyle modifications 341 HIV Visit Gaps
Informal Review Must be requested within 60 days following publication of the feedback report Data can be RESUBMITTED Not submitted for the first time Must be by a third party. Not available for claims, EHR Direct, or web interface 12/4/2014 Copyright Mingle Analytics 37
PQRS MEASURE APPLICABILITY VALIDATION (MAV) When a group or individual reports fewer than nine PQRS measures fewer than 3 Domains no Cross-Cutting Measures MAV will be applied Only applies to Registry or Claims submissions Passing MAV Means Avoiding the Adjustment With as few as one Measure 12/4/2014 Copyright Mingle Analytics 38
MAV Clusters Measures that share a common theme denominator criteria 2 to 7 Measures per MAV Many Measures Stand Alone If you submit one measure in a cluster You are expected to be able to submit all Medicare will analyze claims to understand if there are eligible instances for other measures in the cluster 12/4/2014 Copyright Mingle Analytics 39
PQRS 2015 Submit 9 Measures 3 Domains 1CC NO MAV CMS test for other applicable measures Other applicable Measures not submitted 2% PQRS Adjustment YES No Adjustment No other Applicable measures +4% +2% VBM Quality Tiering No Adjustment -2% -4% Group Size < 10 10 2% VBM Adjustment 4% VBM Adjustment 12/4/2014 Copyright Mingle Analytics 40
Pause for Questions about PQRS Before moving on to: VALUE BASED MODIFIER 12/4/2014 Copyright Mingle Analytics 41
Long Term Plan for VBM Gradual Implementation Expect More Measures Quality expressed in comparative terms Increased stratification into Provider Peer Groups Finer payment distinctions Greater Rewards (Penalties) 12/4/2014 Copyright Mingle Analytics 42
VBM Applies to all groups 2 Physicians and to Solo Physicians for the 2017 Program Year (2015 performance year) Physician = doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, optometry, and chiropracty 12/4/2014 Copyright Mingle Analytics 43
VBM Applies to Non-Physicians in Groups and in solo practice in the 2018 Program Year (2016 performance year) 12/4/2014 Copyright Mingle Analytics 44
Mandatory Quality Tiering for All Groups of 1-9 exempt from downward adjustment for first year 12/4/2014 Copyright Mingle Analytics 45
Payment-at-risk to double 2% 4% for groups of 10 or more Solo Physicians and groups < 10 subject to 2% for 2017 12/4/2014 Copyright Mingle Analytics 46
Informal Review for VBM To be synchronized with PQRS Informal Review dates and processes For VBM Program Year 2015, requests accepted through Feb 28, 2015 Only possible action is to classify Quality as Average For subsequent years, requests due 60 days after publication of QRUR Classify as average OR Resubmit/recalculate quality metrics 12/4/2014 Copyright Mingle Analytics 47
VBM 2017 (2015 Year of Care) Submit PQRS YES VBM Quality Tiering NO 2% PQRS Adjustment + Low Quality Groups of 1-9 Avg Quality High Quality Low Quality Groups of 10 or More Avg Quality High Quality Group Size 10 < 10 4% VBM Adjustment 2% VBM Adjustment 0 +1% +2% 0 0 +1% 0 0 0 Low Cost Avg Cost High Cost 0 +2% +4% -2% 0 +2% -4% -2% 0 Low Cost Avg Cost High Cost 12/4/2014 Copyright Mingle Analytics 48
Statistically Speaking 80% of Participants 10% of Participants 5% 90% 5% Low Quality Avg Quality High Quality 0 +2% +4% -2% 0 +2% -4% -2% 0 Low Cost Avg Cost High Cost 10% of Participants 5% 90% 5% High and Low Defined as 1 Standard Deviation above or below the mean 12/4/2014 Copyright Mingle Analytics 49
Pause for Questions about VBM Before moving on to: PHYSICIAN FEEDBACK PROGRAM 12/4/2014 Copyright Mingle Analytics 50
Quality and Resource Use Report (QRUR) Annual report for TIN Practices Get it at the CMS Enterprise Portal (PV-PQRS) Cost performance Quality Performance Specialty Adjusted Benchmarks PQRS Measure Performance Episode Costs (Episode Groupers) Existing: CHF, Chronic COPD/Asthma, Acute COPD/Asthma, Permanent Pacemaker, Bilateral Cataract/IOLI New: Pneumonia(all, IP, OP), Acute Coronary Syndrome(alone, PCI, CABG), Ischemic Heart Disease(with ACS, without ACS, CABG without ACS, PCI without ACS), 12/4/2014 Copyright Mingle Analytics 51
2015 Reporting Options 2015 PQRS Outcome Tree Individual Group Claims Web Interface Tool Registry GPRO Registry Measure Groups Ask Questions or Contact us: (866)359-4458 Submit 9 Measures 3 Domains 1CC YES No Adjustment NO Pass MAV CMS test for other applicable measures 2% VBM Adjustment Fail Group < 10 Size 10 2% PQRS Adjustment 4% VBM Adjustment EHR GPRO EHR www.pqrssolutions.com VBM Quality Tiering Qualified Clinical Data Registry Certified Survey Vendor Daniel.Mingle@PQRSsolutions.com Gay.DeHart@PQRSsolutions.com Kash.Basavappa@PQRSsolutions.com +4% +2% No Adjustment -2% -4% 12/4/2014 52