Physician Quality Reporting System & VBPM, 2015 Andrew Bienstock Transformation Support Services Manager 1
Agenda 1. PQRS Penalty 2. PQRS Eligibility 3. PQRS Reporting Options 4. Value Based Payment Modifier Participation Quality Measures Cost Measures Quality Tiering QRUR 5. MIPS 6. Q&A 2
Payment Adjustments (PQRS) 2015-1.5% Based on 2013 reporting period Letters sent by CMS December 2014 2016-2.0% Based on 2014 reporting period Letters sent in Fall 2015 2017-2.0% Based on this year s (2015) reporting period 3
PQRS Penalties (Per Provider) Allowable Charges 1.5 % Penalty 2% Penalty $50,000 $750 $1,000 $75,000 $1,125 $1,500 $100,000 $1,500 $2,000 $125,000 $1,875 $2500 $150,000 $2,250 $3,000 $175,000 $2,625 $3,500 $200,000 $3,000 $4,000 4
Determining Eligibility - PQRS Eligible professionals who may participate in Physician Quality Reporting (must bill Medicare under provider NPI to be eligible) Physicians Practitioners Therapists MD, DO, Doctor of Podiatric Medicine, Doctor of Optometry, Doctor of Dental Surgery, Doctor of Dental Medicine, Doctor of Chiropractic PA, NP, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant), Certified Nurse Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional, Audiologists Physical Therapist, Occupational Therapist, Qualified Speech-Language Therapist 5
PQRS Overview Report on 9 measures in 3 quality domains Quality domains: Clinical Care, Patient Experience, Population/Community Health, Patient Safety, Care Coordination, Efficiency If only 1 measure applies it will count (claims and registry) Measure Aplicability Validation Process (MAV) - Subspeciality Performance rate (numerator) can t be zero Need to report on one Cross Cutting Measure (claims and registry) broadly applicable measures 6
PQRS Measure Example PQRS 236: Blood Pressure Management Domain: Clinical Process/Effectiveness FYI: How PQRS 236 aligns with other quality reporting programs Description: percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year. Instructions: this measure is to be reported a minimum of once per reporting period for patients with hypertension seen during the reporting period. The performance period for this measure is 12 months. 7
PQRS Example (continued) Blood Pressure Management Denominator: Patients 18 through 85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period. Numerator: Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg) during the measurement period. 8
4 Methods for PQRS Reporting Choose one of the following: 1. Claims based 2. Registry 3. EHR Direct 4. Data Submission Vendors (DSVs) 9
Claims Based Reporting (PQRS) Medicare providers submit claims (via CMS-1500 Form) for reimbursement on payable services rendered to Part B beneficiaries Eligible professionals use their individual NPI to submit for services on Medicare Part B beneficiaries Standardized reporting codes Provider documents Quality Data Codes (QDC) on claim 50% reporting rate 10
Registry Reporting (PQRS) What is a registry? Entity that captures and stores clinically related data Submits on behalf of providers for a cost ($250-$350) 2015 Qualified Registries: www.cms.gov/pqrs 50% reporting rate Measure Groups (20 Patients) - Disease Specific Good for paper charts 4 measures smallest measure group 11
Registry Reporting (continued) Group Practice Reporting Option (GPRO) Any practice with two or more providers Report measures as a practice Same 9 measures for all providers Had to register as a GPRO between April 1, 2015 Sept. 30, 2015 Once you register you have to commit to GPRO for the reporting year 12
EHR Direct Reporting (PQRS) Report on 9 PQRS quality measures for 2015 calendar year through EHR Direct Practice submits measures to CMS via secure portal EIDM (Enterprise Identity Management) Can submit EHR Direct as GPRO 80% Reporting Rate 13
Data Submission Vendors (PQRS) Report on 9 PQRS quality measures for 2015 calendar year through Data Submission Vendor (DSV) Can now submit GPRO option with Data Submission Vendor 80% Reporting Rate 14
Value Based Payment Modifier (VBPM) 15
Value Based Payment Modifier (VBPM) Pay for Performance based on Quality and Cost By Participating in PQRS you automatically are participating in VBPM Penalty: 2015 program year Solo Providers and Groups with 2-9 providers 2% penalty 2017 Penalty 2015 program year Groups of 10+ 4% penalty in 2017 Ranked in terms of Quality and Cost against other providers 2015 all providers participate in VBPM 16
VBPM Quality Measures Quality Measures (Composite Score) Measures you successfully submit for PQRS All Cause Readmission Composite of Acute Prevention Quality Indicators (bacterial pneumonia, urinary tract infection, dehydration) Composite of Chronic Prevention Quality Indicators (chronic obstructive pulmonary disease, heart failure, diabetes) 17
VBPM Cost Measures Cost Measures (Composite Score) Total per capita costs measure (annual payment standardized and risk-adjusted Part A and Part B costs) Total per capita costs for beneficiaries with four chronic conditions: COPD, Heart Failure, Coronary Artery Disease, Diabetes 18
VBPM Quality Tiering, 2015 Solo Providers & Groups of 2-9 Providers Groups with 10+ Providers Low Quality Avg. Quality High Quality Low Quality Avg. Quality High Quality Low Cost +0.0% +1.0x +2.0x Avg. Cost +0.0% +0.0% +1.0x High Cost +0.0% +0.0% +0.0x Low Cost +0.0% +2.0x +4.0x Avg. Cost -2.0% +0.0% +2.0% High Cost -4.0% -2.0% +0.0x *In order to maintain budget neutrality, CMS will first aggregate the downward payment adjustments in the above table with the -4% adjustments for groups of physicians subject to the VBM. Using the total downward payment adjustment amount, CMS will then solve for the upward payment adjustment payment factor (x). 19
VBPM: QRUR Quality Review Utilization Report Report to see your Value Based Payment Modifier score. It will detail each of the measure and how you score. Important to review to see where you stand. Will come out in the fall of each year. Includes panel. 8% (estimate) of practices nation wide will receive an incentive, 11% (estimate) will receive a negative adjustment and the remainder will receive no adjustment. 20
Penalties Add Up for Non-Participation Performance Year Payment Year MU Penalty PQRS Penalty VBPM Penalty Total Penalties 2013 2015 1-2% 1.5% 1% 3.5-4.5% 2014 2016 2% 2% 2-4% 6-8% 2015 2017 3% 2% 2-4% 7-9% 2016 2018 3-4% 2% TBD by CMS TBD by CMS 2017 2019 3-5% 2% TBD by CMS TBD by CMS 21
MACRA Law & the New MIPS Program The SGR repeal law: Passed in April 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) bill Combines Meaningful Use, PQRS, and other quality initiatives into a new program called MIPS. Physicians will also be able to opt for an alternative program involving slightly higher payments in return for participation in certain Alternative Payment Models (APMs). 22
Merit-based Incentive Payment System (MIPS) Four Focus Areas: 1. Quality (PQRS Measures) 2. Resource Use (Cost Measures, VBPM) 3. Clinical Practice Improvement Activities (PCMH, Patient Satisfaction, in addition new measures) 4. Meaningful Use Payment Adjustment 2019 could range from +/- 4% 2022 could range from +/- 9% Higher payment positive adjustment for highest MIPS performers 23
Contact Information Andrew Bienstock, MHA Transformation Support Services Manager CORHIO abienstock@corhio.org 720-737-4493 24