CMS Programs and Alignment to Date Michael Rapp, M.D., J.D. Director, Quality Measurement and Health Assessment Group, Office of Clinical Standards and Quality March 29, 2012 AMA Meeting 1
Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. CPT only copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 2
Agenda Background/Overview of CMS Programs by Year Alignment Future Issues Question and Answer Session 3
Background OVERVIEW OF CMS PHYSICIAN PROGRAMS BY YEAR 4
Overview of Programs by Year Year Quality Reporting System + MOC erx Program EHR Program Compare Feedback Quality Resource Use Reports and Episode Grouper Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget- Neutral Manner 2011 + 1% incentive + 0.5% MOC More Frequent + 1.0% incentive (not available if receiving EHR incentive for 2011) EHR meaningful use reporting begins Medicare Maximum $44,000 over 4 years or Maximum $63,750 Medicaid over 6 years Launch Compare web site by 1/1/2011; Includes PQRS & erx participation Feedback Reports for limited numbers of physicians as authorized by MIPPA N/A 2012 + 0.5% incentive + 0.5% MOC By 1/1/12 plan to integrate quality reporting EHR incentive program + 1.0% incentive -1.0% adjustment if not successful e-prescriber (regardless of participation in the EHR New Medicare 2012 EHR meaningful users may still receive maximum $44,000 over 4 years or Maximum $63,750 Medicaid over 6 years 1/1/2012 earliest reporting period for which performance information can be reported on Compare By 1/1/2012 develop and establish methodology for use of open source episode grouper to combine closely related items and services into episodes of care and Provide reports that compare resource use beginning 2012 based on claims data, riskadjusted, cost standardized Coordinate with Value Modifier as appropriate Value Modifier: Publish by 1/1/2012 measures of quality and cost, implementation dates, & initial performance period for modifier implemented in budgetneutral manner 55
Overview of Programs by Year (cont.) Year Quality Reporting System + MOC erx Program EHR Program Compare Feedback Quality Resource Use Reports and Episode Grouper Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget- Neutral Manner 2013 + 0.5% incentive + 0.5% Maintenance of Certification Program + 0.5% incentive Last year of erx incentive - 1.5% adjustment New Medicare EHR participants limited to $39,000 maximum over 4 years or Medicaid EHR incentive maximum $63,750 over 6 years By 1/01/2013 implement plan for making performance information on quality and patient experience measures available on web site 2014 + 0.5% incentive + 0.5% MOC program incentive Final year for PQRS incentive and MOC program incentive - 2.0% adjustment Last year of erx adjustment Last year to begin to qualify for Medicare EHR incentive. New participants limited to $24,000 maximum over 3 years or Medicaid EHR incentive maximum $63,750 over 6 years Secretary may include completion of MOC and practice assessment as measure for Value Modifier 66
Overview of Programs by Year (cont.) Year Quality Reporting System erx Program EHR Program Compare Quality Feedback Resource Use Reports and Episode Grouper Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget-Neutral Manner 2015-1.5% adjustment N/A 2015 Medicare adjustment begins for those not Meaningful Users of EHRs - 1 %, or - 2% if for 2014 subject to erx adjustment Submit report to Congress on web site Start of value modifier with a phased implementation so that some physicians or groups of physicians paid under the PFS are subject to modifier No Medicare EHR incentives for those not Meaningful Users in prior years May begin Medicaid EHR incentive maximum $63,750 over 6 years 7
Overview of Programs by Year (cont.) Year Quality Reporting System erx Program EHR Program Compare Feedback Quality Resource Use Reports and Episode Grouper Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget - Neutral Manner 2016-2.0% adjustment N/A Medicare EHR subject to - 2.0% adjustment Last year to begin Medicaid EHR incentive maximum $63,750 over 6 years Value modifier with a phased implementation so that some physicians or groups paid under the PFS are subject to modifier 2017-2.0% adjustment N/A Medicare EHR subject to - 3.0% adjustment Value modifier with a phased implementation so that all physicians and groups paid under the PFS are subject to modifier Payment modifier may apply to eligible professionals other than physicians 8
Overview of Programs by Year (cont.) Year Quality Reporting System erx Program EHR Program Compare Feedback Quality Resource Use Reports and Episode Grouper Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget - Neutral Manner 2018 and beyond - 2.0% adjustment N/A For 2018 and beyond subject to additional - 1.0 % per year if proportion of eligible professionals who are meaningful EHR users is less than 75%; Subject to maximum - 5% Value modifier applies to all physicians and groups paid under the PFS are subject to modifier Payment modifier may apply to eligible professionals other than physicians 9
ACOs Medicare Shared Savings Program ( ACO Program ) Mandated by Section 3022 of the Affordable Care Act Established Accountable Care Organizations (ACOs) effective January 1, 2012 ACOs defined as legal entities that are recognized and authorized under applicable State, Federal or Tribal law, identified by a Taxpayer Identification Number (TIN), and comprised of groups of eligible providers and suppliers (as defined at 425.102) that, according to statute, work together to manage and coordinate care for Medicare fee-for-service beneficiaries ACOs that improve quality of care and reduce growth in expenditures can earn a portion of savings generated 10
CMS Programs ALIGNMENT 11
Alignment (cont.) CMS is striving to align the various quality programs we oversee Not only is this mandated by the Affordable Care Act, but CMS believes this will reduce the burden eligible professionals experience and increase participation in our programs The Affordable Care Act requires the Secretary to have a plan to align PQRS and the EHR M.U. Program by 2012 The 2012 Quality Reporting System-Medicare EHR Pilot actually begins this alignment process 12
Alignment Examples of alignment to date: One HHS-wide set of measures for Million Hearts Allowing the use of an ONC-certified EHR to be used to report the erx measure for the erx Program Previously, the functional requirements of a qualified erx system differed between the 2 programs CMS has launched the Quality Reporting System- Medicare EHR Pilot for 2012 This program introduces a common set of clinical quality measures (CQMs) and a reporting method through which eligible professionals can report to Quality Reporting System and qualify for both incentive programs We will continue to evaluate the pilot, and make improvements as appropriate CMS will evaluate the possibility of introducing EHR group reporting, and further align quality measure reporting in the future 13
Alignment (cont.) Eligible Professional Enter patient information into EHR EHR Direct (Per HITECH Requirements*) * 3 core and/or 3 alt core + 3 Patient Level Data QRDA Level 1 PQRS and HITECH Aggregate HITECH requirements HITECH CQM Reporting Eligible Professional Enter patient information into EHR Data Submission Vendor Either or Both Programs Patient Level QDRA Level 1 PQRS 14
Alignment (cont.) We may add additional measures in 2014 including measures: Not currently part of both 2012 programs Currently being re-tooled That can be e-specified and/or Demonstrate scientific merit (via NQF endorsement or evidencebased review) We envision a state of integration where reporting a single set of measures would demonstrate both use of an ONCcertified EHR and quality of care furnished to an individual Single set of EHR-based measure specifications Single submission would meet requirements for both programs 15
Alignment (cont.) Through integration of the Quality Reporting System and Medicare EHR Program: Reporting of quality measures will be simplified Burden and cost to the eligible professional will be reduced Intended result of improved quality reporting and reliability of the data will be realized Continue to further align Accountable Care Organization (ACO) and Group Practice Reporting Option (GPRO) measures Section 3022 of ACA allows Medicare Shared Savings Program to incorporate the Quality Reporting incentive under its program Eligible professionals of ACO TINS reporting GPRO measures earn Quality Reporting incentive Efforts to align ACO with Quality Reporting and HITECH Consideration of development of single reporting to satisfy multiple programs: Value-based Modifier (VBM), EHR incentive, Quality Reporting, Compare, ACOs 16
CMS Programs FUTURE ISSUES 17
Future Issues Quality Reporting System adjustment begins in 2015 based on reporting in 2013 Utilization of the Quality and Resource Use Reports (QRUR) information for Compare Value-based Modifier begins in 2015 based on performance in 2013 E-prescribing adjustment for participants in the EHR incentive program 18
Future Issues (cont.) Integrating Medicaid EHR reporting with Quality Reporting Continue to work with ABMS and specialty boards to: Implement processes to reduce eligible professional s reporting burden Explore opportunities for alternate data sources Continue to explore opportunities to collect and publicly report patient experience of care measures 19
Resources CMS Quality Reporting website http://www.cms.gov/pqrs CMS erx Program website http://www.cms.gov/erx 2012 PFS Final Rule http://edocket.access.gpo.gov/2010/pdf/2010-27969.pdf Medicare and Medicaid EHR Programs http://www.cms.gov/ehrprograms Feedback Program http://www.cms.gov/physicianfeedbackprogram Compare (for the general public) http://www.medicare.gov/find-a-doctor/provider-search.aspx Physican Compare (for eligible professionals) http://www.medicare.gov/physician-compare-initative Medicare Shared Savings Program http://www.cms.gov/sharedsavingsprogram 20
If You Have Questions QualityNet Help Desk (for PQRS and erx questions only): 866-288-8912 (TTY 877-715-6222) 7:00 a.m. 7:00 p.m. CST M-F or qnetsupport@sdps.org You will be asked to provide basic information such as name, practice, address, phone, and e-mail Please direct inquiries regarding Compare to: Compare@Westat.com Please direct inquiries regarding the Medicare Shared Savings Program to: ACO@cms.hhs.gov For General EHR Programs Questions: EHR-ARRA Information Center: 888-734-6433 (TTY 888-734-6563) 21
Thank You 22