Physician Quality Reporting System & VBPM, 2015€¦ · Agenda. 1. PQRS Penalty 2. PQRS Eligibility 3. PQRS Reporting Options 4. Value Based Payment Modifier • Participation •

Physician Quality Reporting System & VBPM, 2015

Andrew BienstockTransformation Support Services Manager

© 2015 CORHIO – All Rights Reserved – CORHIO Proprietary – Not For Redistribution 1

Agenda1. PQRS Penalty2. PQRS Eligibility3. PQRS Reporting Options4. Value Based Payment Modifier

• Participation• Quality Measures• Cost Measures• Quality Tiering• QRUR

5. MIPS6. Q&A

2

Payment Adjustments (PQRS)

3

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

© 2015 CORHIO – All Rights Reserved – CORHIO Proprietary – Not For Redistribution

PQRS Penalties (Per Provider)

4

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


Determining Eligibility - PQRS

5

Physicians MD, DO, Doctor of Podiatric Medicine, Doctor of Optometry, Doctor of Dental Surgery, Doctor of Dental Medicine, Doctor of Chiropractic

Practitioners 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

Therapists Physical Therapist, Occupational Therapist, Qualified Speech-Language Therapist

Eligible professionals who may participate in Physician Quality Reporting(must bill Medicare under provider NPI to be eligible)


PQRS Overview

6

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


PQRS Measure Example

7

PQRS 236: Blood Pressure Management

Domain: Clinical Process/Effectiveness

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 ofonce per reporting period for patients with hypertension seen during the reporting period. The performance period for this measure is 12 months.

FYI: How PQRS 236 aligns with other quality reporting programs


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


Choose one of the following:1. Claims based

2. Registry

3. EHR Direct

4. Data Submission Vendors (DSVs)

9

4 Methods for PQRS Reporting


• 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

Claims Based 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 (PQRS)


• 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

Registry Reporting (continued)


• 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

EHR Direct Reporting (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

Data Submission Vendors (PQRS)


Value Based Payment Modifier(VBPM)

15


• 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

Value Based Payment Modifier (VBPM)


• 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 Quality 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 Cost Measures

© 2015 CORHIO – All Rights Reserved – CORHIO Proprietary – Not For Redistribution 19

VBPM Quality Tiering, 2015

Low Quality

Avg. Quality

High Quality

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).

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

Solo Providers & Groups of 2-9 Providers Groups with 10+ Providers


• 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

VBPM: QRUR

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


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

MACRA Law & the New MIPS Program


• 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

Merit-based Incentive Payment System (MIPS)


Andrew Bienstock, MHATransformation Support Services [email protected]

24

Contact Information

mailto:[email protected]

Documents

Physician Quality Reporting System & VBPM, 2015€¦ · Agenda. 1. PQRS Penalty 2. PQRS Eligibility 3. PQRS Reporting Options 4. Value Based Payment Modifier • Participation •