An Overview

Presented by the Connecticut State Medical Society

• The New England Quality Innovation Network-

Quality Improvement Organization (QIN-QIO) is administered by Healthcentric Advisors in partnership with Qualidigm. Together, they serve as the QIN-QIO for all six New England states.

• CSMS is assisting the New England QIN-QIO in

developing and disseminating information about Medicare quality programs.

PQRS?

What is PQRS?

Medicare’s Physician Quality Reporting System

• A pay-for-reporting program that gives eligible professionals (EPs) incentives and payment adjustments for satisfactory reporting of quality measures

• Physician participation helps improve the quality of care

• Satisfactory reporting of 2015 data will avoid 2017 Payment Adjustments for PQRS and the Value Modifier (VM)

2015: What You Need to Know There is a 2-year lag between reporting and payment

adjustment

• The 2015 payment adjustment is based on your reported 2013 data

• If you did not report 2014 data, it’s too late to avoid a 2016 payment adjustment

• It’s not too late to avoid a 2017 payment adjustment

• This is the first year that PQRS performance will be used to determine your Value-Based Payment Modifier (VM) – more on that later

The ABCs of PQRS

PQRS: Five Basic Questions

• Who can participate? • How do you want to participate? • What measures will you report? • How will you report your data? • How do you calculate your payment adjustment?

Who Can Participate in PQRS? CMS recognizes 2 types of Eligible Professional (EP):

Medicare Physicians Practitioners 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* (and Anesthesiologist Assistant) Certified Nurse Midwife* Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists *Includes Advanced Practice Registered Nurse (APRN)

How Do You Want to Participate?

• As an Individual EP? • As part of a group practice?

Individual Group

Individual National Practitioner Identification (NPI) and Tax Identification Number (TIN)

A single TIN with 2+ Individual EPs who have reassigned billing to a group TIN Groups using the Group Practice Reporting Option (GPRO) can be analyzed at the Group TIN level

a/k/a “PQRS Group Practices”

Select Your Measures

Factors to consider:

• Clinical conditions you usually treat • Types of care you typically provide (preventive,

chronic, acute) • Settings where care is usually delivered (office, ED,

surgical suite) • Your quality improvement goals for 2015 • Other quality programs you use, or are considering

Select Your Measures: How Many?

9 Individual Measures across 3 National Quality Strategy

domains

OR

1 Measures Group* (not available for GPRO web interface)

1 cross-cutting measure

Required if you have at least 1 face-to-face encounter with a Medicare patient

* For 2015, PQRS measure groups are reportable only through a registry

Select Your Measures: Choices Individual Measures Measures Groups

2015 PQRS Measures List 2015 PQRS Measures List

2015 PQRS Quality Data Code (QDC) Categories

2015 PQRS Quality Data Code (QDC) Categories

2015 Cross-Cutting Measures List 2015 Cross-Cutting Measures List

2015 Measure Specifications Manual for Individual Claims*

2015 Measures Groups Specifications Manual for registry-based reporting*

2015 PQRS Individual Measures Single Source

2015 PQRS Measures Groups Single Source

2015 PQRS Measures Groups Release Notes

2015 PQRS Implementation Guide

2015 PQRS List of Face-to-Face Encounter Codes

*TIP: Just print the pages for the measures specifications you are reporting (these are large documents)

Using a Measures Group? • Measures Group specifications are different from those of

the individual measures that form the measures group • A majority of the patients in the measures group have to be

Medicare Part B FFS patients (at least 11 out of 20). • Review Getting Started with 2015 PQRS Reporting of

Measures Groups on the Measures Codes page of the CMS PQRS website.

*Please note that Measures Groups are not available to PQRS

group practices (GPRO)

How Will You Report?

Individual Group

Medicare Part B claims Web interface (groups of 25+)

Qualified Clinical Data Registry (QCDR) CAHPS for PQRS (using CMS-certified survey vendor – groups of 2+) to supplement GPRO

Qualified PQRS Registry Qualified PQRS Registry

Direct EHR (CEHRT) Direct EHR (CEHRT)

CEHRT with data submission vendor CEHRT with data submission vendor

Individual Reporting Options Medicare Part B Claims

• Report the Quality Data Code (QDC) on each eligible claim that falls into the eligible patient (denominator) population.

• If you don’t submit a QDC on claims for these patients, it will result in a “missed” reporting opportunity and can affect your payment adjustment

Individual Reporting Options QCDR

• A Qualified Clinical Data Registry is a CMS-approved entity (registry, certification board, collaborative, other) that collects medical and/or clinical data to support improvements to patient care quality

• QCDR data isn’t limited to Medicare beneficiaries – it includes multiple payers

• A QCDR isn’t limited to current PQRS measures – it can include up to 20 “non-PQRS” measures

Individual and Group Reporting Qualified PQRS Registry

CMS has a list of Qualified registries, including contact information, cost and other details

• Be sure to provide the correct TIN/NPI combination to your registry for payment adjustment purposes

• Your registry will provide specific instructions on how and when to submit data

• The 2015 PQRS data submission window will be in the first quarter of 2016

Individual and Group Reporting Direct EHR (CEHRT*)

Be sure that your Electronic Health Record is certified to the correct eCQM version

Your EHR will submit PQRS data directly to CMS

in the correct format on your behalf *Certified Electronic Health Record Technology

Individual and Group Reporting CEHRT w/Data Submission Vendor

A Data Submission Vendor (DSV) is an entity that collects clinical quality data directly from the EP’s or PQRS group practice’s CEHRT.

DSVs submit PQRS measures data to CMS on

behalf of the EP or the PQRS group practice via a CMS-specified format(s).

Group Reporting GPRO Web Interface

Web interface reporting is available for groups of 25+ EPs • CMS pre-populates the GPRO Web Interface with a

sample patient population. • You must successfully complete 17 Web Interface

measures for the required number of patients. • Once your group TIN has registered in GPRO, the

reporting mechanism chosen is the only PQRS submission mechanism that CMS will analyze to determine payment adjustment for the group and all individual associated NPIs who bill Medicare under the group's TIN.

Group Reporting CAHPS for PQRS

This is an extra and companion reporting option for groups with 2-99 EPs, and for EHR and registry reporting (required for group practices of 100+ EPs).

• In 2015, groups have 3 options to report with CAHPS for PQRS: – PQRS group practices of 2+ EPs reporting via qualified

registry with CAHPS for PQRS – PQRS group practices of 2+ EPs reporting via EHR with

CAHPS for PQRS – PQRS group practices of 25-99 EPs reporting via GPRO

Web Interface

Key Reporting Dates

June 30, 2015 • Last day to register for GPRO (group reporting)

December 31, 2015 • Reporting ends for 2015 PQRS program year

January 1, 2016 • Reporting begins for 2016 PQRS program year • Payment adjustments begin for groups & individuals who did not satisfactorily report 2014 quality data

Key Reporting Dates February 26, 2016 • Last day 2015 claims will be processed to count for PQRS reporting,

determining 2017 payment adjustment

February 29, 2016 • Last day to submit 2015 CQMs for dual participation in PQRS

and the Medicare EHR Incentive Program • Last day for QCDRs (QRDA) and EHRs to submit 2015 data

March 31, 2016 • Last day for QCDRs (QCDR XML only) and registries to submit

2015 data

Value Modifier

Value Modifier (VM)

• New in 2017 • VM is based on 2015 PQRS participation

o Non-participation or unsatisfactory reporting = downward adjustment

o Satisfactory reporting = upward adjustment • Quality tiering incentive

o Methodology used to evaluate performance on cost and quality measures

o VM Adjustment Factor based on quality tier

Value Modifier (VM) • VM assesses both quality of care furnished and

the cost of that care under the Medicare Physician Fee Schedule (MPFS)

• A per-claim adjustment to MPFS applied at the group TIN level; varies by calendar year

• For 2015 and 2016, the VM does not apply to groups participating in – Comprehensive Primary Care Initiative (CPCI) – Medicare Shared Savings Programs (MSSP) – Pioneer ACOs

2017 VM Adjustment Factor

• Max +2.0x for solo, 2-9 EPs* • Max +4.0x for 10+ EPs* Upward

• No adjustment Neutral

• Solo, 2-9 EPs held harmless • Max -4.0x for 10+ EPs Downward

*If the average beneficiary risk score is in the top 25%, EPs can receive an additional +1.0x adjustment

Medicare Payment Adjustment: The Big Picture

For solo EPs or groups of 2-9 EPs who successfully participate in PQRS and MU in 2015:

*Solo EPs & groups of 2-9 EPs will be held harmless from downward VM adjustments if they successfully participate in PQRS

**Amount depends on date of first demonstration of MU

PQRS

no downward payment

adjustment in 2017

VM * +2.0x or +1.0x or Neutral

in 2017

MU ** $4,000- $12,000

in 2017

Medicare Payment Adjustment: The Big Picture

For solo EPs or groups of 2-9 EPs who do not participate in PQRS or MU in 2015:

-7.0 % total Medicare payment adjustment in 2017

PQRS -2.0%

payment adjustment in

2017

VM -2.0x

payment adjustment in

2017

MU -3.0%

payment adjustment in

2017

Medicare Payment Adjustment: The Big Picture

For groups of 10+ EPs who Successfully participate in PQRS and MU in 2015:

PQRS

no downward payment

adjustment in 2017

VM +4.0x or +2.0x or Neutral

in 2017

MU $4,000-

$12,000* in 2017

* Amount depends on date of first demonstration of MU

Medicare Payment Adjustment: The Big Picture

For groups of 10+ EPs who do not participate in PQRS or MU in 2015:

Up to -9.0 % Medicare payment adjustment in 2017

PQRS -2.0%

payment adjustment in

2017

VM Up to -4.0x

payment adjustment in

2017

MU -3.0%

payment adjustment in

2017

Medicare Payment Adjustment: Groups of 10+ EPs

Unsuccessful participation in PQRS, non-participation in MU in 2015:

Up to -9.0% Medicare payment adjustment in 2017

PQRS -2.0%

payment adjustment in

2017

VM Up to -4.0x

payment adjustment in

2017

MU -3.0%

payment adjustment in

2017

Mid-Year Quality and Resource Use Reports

QRUR • 2015 Quality and Resource Use Reports data will be

used to calculate the 2017 VM • 2017 is the first year that quality tiering will be

mandatory for solo EPs and 2-9 EPs • Based on 6 cost measures, 3 quality measures

Cost Measures – Per Capita Costs Quality Measures

• All attributed beneficiaries • Beneficiaries with Diabetes • Beneficiaries with COPD • Beneficiaries with CAD • Beneficiaries with Heart Failure • Medicare Spending per Beneficiary (MSPB)

• 30-Day All Cause Hospital Readmission • Acute Ambulatory Care-Sensitive Condition (ACSC) Composite • Chronic ACSC Composite

Mid-Year QRUR (MYQRUR) • 2014 MYQRURs now available • Interim information about performance on 6

cost and 3 quality outcomes measures – These performance measures will be used in the

Annual QRUR (AQRUR) to calculate the 2016 Value Modifier

• MYQRUR information is based on care provided from 7/1/13 - 6/30/14

What Can You Do With MYQRUR?

Use MYQRUR data to • Improve the quality of care • Streamline resource use • Identify care coordination opportunities • Learn more about your TIN’s beneficiary

population and their use of health services • Become aware of all EPs involved in your TIN-

attributed beneficiaries’ care (even if they aren’t part of your TIN)

Summing It Up: Successful 2015 PQRS Participation

No downward 2017 PQRS payment adjustment

+1x / +2x or neutral for solo, 2-9 EPs +2x / +4x or neutral for 10+ EPs

Remember: use your MYQRUR data to identify

opportunities for 2015 cost/quality improvement

PQRS Resources Getting Started http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html PQRS Measures http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html 2015 – 2017 PQRS Timeline http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015-

17_CMS_PQRS_Timeline.pdf Value Modifier https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/What-To-Do-

In-2015-For-The-2017-VM-03-24-15.pdf Payment Adjustment http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-

Information.html MYQRUR http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2014-

Understanding-Your-QRUR.pdf

CSMS provides regular updates on PQRS and other Medicare quality programs: http://csms.org/Medicare

Additional Resources QCDR http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html CEHRT http://www.healthit.gov/policy-researchers-implementers/certified-health-it-product-list-

chpl CAHPs for PQRS http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2015PQRS_CMS-CertifSurveyVendorMadeSimple.pdf Clinical Quality Measures http://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html

Questions?

Thank You!

www.csms.org/Medicare