Quality Reporting Initiatives Part 1 - Physicians Quality Reporting - - PowerPoint PPT Presentation

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Part 1 - Physicians Quality Reporting Systems

Quality Reporting Initiatives

Purpose

✦ Overview of the Quality Reporting Initiatives to gain an

understanding of the requirements to report successfully and avoid negative/downward payment adjustments in 2018.

✦ Review changes coming to Quality Reporting Initiatives

starting in the 2017 reporting year.

Agenda

• Overview of Quality Reporting
• Quality Reporting changes
• PQRS measures and requirements for 2016
• PQRS reporting options for 2016
• Value-Based Modifier
• Available resources

Acronyms

MACRA -Medicare Access & CHIP Reauthorization Act of 2015 MIPS - Merit-Based Incentive Payment System APM - Alternative Payment Models EP - Eligible Professional CHIP - Children’s Health Insurance Program PQRS - Physician Quality Reporting System VBM - Value-Based Modifier QCRD - Qualified Clinical Data Registry CAHPS - Consumer Assessment of Healthcare Providers & Systems

Quality Reporting Initiatives

Quality Reporting Initiatives

For over a decade the Department of Health and Human Services (HHS) along with CMS began launching Quality Initiatives in 2001 to assure quality health care for all Americans through accountability and public disclosure. The various Quality Initiatives touch every aspect of the healthcare system. The goal is to achieve better outcomes for beneficiaries and communities by driving care improvements.

What is Quality Reporting?

• Health care providers report quality measures to CMS about

health care services provided to Medicare beneficiaries.

• Quality measures are tools that help CMS assess various

aspects of care such as health outcomes, patient perceptions, and organizational structure.

• The measures reported by health care professionals inform

CMS on the ability to provide high-quality health care and relate to the goal of effective, safe, efficient, patient- centered, equitable, and timely care.

Future of Quality Reporting Initiatives 2017

MACRA

★Medicare Access & CHIP Reauthorization Act 2015

MACRA was passed by congress on March 26, 2015 and was signed into law on April 16, 2015 by president Obama, as part of the Medicare payment reform. The MACRA makes three important changes to how Medicare pays

provider who care for Medicare beneficiaries. These changes include:

• Ending the Sustainable Growth Rate (SGR) formula for determining

Medicare payments for health care providers’ services.

• Making a new framework for rewarding health care providers for giving

better care, not more just more care.

• Combining the existing quality reporting programs into one new system.

MACRA

• The separate applications of payment adjustments

under PQRS, EHR Meaningful Use and Value-Based Modifier will sunset on Dec. 31, 2018 (2016 reporting year)

• January 1, 2019 - Merit Based Incentive payment

system (MIPS) and Alternative Payment Model (APM) incentive payments begin (2017 reporting year)

• Eligible Professionals (EPs) can participate in MIPS or

meet requirements to qualify for APM participation

Merit-Based Incentive Payment System (MIPS)

Merit-Based Incentive Payment System (MIPS) is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) Meaningful Use incentive program into

• ne single program based on:
• Quality
• Resource use
• Clinical practice improvement
• Meaningful use of certified EHR technology

Merit-Based Incentive Payment System (MIPS)

} Applied to individual EP, groups of EPs or vital groups

Year Quality Measures Resource Use

Clinical Improvement Activites

EHR MU

MIPS Adj. Factor (+/-)

2019 50% 10% 15% 25% +/- 4% 2020 45% 15% 15% 25 +/- 5% 2021 30% 30% 15% 25% +/- 7% 2022+ 30% 30% 15% 25% +/- 9%

Merit-Based Incentive Payment System (MIPS)

• The composite performance score will range from 0-100
• Statute established formula for calculating payment

adjustment factors are relative to performance and establish “applicable percent” amounts

• EPs receive a positive/upward adjustment if score

above the performance threshold and a negative/downward adjustment if score is below threshold

• Upward payment adjustments will remain budget

neutral

Alternative Payment Models (APM)

Alternative Payment Models (APM) give new ways to pay health care providers for the care they give Medicare beneficiaries. For example:

• From 2019-2024, pay some participating health care providers a

lump-sum incentive payment.

• Increased transparency of Physician-Focused payment models
• Starting in 2026, offers some participating health care providers

higher annual payments. Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs.

Alternative Payment Models (APM)

Beginning in 2019 and for 6 years 5% incentive payment for:

• EPs or groups of EPs who participate in certain types of

APMs and who meet specified payment amounts or patient count thresholds

• Payment is made in a lump sum on an annual basis
• EPs or groups of EPs meeting criteria to receive APM

incentive payments are excluded from the requirements

• f MIPS

Alternative Payment Models (APM)

To earn the incentive payment, an EPs must participate in an APM that meets the following criteria:

• Requires participants to use certified EHR technology
• Provides payment for covered professional services based on quality

measures “comparable to” MIPS quality measures AND Either

• a) Entities participating in the APM bear financial risk for monetary losses

that are in excess of a normal amount, OR

• b) APM is a medical home model expanded under section 1115A(c) of the

SSA https://www.ssa.gov/OP_Home/ssact/title11/1115A.htm

Quality Reporting Initiatives 2016

Quality Reporting Initiatives 2016

• Physician Quality Reporting System (PQRS)
• Value-Based Payment Modifier (VM)
• EHR Meaningful Use incentive Program (MU)

About PQRS

The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. PQRS gives participating EPs and group practices the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time. By reporting on PQRS quality measures, individual EPs and group practices can also quantify how often they are meeting a particular quality metric. Beginning in 2015, the program began to apply a negative payment adjustment to individual EPs and group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. Those who report satisfactorily for the 2015 program year will avoid the 2017 PQRS negative payment adjustment.

Who Can Participate?

The following are considered “eligible professionals” who can participate in the Physician Quality Reporting System:

• Doctors of medicine or osteopathy
• Doctors of dental surgery or dental medicine
• Doctors of podiatry
• Doctors of optometry
• Chiropractors

Why do I need to report?

Those who do not satisfactorily report data on quality measures for covered Medicare Physician Fee Schedule (MPFS) services furnished to Medicare Part B beneficiaries (including Railroad Retirement Board, and Medicare Secondary Payer) will be subject to a negative payment adjustment under PQRS. Medicare Part C–Medicare Advantage beneficiaries are not included. All EPs who do not meet the criteria for satisfactory reporting

• r participating for 2016 PQRS will be subject to the 2% 2018

negative payment adjustment with no exceptions.

How-To Get Started to Report 2016

To avoid the 2018 negative payment adjustment, individual EP reporters may choose from the following reporting mechanisms to submit data:

• Medicare Part B claims based reporting
• EHR data submission vendor (DSV) that is CEHRT
• EHR direct product that is CEHRT
• Qualified PQRS Registry

How-To Get Started to Report 2016

There is no prior registration is needed to begin reporting. To review feedback reports during and after reporting will need to register with Quality Net. Complete feedback reports are available in the fall of the following year. www.qualitynet.org - PQRS Quality Net Help Desk 7 a.m. - 7 p.m. CT Monday - Friday Phone: (866) 288-8912*

What are Quality Measures?

• Quality measures are indicators of the quality of care

provided by physicians.

• They are tools that help CMS measure or quantify health

care processes, outcomes, patient perceptions, and

• rganizational structure and/or systems that are associated

with the ability to provide high-quality health care

• And/or relate to one or more quality goals for health care.

These goals include: effective, safe, efficient, patient centered, equitable, and timely care

Physicians Quality Reporting System (PQRS)

How to determine which measures to report?

• Step 1: Review the “2016 Physician Quality Reporting System

(PQRS) Measures List” and the PQRS Web-Based Measure Search Tool, available on the PQRS Measures Codes webpage, to determine which measures, associated domains,and reporting mechanism(s) may be of interest and applicable to individual EP.

• Step 2: Consider important factors when selecting measures for

reporting

• Step 3: Review specification for each measures selected

The National Quality Strategy (NQS)

The Six NQS Domains

• Patient Safety
• Person and Caregiver Centered Experiences and

Outcomes

• Communication and Care Coordination
• Effective Clinical Care
• Community Population Health
• Efficiency and Cost Reduction

What is a measure?

Measures consist of two major components, denominators and numerators Denominator

• Must describe the episode of care to be evaluated by the measure. This

should indicate age, condition, setting, and timeframe For example: “Patients age 18 or older with a diagnosis of primary

• pen angle glaucoma”

Numerator

• Detail the quality clinical action expected that satisfies the condition(s)

and is the focus of the measurement for each patient or procedure

Example of measurement specifications construction

Each component is defined by specific codes described in the respective measure’s specification along with the reporting instructions and use of modifiers.

Measure Specifications Construct (example)

Numerator

CPT II 2027F CPT II 2027F with 8P CPT II 2027 with 1P

Denominator

92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, etc. AND H40.10X4, H40.11X0, H40.11X1, H40.11X2, H40.11X3, etc.

Reporting Frequency

Each measure specification includes a reporting frequency for each denominator per eligible patient. The reporting frequency is used in analyzing each measure to help determine satisfactory reporting

Measure 12 - POAG - Optic Nerve Evaluation INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. It is anticipated that clinicians who provide the primary management of patients with primary open-angle glaucoma (in either one or both eyes) will submit this measure.

2016 PQRS Measures

NQS Domain - Effective Clinical Care

• Measure 12 - POAG; Optic Nerve Evaluation
• Measure 14 - AMD; Dilated Macular Examination
• Measure 117 - Diabetes Mellitus: Dilated eye exam
• Measure 140 - AMD: Counseling on Antioxidant Supplement

NQS Domain - Communication & Care Coordination

• Measure 19 - Diabetic Retinopathy: Findings of dilated macular or funds

exam communicated with the physician responsible for managing ongoing diabetes care

• Measure 131 - Pain Assessment
• Measure 141 - POAG: Reduction of IOP

2016 PQRS Measures

NQS Domain - Patient Safety

• Measure 130 - Current Medications

NQS Domain - Community / Population Health

• Measure 226 - Patient screened for tobacco use
• Measure 317 - Documented blood pressure reading

2016 PQRS Claims Reporting

• Reporting requirements remain unchanged from 2015

reporting period

• Requirement is to report 9 measures covering at least 3

National Quality Strategy (NQS) domains of the 6 available domains

• Required to report one cross-cutting measure if at least 1

Medicare face to face encounter (found on PECAA website)

• Measure applicability validation (MAV) process will be used

to determine if EP could have reported 9 measures covering at least 3 domains.

2016 PQRS Claims Reporting

• For claims reporting only individual measures can be reported
• Report 9 measures covering at least 3 National Quality Strategy (NQS)

domains of the 6 available domains If can not meet this requirement then

• Report 1 - 8 measures covering 1 -3 NQS domains
• In either case EP that have at least 1 face-to-face encounter, must report
• n at least 1 cross-cutting measure

AND

• Report each measure for at least 50% of the Medicare Part B FFS

patients seen during the entire 12 month period

• Measures with a 0 percent performance rate would not be counted
• And will be subject to the Measure Applicability Validation (MAV) process

2016 PQRS Claims Reporting

To ensure your claim data is being processed look for these denial code(s) on your Medicare Remittance Advice

• EPs who bill with $0.00 charge on a quality data code

line item will receive an N620 code on the EOB

• EPs who bill with a charge of $0.01 on a quality data

code item will receive CO 246 N620 on the EOB.

2016 PQRS Quality Registry Reporting

• Can report individual measures or measure groups
• Requirement is to report 9 measures covering at least 3

National Quality Strategy (NQS) domains of the 6 available domains

• Required to report one cross-cutting measure if the EP

has at least 1 Medicare face to face encounter

• Registries attest through the web that quality measures

results and associated data are accurate (written attestation statement is no longer required)

2016 PQRS Quality Registry Reporting

When selecting a registry…

• Inquire as to what types of measure prepared to report on
• Ensure can report on individual measures or group measure depending on the

needs of your practice

• If reporting on individual measures, requirements remain the same as with

claims reporting. MUST report at least 50% of the Medicare Part B FFS patients

• If reporting on Group measures, must report at least 1 measure group AND

report on at least 20 patients within that group with the majority being Medicare Part B FFS patients. (example if 20 patients reported, at least 11 need to be Medicare Part B FFS patients.) Medicare advantage patients do not count. Measures groups with a 0% performance rate will not count

• Any EP submitting less then 9 measures covering 3 domains will be subject to

the measure applicability validation (MAV) process

Direct reporting EHR (CEHRT) Product or Vendor

• May report individual measures
• Requirement is to report 9 measures covering at least 3

National Quality Strategy (NQS) domains of the 6 available domains

• If CEHRT or EHR data submission vendor does not

contain patient data for at least 9 measures covering at least 3 domains, then the EP must report on all measures for which there is Medicare patient data

• An EP must report on at least 1 measure for which there is

Medicare patient data

Qualified Clinical Data Registry Reporting

• Report individual PQRS measures
• Report at least 9 measures covering at least 3 National Quality Strategy

(NQS) domains of the 6 available domains for PQRS

• AND report each measure for at least 50% of the EP’s applicable

patients seen during the reporting period to which the measures applies

• Of the measures reported via QCDR must report on at least 2 outcome

measures OR

• Report on at least 1 outcome measure and at least 1 of the following:

Resource use, patient experience of care, efficiency/appropriate use, or patient safety

CAHPS for PQRS Survey

• Consumer Assessment of Healthcare Providers & Systems
• CAHPS became mandatory for groups of 100+ EP in 2015
• Is optional for EPs of 2 - 99 EPs, if would like to include

survey data as part of quality measures

• CMS-Certified survey vendor will administer and collect 12

summary survey modules on behalf of the practice’s patients

• Cost for the CAHPS survey is the responsibility of the

practice www.pqrscahps.org

PQRS Resources

• How-to get started

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/How_to_Get_Started.html

• PQRS

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/index.html

• 2016 PQRS Measure

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/MeasuresCodes.html

• CMS Web-Based PQRS Tool

https://pqrs.cms.gov/#/home

Value-Based Modifier

Value-Based Modifier

• The Value Modifier Program measures the quality and cost of care

provided to Medicare beneficiaries under the Medicare Physician Fee Schedule (PFS)

• The Value Modifier is an adjustment made on a per claim basis to

Medicare payments for items and services under the Medicare

• PFS. It’s applied at the Taxpayer Identification Number (TIN) level

to doctors billing under the TIN.

• The Value Modifier Program determines the amount of Medicare

payments to physicians based on their performance on specified quality and cost measures. The program rewards quality performance and lower costs.

Value-Based Modifier

CMS has been phasing in the Value Modifier Program since

• 2013. Starting with medical group practices of 100+

providers

• In 2017, payment adjustments will apply to physician solo

practitioners and physicians in groups of 2 or more EPs based on their performance in 2015 reporting year.

• In 2018, in addition to all physicians, payment adjustments

will apply to all specialties and size practices including solo practitioners or in groups of 2 or more EPs based on their performance in 2016.

Value-Based Modifier

} VM reimbursement impact is 2 years in the future } Tiered payment levels based on PQRS & claims data used

to compare practice to national average on quality and costs

Cost / Quality Low Quality Average Quality High Quality Low Cost +0.00% +1.0X* +2.0X* Average Cost

• 1.00%

+0.00% + 1.0X* High Cost

• 2.00%
• 1.00%

+0.00%

Value-Based Modifier

Resource for more information https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeedbackProgram/ValueBasedPaymentM

• difier.html

Quality and Resource Use Reports (QRUR)

• Each fall CMS put out QRUR feedback reports for the

previous calendar year

• QRUR reports will reflect cost and quality data, assigned

to your practice

• To accesses the feedback reports

https://portal.cms.gov PV-PQRS application on the portal EIDM Login (previously IACS)

Additional Resource

• MLN Connect Provider News - March 10, 2016

7 Videos focusing on Medicare Quality Reporting — New

(information in Modules 1- 4 touched on today)

https://www.cms.gov/Outreach-and- Education/Outreach/FFSProvPartProg/Provider-Partnership-Email- Archive-Items/2016-03-10- eNews.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descen ding

Reminder

On Tuesday April 19th at 11:00 am PST Part 2 - Quality Reporting Initiatives: EHR Incentive Program - Meaningful Use

Thank you!

Contact information: Teri Thurston teri@pecaa.com 503 670-9200