PQRS IN 2015: WHAT YOU NEED TO KNOW. James R. Christina, DPM Director Scientific Affairs

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1 PQRS IN 2015: WHAT YOU NEED TO KNOW James R. Christina, DPM Director Scientific Affairs

2 IS IT TOO LATE TO SUBMIT PQRS FOR 2014 If you are simply trying to avoid the penalty and you utilize an EHR you can still sign up with a registry and report for 2014: Report on the Diabetes Measure Group (must report on 20 patients with DM with at least 11 being Medicare Part B) reporting on all measures in the group for all 20 patients (successfully doing this avoids penalty and earns incentive) Report on measures 126, 127 and 163 (the diabetic foot measures) a registry would allow you to report that you did not do the measure on a patient so you meet the 50% threshold for each measure however, it will show a very poor performance on the measure however you must perform each measure on at least one patient (0% performance on a measure will not be counted)

3 PQRS IN 2015: A SNAPSHOT No more incentive payments--participation is required to avoid the 2017 payment reduction (2% of all Medicare Part B FFS payments) All eligible professionals who do not meet the criteria for satisfactory reporting or satisfactory participation for the 2017 PQRS payment adjustment will be subject to the 2017 PQRS payment adjustment with no exceptions The 2015 PQRS includes the following reporting mechanisms: claims; qualified registry; EHR (including direct EHR products and EHR data submission vendor products); the Group Practice Reporting Option (GPRO) web interface; certified survey vendors-- for the CAHPS for PQRS survey measures; and the QCDR. The push is for registry and EHR reporting In the future it will become more and more difficult for providers to participate in PQRS without an EHR

4 2017 PAYMENT ADJUSTMENTS

5 MEASURE UPDATES FOR 2015

6 QUALIFIED REGISTRY UPDATES

7 QUALIFIED CLINICAL DATA REGISTRY (QCDR) UPDATES

8 DIRECT EHR AND EHR DATA SUBMISSION VENDOR (DSV) UPDATES

9 CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS) FOR PQRS UPDATES

10 REQUIREMENTS: CLAIMS AND REGISTRY REPORTING For the 12-month reporting period for the 2017 PQRS payment adjustment (which is 2015), report at least 9 measures, covering at least 3 of the NQS domains AND report each measure for at least 50 percent of the eligible professional s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Of the measures reported, if the eligible professional sees at least 1 Medicare patient in a face-to-face encounter, the eligible professional will report on at least 1 measure contained in the cross-cutting measure set. If less than 9 measures apply to the eligible professional, the eligible professional would report up to 8 measure(s), AND report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.

11 REQUIREMENTS: DIRECT EHR PRODUCT THAT IS CEHRT OR AN EHR DATA SUBMISSION VENDOR (DSV) For the 12-month reporting period for the 2017 PQRS payment adjustment, report 9 measures covering at least 3 of the NQS domains. If an eligible professional s CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the eligible professional would be required to report all of the measures for which there is Medicare patient data. An eligible professional would be required to report on at least 1 measure for which there is Medicare patient data.

12 REQUIREMENTS: QUALIFIED CLINICAL DATA REGISTRY (QCDR) For the 12-month reporting period for the 2017 PQRS payment adjustment, report at least 9 measures available for reporting under a QCDR covering at least 3 of the NQS domains, AND report each measure for at least 50 percent of the eligible professional s patients. Of these measures, the eligible professional would report on at least 2 outcome measures, OR, if 2 outcomes measures are not available, report on at least 1 outcome measures and at least 1 of the following types of measures resource use, patient experience of care, efficiency/appropriate use, or patient safety.

13 NATIONAL QUALITY STRATEGY DOMAINS 1. Person and Caregiver-Centered Experience Outcomes Measures that reflect the potential to improve patient-centered care and the quality of care delivered to patients. They emphasize the importance of collecting patient-reported data and the ability to impact care at the individual patient level as well as the population level through greater involvement of patients and families in decision making, self-care, activation, and understanding of their health condition and its effective management. (Formerly Patient and Family Engagement Ensuring that each person and family is engaged as partners in their care.) 2. Patient Safety Making care safer by reducing harm caused in the delivery of care. Measures that reflect the safe delivery of clinical services in both hospital and ambulatory settings and include processes that would reduce harm to patients and reduce burden of illness. These measures should enable longitudinal assessment of condition-specific, patient-focused episodes of care. 3. Communication and Care Coordination Promoting effective communication and coordination of care. Measures that demonstrate appropriate and timely sharing of information and coordination of clinical and preventive services among health professionals in the care team and with patients, caregivers, and families to improve appropriate and timely patient and care team communication. 4. Community, Population and Public Health Working with communities to promote wide use of best practices to enable healthy living. Measures that reflect the use of clinical and preventive services and achieve improvements in the health of the population served. These are outcome-focused and have the ability to achieve longitudinal measurement that will demonstrate improvement or lack of improvement in the health of the US population. 5. Efficiency and Cost Reduction Use of Healthcare Resources Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. Measures that reflect efforts to significantly improve outcomes and reduce errors. These measures also impact and benefit a large number of patients and emphasize the use of evidence to best manage high priority conditions and determine appropriate use of healthcare resources. 6. Effective Clinical Care Promoting the most effective prevention and treatment practices for the leading causes of mortality. Measures that reflect clinical care processes closely linked to outcomes based on evidence and practice guidelines.

14 REPORTING VERSUS PERFORMANCE Reporting means that you reporting one of the codes associated with a quality measure Performance means that you did the prescribed measure For example for measure 163 (Diabetic Foot Exam) you report the code: G9225: Foot Exam not Performed, Reason not Given you have successfully reported measure 163 However, if you report G9225 for measure 163, performance would not be met The measure specifications will indicate with the code to report if performance is met or not

15 CLAIMS REPORTING: AN IN DEPTH LOOK Measure # (Domain) 20 (PS) 21 (PS) 22 (PS) Measure Description Status for CY 2015 Perioperative Care: Timing of Prophylactic Antibiotic-Ordering Physician Perioperative Care: Selection of Prophylactic Antibiotic Perioperative Care: Discontinuation of Prophylactic Antibiotic Deleted Retained but only reportable through claims and registry as Perioperative Care Measures Group has been removed Retained but only reportable through claims and registry as Perioperative Care Measures Group has been removed 46 (CCC) *Medication Reconciliation Retained but domain changed to Communication and Care Coordination (CCC); claims-based reporting retained 110 (C/PH) 111 (C/PH) 128 (C/PH) 130 (PS) *Preventive Care and Screening: Influenza Immunization *Pneumonia Vaccination Status for Older Adults *Preventive Care and Screening: Body Mass Index (BMI) Screening and F/U *Documentation of Current Medications in Medical Record No change; claims, registry and EHR reporting mechanisms available Retained but domain changed to C/PH; claims, registry and EHR reporting mechanisms available No change; claims, registry and EHR reporting mechanisms available No change; claims, registry and EHR reporting mechanisms available 131 (C/PH) *Pain Assessment and Follow-Up No change; claims and registry reporting mechanisms available 154 (PS) Falls: Risk Assessment No change; claims and registry reporting mechanisms available 155 (CCC) Falls: Plan of Care No change claims and registry reporting mechanisms available 163 (ECC) Diabetes Mellitus: Foot Exam 226 (C/PH) 245 (ECC) 246 (ECC) 317 (C/PH) *Preventive Care and Screening: Tobacco Use: Screening and Cessation Chronic Wound Care: Use of Wound Surface Culture Technique Chronic Wound Care: Use of Wet to Dry Dressings in Patients *Preventive Care and Screening: Screening for High Blood Pressure and F/U documented No change: claims, registry and EHR reporting mechanisms available No change; claims, registry and EHR reporting mechanisms available Deleted Deleted No change; claims, registry and EHR reporting mechanisms available *indicates cross cutting measure

16 AVAILABLE FOR 2015 REPORTING BY CLAIMS Measure # (Domain) 46 (CCC) *Medication Reconciliation 110 (C/PH) 111 (C/PH) Measure Description Status for CY 2015 *Preventive Care and Screening: Influenza Immunization *Pneumonia Vaccination Status for Older Adults Retained but domain changed to Communication and Care Coordination (CCC); claims-based reporting retained No change; claims, registry and EHR reporting mechanisms available Retained but domain changed to C/PH; claims, registry and EHR reporting mechanisms available 128 (C/PH) 130 (PS) *Preventive Care and Screening: Body Mass Index (BMI) Screening and F/U *Documentation of Current Medications in Medical Record No change; claims, registry and EHR reporting mechanisms available No change; claims, registry and EHR reporting mechanisms available 131 (C/PH) *Pain Assessment and Follow-Up No change; claims and registry reporting mechanisms available 154 (PS) Falls: Risk Assessment No change; claims and registry reporting mechanisms available 155 (CCC) Falls: Plan of Care 163 (ECC) Diabetes Mellitus: Foot Exam 226 (C/PH) 317 (C/PH) *Preventive Care and Screening: Tobacco Use: Screening and Cessation *Preventive Care and Screening: Screening for High Blood Pressure and F/U documented No change proposed for CY 2015; claims and registry reporting mechanisms available No change: claims, registry and EHR reporting mechanisms available No change; claims, registry and EHR reporting mechanisms available No change; claims, registry and EHR reporting mechanisms available *indicates cross-cutting measure Measure # (Domain) 21 (PS) 22 (PS) Measure Description Status for CY 2015 Perioperative Care: Selection of Prophylactic Antibiotic Perioperative Care: Discontinuation of Prophylactic Antibiotic Retained but only reportable through claims and registry as Perioperative Care Measures Group has been removed Retained but only reportable through claims and registry as Perioperative Care Measures Group has been removed

17 IN-DEPTH LOOK AT A MEASURE CMS publishes a measures specification manual (for both individual and group measures)that details everything about a particular measure Denominator: describes what patients are eligible for a particular measure Numerator: describes what has to be done for that eligible patient on a particular visit to have successfully performed the measure Your performance on a particular measure is calculated by all eligible patients for a particular measure that you see (denominator) and all eligible patients you perform the measure on (numerator)

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19 MEASURE 130: DOCUMENTATION OF CURRENT MEDICATIONS IN THE MEDICAL RECORD

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21 REQUIREMENTS: MEASURE GROUP REPORTING For the 12-month reporting period for the 2017 PQRS payment adjustment, report at least 1 measures group AND report each measures group for at least 20 patients, the majority (11 patients) of which are required to be Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent performance rate will not be counted.

22 DIABETES MEASURES GROUP FOR 2015 AND BEYOND Measure groups must be submitted through a qualified registry

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25 SUMMARY OF REQUIREMENTS FOR THE 2017 PQRS PAYMENT ADJUSTMENT: INDIVIDUAL REPORTING CRITERIA FOR THE SATISFACTORY REPORTING OF QUALITY MEASURES DATA VIA CLAIMS, QUALIFIED REGISTRY, AND EHRS AND SATISFACTORY PARTICIPATION CRITERION IN QCDRS

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27 SUMMARY OF REQUIREMENTS FOR THE 2017 PQRS PAYMENT ADJUSTMENT: GROUP PRACTICE REPORTING CRITERIA FOR SATISFACTORY REPORTING OF QUALITY MEASURES DATA VIA THE GPRO

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30 VALUE BASED PAYMENT MODIFIER (VM) Section 1848(p) of the Act requires that we establish a value-based payment modifier (VM) and apply it to specific physicians and groups of physicians the Secretary determines appropriate starting January 1, 2015, and to all physicians and groups of physicians by January 1, Section 1848(p)(4)(C) of the Act requires the VM to be budget neutral.

31 VALUE MODIFIER UPDATES

32 HOW DOES CMS USE THE QUALITY AND COST MEASURES TO CREATE A VALUE MODIFIER PAYMENT ADJUSTMENT Each group receives two composite scores (quality and cost) CMS uses the following steps to create each composite: Create a standardized score for each measure (performance rate for performance period prior year benchmark / standard deviation) Equally weight each measure s standardized score within each domain. Equally weight each domain s score into the composite score.

33 QUALITY-TIERING METHODOLOGY

34 A FOCUS ON MEASUREMENT AND ALIGNMENT Measures for the VM should consistently reflect differences in performance among groups or solo practitioners, reflect the diversity of services furnished, and be consistent with the National and CMS Quality Strategies and other CMS quality initiatives, including the PQRS, the Shared Savings Program, and the Medicare EHR Incentive Program.

35 A FOCUS ON PHYSICIAN AND ELIGIBLE PROFESSIONAL CHOICE Physicians and other non-physician eligible professionals should be able to choose the level (individual or group) at which their quality performance will be assessed, reflecting eligible professionals choice over their practice configurations. The choice of level should align with the requirements of other physician quality reporting programs.

36 A FOCUS ON SHARED ACCOUNTABILITY The VM can facilitate shared accountability by assessing performance at the group level and by focusing on the total costs of care, not just the costs of care furnished by an individual professional.

37 A FOCUS ON ACTIONABLE INFORMATION The Quality and Resource Use Reports (QRURs) should provide meaningful and actionable information to help groups and solo practitioners identify clinical, efficiency and effectiveness areas where they are doing well, as well as areas in which performance could be improved by providing groups and solo practitioners with QRURs on the quality and cost of care they furnish to their patients.

38 A FOCUS ON A GRADUAL IMPLEMENTATION The VM should focus initially on identifying high and low performing groups and solo practitioners. As we gain more experience with physician measurement tools and methodologies, we can broaden the scope of measures assessed, refine physician peer groups, create finer payment distinctions, and provide greater payment incentives for high performance.

39 GRADUAL IMPLEMENTATION In the 2013 PFS final rule, VM scheduled to be applied to physicians in groups of 100 or more starting January 1, In the 2014 PFS final rule, VM scheduled to be applied to physicians in groups of 10 or more starting January 1, In the 2015 PFS final rule, VM to all physicians in groups with two or more eligible professionals and to solo practitioners starting in CY 2017.

40 ELIGIBLE PROFESSIONAL/PHYSICIAN GROUP SIZE DISTRIBUTION (2013 CLAIMS)

41 APPLICATION OF THE 2017 VALUE- BASED PAYMENT MODIFIER AND PQRS

42 CALCULATION OF THE 2017 VALUE MODIFIER USING THE QUALITY-TIERING APPROACH

43 MEANINGFUL USE FOR 2015 The flexibility rule extended Stage 2 through 2016, so right now the earliest anyone will have to report Stage 3 is 2017 Beginning in CY 2015, EPs are not required to ensure that their CEHRT products are recertified to the most recent version of the electronic specifications for the CQMs. Although CMS is not requiring recertification, EPs must still report the most recent version of the electronic specifications for the CQMs. For 2015, all eligible providers will be required to use a 2014 CEHRT and the reporting period will be the entire year (unless 2015 is your first year attesting to MU)

44 QUESTIONS? James R. Christina, DPM