Behavioral Health and CMS Quality Programs January 26, 2015 Agenda - - PowerPoint PPT Presentation

Behavioral Health and CMS Quality Programs

January 26, 2015

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Agenda

• Introduction
• Three CMS Programs

– Meaningful Use – PQRS – MIPS

• MeHI’s Role

– Interpret & Navigate the Regulations – Prepare & Strategize – Services & Solutions

• Questions & Answers
• Facilitated Dialogue

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Current State of Affairs: Behavioral Health

Source: A Place at the Table: Behavioral Health and CMS’ Physician Quality Reporting System. National Council for Behavioral Health.

“If 10% reduction can be made in excess healthcare costs of patients with comorbid psychiatric disorders via an effective integrated medical-behavioral healthcare program, $5.4 million of healthcare savings could be achieved for each group of 100,000 insured members…the cost of doing nothing may exceed $300 billion per year in the United States.23”

High Prevalence High Cost High Co-Morbidity Treatment Challenges

Importance of Behavioral Health Integration

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Barriers to Effective Behavioral Health Integration

Licensing

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Privacy Reimbursement Data Sharing Privacy Laws Provider Access & Training Financial Systems

Source: Barriers to Behavioral Health and Physical Health Integration in Massachusetts, June 2015, Blue Cross Blue Shield Foundation of Massachusetts Source: MassHealth Approaches to Behavioral Health Integration: Integration through Innovation,

• Dr. Julian Harris, Medicaid Director, Health Policy Commission, April 3 2013.

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Expanded Role of Health IT Drives Change

• Payment Reform
• Quality Reporting
• Practice Transformation

Improve Care Delivery Outcomes

Meaningful Use

Al Wroblewski, PCMH CCE Client Services Relationship Manager

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Meaningful Use Eligible Professionals (EPs)

Eligible Professionals

Medicare

• Doctor of medicine or osteopathy (MD or DO)
• Doctor of oral surgery or dental medicine
• Doctor of podiatric medicine
• Doctor of optometry
• Chiropractor

Medicaid

• Physicians (MD or DO)
• Nurse Practitioners
• Certified Nurse-Midwives
• Dentists
• Physician Assistants who furnish services in a Federally Qualified

Health Center (FQHC) or Rural Health Clinic (RHC) led by a Physician Assistant

• Clinical Nurse Specialists – to be determined

CMS Meaningful Use Rules: 2015-2017

CMS Final Rule – Changes to Participation Timeline

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2015 2016 2017 2018

Attest to modified criteria for 2015-2017 (Modified Stage 2) with accommodations for Stage 1 providers Attest to 2015-2017 criteria (Modified Stage 2)* Attest to either 2015-2017 criteria (Modified Stage 2) or full version of Stage 3 using 2015 Edition CEHRT Attest to full version of Stage 3 using 2015 Edition CEHRT

*some alternate exclusions remain in 2016 for Stage 1 providers

CMS Final Rule – Changes to EHR Reporting Periods

• In 2015, all providers attest using an EHR reporting period of any

continuous 90-day period within the calendar year

• In 2016:

– first-time MU participants will attest using any continuous 90-day period within the calendar year – returning participants will attest using a full calendar year (January 1, 2016 through December 31, 2016)

• In 2017:

– first-time MU participants and anyone choosing to demonstrate Stage 3 will attest using any continuous 90-day period within the calendar year – returning Stage 2 participants will attest using the full calendar year (January 1, 2017 through December 31, 2017)

• In 2018, all providers will attest to Stage 3 using the full calendar year

(January 1, 2018 through December 31, 2018)

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CMS Final Rule – List of Objectives

• Meaningful Use Objectives – Modified Stage 2

1. Protect Patient Health Information – Security Risk Analysis 2. Clinical Decision Support (CDS) 3. Computerized Provider Order Entry (CPOE) 4. Electronic Prescribing (eRx) 5. Health Information Exchange (HIE) – previously known as “Summary of Care” 6. Patient Specific Education 7. Medication Reconciliation 8. Patient Electronic Access (Patient Portal) 9. Secure Electronic Messaging (Eligible Professionals only)

• 10. Public Health and Clinical Data Registry Reporting

a. Immunization Registry Reporting b. Syndromic Surveillance Reporting c. Specialized Registry Reporting d. Reportable Lab Results Reporting (Eligible Hospitals only) [Note: No change in General Requirements or Clinical Quality Measure reporting]

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CMS Meaningful Use Rules: Stage 3

Stage 3 Meaningful Use - Objectives

1. Protect Electronic Health Information 2. Electronic Prescribing (eRx) 3. Clinical Decision Support 4. Computerized Provider Order Entry (CPOE) 5. Patient Electronic Access to Health Information 6. Coordination of Care through Patient Engagement 7. Health Information Exchange 8. Public Health Reporting

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Stage 3 Meaningful Use – Key Elements

• Coordination of Care through Patient Engagement

– 10% of patients use portal or API – 25% of patients must receive message from EP – 5% of patients enter their own data or may come from

• ther agencies

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Stage 3 Meaningful Use – Key Elements

• Health Information Exchange

– 50% of outgoing referrals/transitions sent electronically – 40% of incoming referrals/transitions and new patients come with summaries of care – 80% of incoming referrals/transitions and new patients have medications, allergies, and problem lists reconciled

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Stage 3 Meaningful Use – Key Elements

• Public Health Reporting

– Must report 3 measures – Types of Registries

• Immunization
• Syndromic Surveillance
• Electronic Case Reporting
• Other Public Health Registries
• Clinical Data Registries

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Physician Quality Reporting System (PQRS)

Elisabeth Renczkowski, Content Specialist

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PQRS Overview How does PQRS work?

• PQRS is a reporting program that uses payment adjustments to

promote reporting of quality information by Eligible Professionals (EPs)

• EPs report data to CMS on quality measures for covered Physician

Fee Schedule (PFS) services furnished to Medicare Part B FFS beneficiaries

• EPs must report on each unique NPI/TIN combination they use to bill

Medicare

• Two-year gap between performance year and payment year

– Providers who satisfactorily report PQRS for Program Year 2015 will avoid negative payment adjustments to their Medicare reimbursements in 2017 and so on

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PQRS Eligible Professionals (EPs) PQRS Eligible Professionals

• 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*

• Certified Nurse Midwife*
• Clinical Social Worker
• Clinical Psychologist
• Registered Dietician
• Nutrition Professional
• Audiologists
• Physical Therapist
• Occupational Therapist
• Speech-Language

Therapist

* Includes Advanced Practice Registered Nurse (APRN)

Payment Adjustments

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Payment Adjustments PQRS Value Modifier

No incentive for EPs who successfully report (last year was 2014) Upward, neutral, or downward payment adjustments for EPs who successfully report PQRS measures

(performance-based payment adjustments)

Penalty for failure to report Penalty for failure to report

(automatic payment adjustments)

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Total Payment Adjustments – Failure to Report

• If an EP fails to report PQRS in 2015, the following payment

penalties will apply to their 2017 reimbursements:

• Bottom line: Total penalty for failing to report in 2015
• -4% for solo EPs and groups of 2-9
• -6% for groups of 10 or more

PQRS Penalty Value Modifier Penalty

applies to all EPs solo EPs and groups of 2-9 groups of 10+

• 2%
• 2%
• 4%

Value Modifier

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Value Modifier

• The Value Modifier (VM) provides differential payment based on the

quality of care compared to the cost of care

• PQRS reporting is the basis for the quality portion of the Value Modifier

performance-based payment adjustments

• Performance on PQRS measures matters!
• This differs from reporting CQMs for the Meaningful Use (MU) programs,

where it is acceptable to report a performance rate of 0

• Performance-based payment adjustments for those who do report

PQRS in 2015:

• upward or neutral adjustment (solo practitioners and groups of 2-9)
• upward, neutral, or downward adjustment (groups of 10 or more)

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Value Modifier

• All EPs are included to determine group size

– Currently, upward and downward VM payment adjustments are only applied to reimbursement of physicians in the group

2017 Value Modifier

based on 2015 PQRS reporting Solo EP 2-9 EPs 10+ EPs Physicians Upward or Neutral Upward or Neutral Upward, Neutral, or Downward Practitioners N/A N/A N/A Therapists N/A N/A N/A

• In 2018, CMS will apply the VM to all EPs, including practitioners

and therapists. CMS will finalize exactly how the VM will apply to those EPs in future rulemaking

Reporting Methods

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Reporting Methods

Individual Eligible Professionals (EPs) can report via:

• Medicare Part B Claims
• Qualified PQRS Registry
• Direct EHR product that is certified (CEHRT)
• CEHRT via Data Submission Vendor
• Qualified Clinical Data Registry

Group Practice Reporting Option (GPRO)

• A group is defined as 2 or more EPs who have reassigned their billing rights

to the group TIN

• Depending on the group size, groups can report via:
• Qualified PQRS Registry
• Direct EHR product that is certified (CEHRT)
• CEHRT via Data Submission Vendor
• CMS Web Interface (25+ only)
• Clinician & Group Consumer Assessment of Healthcare Providers and

Systems (CG-CAHPS), paired with one of the options above (25+ only)

Reporting Considerations

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Reporting Considerations

• Individual Measures - EPs and groups must report on at least 50% of

eligible instances

– Definition of “eligible instance” depends on the specific measure – Must report on 9 measures across 3 NQS domains – Must include at least 1 cross-cutting measure – All measures must have a >0% performance rate (i.e. must be performed successfully for at least 1 eligible patient) – If reporting using GPRO, must report Individual Measures

• Measures Groups - EP selects a group of related measures and

reports on all of those measures for 20 eligible patients

– Majority of patient sample (at least 11 patients) must be traditional Medicare Part B beneficiaries – All measures must have a >0% performance rate (i.e. be performed successfully for at least 1 eligible patient) – Measures Groups are only an option for Individual EPs and only available through a Qualified PQRS Registry

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Reporting Considerations Measures-Applicability Validation (MAV)

• If an EP reports less than 9 measures (or reports ≥9 measures

across fewer than 3 domains), the MAV process will be applied

• MAV determines if an EP or group has met the requirements to

avoid the PQRS payment adjustment, despite reporting less than 9 measures (or reporting ≥9 measures, but covering fewer than 3 domains)

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Reporting Considerations – Behavioral Health Recommended Measures for Behavioral Health:

• Dementia Measures Group
• Individual Measures – Examples:

– #325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions – #134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan – #173: Preventive Care and Screening: Unhealthy Alcohol Use – #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention – #383: Adherence to Antipsychotic Medications for Individuals with Schizophrenia

• MAV strategy

– Report on Measure #173 and #226

Medicare Access and CHIP Reauthorization Act (MACRA)

Thomas Bennett, Client Services Relationship Manager

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• Medicare Access and CHIP Reauthorization Act (MACRA)

– signed into law April 16, 2015 – replaces the Sustainable Growth Rate (SGR) with a revised reimbursement model – contains several other provisions related to:

• program integrity
• fraud and abuse
• extension of the Children’s Health Insurance Program (CHIP)
• Bottom line: MACRA will change how Medicare pays physicians

and other health care providers

• CMS is currently developing proposals to implement the key

elements of MACRA

Legislative Background

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Emerging Payment Methodologies

Merit-Based Incentive Payment System (MIPS) Alternative Payment Models (APMs) Physician-Focused Payment Models (PFPMs)

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• From 2015-2019, annual increase (fee schedule update) of 0.5%
• Starting in 2019, the base reimbursement rate holds steady

– physicians can supplement their reimbursement by participating in the Merit-Based Incentive Payment System (MIPS) and/or Alternative Payment Models, such as Accountable Care Organizations (ACOs) – MIPS payment adjustments based on composite performance score increase from +/- 4% in 2019 to +/- 9% in 2022 and beyond – APM incentive payment (5% lump sum) will be available from 2019-2024

• Starting in 2026, an annual increase (fee schedule update) of

0.25% resumes

– physicians who participate in an Alternative Payment Model (APM) are eligible for a higher annual increase of 0.75%

MACRA Reimbursement Rates

Massachusetts eHealth Institute

Merit-Based Incentive Payment System (MIPS)

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Merit-Based Incentive Payment System (MIPS)

• Merit-Based Incentive Payment System (MIPS) consolidates

3 existing programs

• Physician Quality Reporting System (PQRS)
• Value-based Modifier (VM)
• EHR Incentive Payment Program (Meaningful Use)
• For the 2015 and 2016 performance years (and the

corresponding 2017 and 2018 payment years), PQRS, VM and MU will continue as separate and distinct programs

• Anticipated that 2017 will be the first MIPS performance year

(2017 performance would dictate 2019 payment adjustments)

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Merit-Based Incentive Payment System (MIPS)

MIPS Eligible Professionals

First two years

• Physicians
• Physician Assistants
• Nurse Practitioners
• Clinical Nurse Specialists
• Nurse Anesthetists

Third year and beyond

• All of the above, plus:
• Physical Therapists
• Occupational Therapists
• Speech-language Pathologists
• Audiologists
• Nurse Midwives
• Clinical Social Workers
• Clinical Psychologists
• Dietitians

MIPS Composite Performance Score

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Four Steps to Prepare for MIPS

Start the Conversation Expand Knowledge Beyond MU, PQRS, and VM Maintain or Expand Efforts with MU, PQRS, and VM Contact MeHI

Massachusetts eHealth Institute

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Your Massachusetts Health IT Resource

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MeHI’s eHealth Services

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Questions

Questions?

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Contact Us

Al Wroblewski & Thomas Bennett Client Services Relationship Managers (508) 870-0312 ext. 603 ext. 403 wroblewski@masstech.org tbennett@masstech.org Elisabeth Renczkowski Content Specialist (508) 870-0312 ext. 623 renczkowski@masstech.org