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PQRS: An Overview of the Physician Quality Reporting System Don Gettinger, BS, CHTS-IM. Conflict of Interest Disclosures. No Conflicts to Disclose. What is PQRS?. - PowerPoint PPT Presentation
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PQRS: An Overview of the Physician Quality Reporting
System Don Gettinger, BS, CHTS-IM
Conflict of Interest Disclosures
No Conflicts to Disclose
What is PQRS?
o PQRS is a Medicare program that provides an incentive payment to eligible providers (EPs) who voluntarily report specific clinical quality measures (CQMs) for their qualifying Medicare patients.
o Providers who successfully report data can earn an additional 0.5 % of their total allowable Medicare charges in and 2014.
o In 2016, payment adjustments will be made to providers who choose not to report. This adjustment will be based upon participation in 2014.
Who is Eligible?
Eligible & Able to Participate
Medicare Physicians – • Doctor of Medicine (MD)• Doctor of Osteopathy (DO)• Doctor of Podiatric
Medicine (DPM)• Doctor of Dental Medicine
(DMD)• Doctor of Chiropractic
(DC)
Practitioners – • Physician Assistant (PA)• Nurse Practitioner (NP)• Registered Dietician (RD)• Clinical Social Worker
(CSW)
Therapists – • Physical Therapist (PT)• Occupational Therapist
(OT)• Qualified Speech Therapist
Who is Eligible?
Eligible BUT not able to Participate
Professionals paid under or based upon PFS billing Medicare Carriers/Medicare Administrative Contractors (MACs) who do not bill directly.
Federally Qualified Health Clinics (FQHCs), Rural Health Clinics (RHCs), ambulatory surgery center facilities
Significant Changes for 2014 Reporting
• Last year to receive incentive and avoid 2016 payment adjustment
• Must report nine measures representing three of the six National Quality Strategy domains
• Killing three birds with one stone, PQRS reporting can satisfy requirements for Stage 2 Meaningful Use Clinical Quality Measures (CQMs) and for the 2014 Value-based Modifier
• New reporting methods added
How is the data reported?
o To successfully report and receive the incentive, providers must select and submit at least nine measures.
o Submission of measures can be through claims, registry, a certified EHR or data submission vendor*, or a qualified clinical data registry*.
o Eligible providers may report measures as individual providers or as a group practice (GPRO).
*These methods align with Meaningful Use
Reporting Methods
Claims-Based Reporting Individual EPs only Report on 9 measures across at least three NQS
domains Must report on at least 50% of applicable Medicare
part B fee for service (FFS) patients
Reporting Methods
Registry-Based Reporting Individual or Group Report on 9 measures across at least three NQS
domains Must report on at least 50% of applicable Medicare
part B fee for service (FFS) patients
Reporting Methods
EHR-Based reporting Certified Direct EHR-Based Product or Certified Data
Submission Vendor Individual or Group Report on 9 measures across at least three NQS
domains
Reporting Methods
Qualified Clinical Data Registry-Based Individual EPs only Report on 9 measures across at least three NQS
domains Must report on at least 50% of applicable Medicare
part B fee for service (FFS) patients
The list of QCDRs should be available on the CMS PQRS website by the end of May, 2014
Reporting Methods
Additional Group Reporting methods To Report using the Group Practice Reporting Option
(GPRO) you must register your intent with CMS by September 30, 2014
GPRO Web Interface Must have 25 or more eligible professionals Report on assigned patient sample
Certified Survey Vendor (CG-CHAPS) Optional for groups of 25-99 EPs Required for groups of 100+ EPs
PQRS
EHR INCENTIVE PROGRAM
VALUE-BASED MODIFIER
Reporting Alignment
Step 1 - Am I an eligible professional for both programs?
Check eligibility for the Meaningful Use program http://cms.gov/apps/ehealth-eligibility/ehealth-
eligibility-assessment-tool.aspxCheck eligibility for the PQRS program
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf
MedicareMedicaid
MDDODentists and Oral
SurgeonsPodiatristsOptometristsChiropractors
MDDONPCertified Nurse-MidwifeDentistsPhysician assistant (PA)
who furnishes services in a Federally Qualified Health Center of Rural Health Clinic that is led by a physician assistant
Eligible Providers Meaningful Use
Eligible Providers PQRS & VM
Doctor of MedicineDoctor of OsteopathyDoctor of Podiatric
MedicineDoctor of OptometryDoctor of Oral SurgeryDoctor of Dental
MedicineDoctor of Chiropractic
Nurse PractitionerCertified Nurse MidwifePhysician Assistant
Clinical Nurse SpecialistCertified Registered
Nurse Anesthetist (and Anesthesiologist Assistant)
Clinical Social WorkerClinical PsychologistRegistered DieticianNutrition ProfessionalAudiologistsPhysical TherapistOccupational TherapistQualified Speech-
Language Therapist
MU and PQRS Alignment
9 Clinical Quality Measures that cover at least 3 of the 6 Nation Quality Strategy (NQS) Domains Patient and Family Engagement Patient Safety Care Coordination Population/Public health Efficient Use of Healthcare Resources Clinical Process/Effectiveness
PQRS EHR Based Reporting
Qualified Clinical Data Registry
Submit PQRS measures data directly through the certified electronic health record technology (CEHRT)
Submit PQRS quality measure data extracted from their CEHRT to a qualified EHR Data Submission Vendor
New for 2014The data submitted
to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries.
Choose Reporting Option
Option A Option B
EPs in an ACO (Medicare Shared Savings Program or Pioneer ACO) who satisfy requirements of the Medicare Shared Savings Program using Certified EHR Technology
EPs who satisfy the requirements of PQRS GPRO option using Certified EHR Technology
Group Reporting (GPRO)
Value-based Modifier
Cost data and Quality measures includedPer-claim adjustment Applied at the Group LevelCY 2015 – CMS will apply the VM to groups of
physicians with 100 or more eligible professionals (EPs) based on 2013 performance.
CY 2016 - CMS will apply the VM to groups of physicians with 10 or more EPs based on 2014 performance.
CMS is required to apply the VM to all physicians and groups of physicians starting in 2017.
PQRS Reporters Non-PQRS Reporters
Groups with 10-99 EPs Upward or no VM
based on quality tiering
Groups with 100+ Eps Upward, neutral, or
downward VM based on quality tiering
-2.0% (Automatic VM downward adjustment)
Separate from the PQRS payment adjustment and payment adjustments from other Medicare sponsored programs.
Value-based Modifier
Value-based Modifier
Low QualityAverage Quality
High Quality
Low Cost 0.0% +1.0x%* +2.0x%*
Average Cost-0.5% 0.0% +1.0x%*
High Cost -1.0% -0.5% 0.0%
"x” refers to a payment adjustment factor yet to be determined * higher performing groups serving high-risk beneficiaries (based on average risk scores) are eligible for an additional adjustment of +1.0x%
Why CQMs?
Clinical Quality Measures support achievement of health care goals (Triple Aim) Better Health Better Health Care Lower Cost
Selecting CQMs To Report
3 questions to ask about your practice settingAre there any existing quality
improvement efforts in place?What is the patient population
served?What is my EHR capable of
reporting?
Examples of Measures for Each Domain
• Patient and Family Engagemento PQRS # 377 -Functional Status Assessment for
Complex Chronic Conditionso Percentage of patients aged 65 years and older with
heart failure who completed initial and follow-up patient-reported functional status assessments
Examples of Measures for Each Domain
• Patient Safetyo PQRS # 130 -Documentation of Current Medications in the
Medical Recordo Percentage of visits for patients aged 18 years and older for which
the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration
Examples of Measures for Each Domain
• Care Coordinationo PQRS # 374 - Closing the Referral Loop: Receipt of
Specialist Reporto Percentage of patients with referrals, regardless of
age, for which the referring provider receives a report from the provider to whom the patient was referred
Examples of Measures for Each Domain
• Population/Public Healtho PQRS # 226 - Preventive Care and Screening:
Tobacco Use: Screening and Cessation Interventiono Percentage of patients aged 18 years and older who
were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user
Examples of Measures for Each Domain
• Efficient Use of Healthcare Resourceso PQRS # 312 -Use of Imaging Studies for Low Back
Paino Percentage of patients 18-50 years of age with a
diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis
Examples of Measures for Each Domain
• Clinical Process/Effectivenesso PQRS # 236 - Controlling High Blood Pressureo Percentage of patients 18-85 years of age who had a
diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90mmHg) during the measurement period
Resources
PQRS reporting options and measures www.cms.gov/pqrs
Value-based Modifier information http://
www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/index.html
EHR Incentive Program www.cms.gov/ehrincentiveprograms
Institute for Healthcare Improvement http://
www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
Questions?
Don Gettinger, BS, Program Manager812.234-1499 x336dgettinger@inqio.sdps.org
Stacy Colson, RN Clinical Advisor812.234-1499 x314scolson@inqio.sdps.org
Health Care ExcelPopulation Health Team
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