Quality Reporting and Value-Based Payment:
The Physician Practice
July 31, 2015
VHQC
Non-profit health quality consulting company since 1984
Virginia and Maryland’s Quality Innovation Network
Quality Improvement Organization for CMS
Virginia’s Regional Extension Center as designated
by ONC
Provides outreach, education, and comprehensive
EHR services to providers and healthcare organizations
Agenda
1) VHQC Introduction
2) Meaningful Use (MU)
a. Timeline Highlights
b. Payment Adjustments & Hardship Exception
3) Physician Quality Reporting System (PQRS)
a. Incentive & Adjustments
b. Reporting Methods
c. PQRS Measure Information
d. Measures Applicability Validation
e. Quality and Resource Use Report (QRUR)
4) Value-Based Payment Modifier
5) Resources
EHR Incentive Program: Meaningful Use
Improved Quality and Outcomes
Stage 2
Advanced clinical
processes
Stage 3
Improved
outcomes
Stage 1
Data capture
and sharing





Better clinical outcomes
Improved population health outcomes
Increased transparency and efficiency
Empowered individuals
More robust research data on health
system
Notice of Proposed Rulemaking
to Meaningful Use in 2015-2017
Stay Tuned for
Changes!
To better align Stages 1 & 2 with Stage 3, CMS proposes:
1. Reducing the overall number of objectives to focus on
advanced use of electronic health records (EHRs);
2. Removing measures that have become redundant,
duplicative or have reached wide-spread adoption;
3. Realigning the reporting period beginning in 2015, so
hospitals would participate on the calendar year
instead of the fiscal year; and
4. Allowing a 90 day reporting period in 2015 to
accommodate the implementation of these proposed
changes in 2015.
MU Timeline Highlights
2015 Reporting Periods
Stay Tuned for
Changes!
1) First time attesters only: 90-day reporting
period
2) Providers beyond their first year of
Meaningful Use: FULL CALENDAR YEAR –
follow CMS closely for changes
MU Timeline Highlights
2015 Reporting Periods
1) Anticipated to be February 28, 2016 for the
2015 reporting period
2) 2014 was the last year to start Medicare
Electronic Health Record (EHR) Incentive
Program and receive incentives. First time
attesters in 2015 will not receive an incentive,
but will avoid the 2017 payment adjustment.
How do meaningful use
payment adjustments work?
Stay Tuned for
Changes!
-1% 2015 Payment
Adjustment Avoided If
-2% 2016 Payment
Adjustment Avoided If
-3% 2017 Payment
Adjustment Avoided If
Attested to MU for the
Attested to MU for the
2013 reporting period OR
2014 reporting period OR
Attested to MU for the 2015
reporting period OR
Attested to MU for the first
time by October 1, 2015 OR
Attested to MU for the first
time by October 1, 2016 OR
CMS approves a hardship
exception application specific
to 2016 payment adjustment
CMS approves a hardship
exception application (form not
yet released) specific to 2017
payment adjustment
Attested to MU for the first
time by
October 1, 2014 OR
CMS approved a hardship
exception application specific
to 2015 payment adjustment
Payment Adjustments
1) Affect Medicare Part B payments
2) Follow the individual provider
3) CMS Payment Adjustment Tip sheet
https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/Pay
mentAdj_HardshipExcepTipSheetforEP.pdf
Hardship Applications
1) Hardship exception applications are
developed for each payment adjustment year
2) Hardship exception application for 2015
reporting period (to avoid 2017 payment
adjustments) not yet released
3) Cannot use old hardship applications from
previous years
EHR Participation Timeline
Online tool to help
determine a provider’s
year and stage of
Meaningful Use
http://cms.gov/Regulation
s-andGuidance/Legislation/EHRI
ncentivePrograms/Particip
ation-Timeline.html
Medicare
What stage am I in?
Stay Tuned for
Changes!
Started 2011
2015 MU
Attestation
•
•
•
•
Stage 2
Full calendar year
$1,960 incentive
Avoids 2017
payment
adjustment
Started 2012
2015 MU
Attestation
•
•
•
•
Stage 2
Full calendar year
$3,920 incentive
Avoids 2017
payment
adjustment
Started 2013
In 2015 MU
Attestation
Started 2014
•
•
•
•
2015 MU
Attestation
Stage 2
Full calendar year
$7,840 incentive
Avoids 2017
payment
adjustment
*Stages shown are not reflective of providers who
have skipped program years.
•
•
•
•
Stage 1
Full calendar year
$7,840 incentive
Avoids 2017
payment
adjustment
Medicaid
What stage am I in?
Stay Tuned for
Changes!
AIU 2012
AIU 2013
2015 MU Attestation
• Stage 2
• Full calendar year
• $8,500 incentive
• Avoids 2017 payment
adjustment for
Medicare Part B
claims
2015 MU Attestation
• Stage 1
• Full calendar year
• $8,500 incentive
• Avoids 2017 payment
adjustment for
Medicare Part B
claims
*Stages shown are not reflective of providers who
have skipped program years.
AIU 2014
2015 MU Attestation
• Stage 1
• Any 90 days
• $8,500 incentive
• Avoids 2017 payment
adjustment for
Medicare Part B
claims
Questions to ask now!
1) Are provider claims already subject to payment
adjustment in 2015?
2) What stage should I be working on in 2015?
3) Does staff know if your reporting period has
already started?
4) Does staff know how to utilize technology (EHR
and patient portal) in a way that counts for
meaningful use reports?
Physician Quality Reporting System
Program
Payment Adjustments
1) Individual Eligible Professionals (EPs) and group practices that
do not satisfactorily participate and report in the 2015 PQRS
program year will be subject to a 2% penalty downward
payment adjustment in 2017
PQRS Performance
Year
PQRS Payment
Year
Negative Adjustment Rate
2013
2015
-1.5%
2014
2016
-2.0%
2015
2017
-2.0%
1) Penalty applied to all of the EP’s Part B covered professional
services under Medicare Physician Fee Schedule (MPFS)
during the payment adjustment year
2) EPs are identified by their individual national provider
identifier (NPI) and tax identification number (TIN)
Reporting Methods
Claims
• Select measures and begin reporting by submitting Quality Data
Codes on claims
Qualified Registry
• Entity that collects clinical data from an EP or Group and submits to
CMS on behalf of the EP/Group. Refer to the 2015 Participating
Registry Vendors
EHR-Direct
• EP generates files from their EHR – EP uploads to CMS at year end
EHR-Data Submission
Vendor
• Data electronically shared with DSV – DSV uploads to CMS at year
end
Qualified Clinical Data
Registry (QCDR)
• CMS approved entity that collects & submits data on behalf of EPrefer to 2015 Participating Qualified Clinical Data Registry
GPRO Web Interface
• Secured internet-based application available in the PQRS portal to
pre-registered users
CAHPS – Certified Survey
Vendor
• Supplemental to other reporting mechanisms
Individual or Group Reporting
Individual Reporting
• EHR Direct Product that is
Certified Electronic Health
Record Technology (CEHRT)
• EHR Data Submission
Vendor that is CEHRT
• Qualified PQRS registry
• Qualified Clinical Data
Registry (QCDR)
• Medicare Part B Claims
Group Reporting
• EHR Direct Product that is CEHRT
• EHR Data Submission Vendor that
is CEHRT
• Qualified PQRS registry
• GPRO Web Interface (25+
providers)
• Consumer Assessment of
Healthcare Providers and Systems
(CAHPS) survey for PQRSsupplemental to other reporting
mechanisms
Group Practice Reporting
GPRO Registration
1) Three GPRO group sizes:
a. 100 + EPs
b. 25 – 99 EPs
c. 2 – 24 EPs
2) Reporting mechanisms & requirements vary depending on
the group size at time of registration
3) The reporting mechanism selected during registration will
be the only PQRS submission method available to the
group and all individual NPIs that bill Medicare under the
group’s TIN for PQRS during the reporting year
Measure Selection
Consider important factors when selecting 2015 PQRS
measures for reporting:
1. Clinical conditions usually treated
2. Types of care typically provided, e.g. preventive,
chronic, acute
3. Settings where care is usually delivered, e.g. office,
ED, surgical suite
4. Quality Improvement goals for 2015
5. Other quality reporting programs in use or being
considered
6. Review specifications for the selected reporting option
for each measure under consideration
Measure Selection
Review the 2015 PQRS Measures List available in the Measure
Codes section of the CMS-PQRS website
1. http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/MeasuresCodes.html
2. Not all measures are available under each PQRS reporting
option
3. The GPRO Web interface reporting option has set
measures, all of which must be reported
4. Avoid individual measures that do not or may infrequently
apply to the services provided
5. PQRS measure set and resulting measure specifications
change from year to year
Measure Selection
1) New - 2015 Cross-Cutting
Measures Requirement:
a. Applies to PQRS claims
and registry reporting
options
b. EPs and groups are
required to report one
cross-cutting measure
if they have at least
one Medicare patient
face-to-face encounter
PQRS
Cross-Cutting Measure Title
Measure #
CAHPS for PQRS Clinician/Group Survey
321
047
046
131
Care Plan
Childhood Immunization Status
Closing the Referral Loop Receipt of Specialist
Report
Controlling High Blood Pressure
Diabetes: Hemoglobin A1c Poor Control
Documentation of Current Medications in the
Medical Record
Falls: Screening for Fall Risk
Functional Outcome Assessment
Hepatitis C: One-Time Screening for Hepatitis
C Virus (HCV) for Patients at Risk
Medication Reconciliation
Pain Assessment & Follow-Up
111
Pneumonia Vaccination Status for Older Adults
240
374
236
001
130
318
182
400
110
128
134
317
226
402
Preventative Care & Screening: Influenza
Immunization
Preventive Care & Screening: BMI Screening
and Follow-Up Plan
Preventive Care & Screening: Screening for
Clinical Depression & Follow-Up Plan
Preventive Care & Screening: Screening for
High Blood Pressure & Follow-Up Documented
Preventive Care & Screening: Tobacco Use:
Screening & Cessation Intervention
Tobacco Use and Help with Quitting Among
Adolescents
Measures & Reporting Resources
1)
2015 PQRS Implementation Guide
a. Provides guidance about how to select measures for reporting, how
to read and understand a measure specification, and outlines the
various reporting methods available for 2015 PQRS
b. Details how to implement claims-based reporting of measures to
facilitate satisfactory reporting of Quality-Data Codes (QDCs) by EPs
c. Provides decision trees to assist EPs with selecting reporting method
2) 2015 PQRS Measures List
a. Identifies & describes the measures used in PQRS, including all
available reporting methods, PQRS & National Quality Forum (NQF)
numbers, National Quality Strategy (NQS) domains, & measure
developers
Both resources are available at: http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
Measure Applicability Validation
1)
Satisfactory Claim and Registry-Based Reporting
a. Report each measure for at least 50% of the Medicare Part B
FFS patients seen during the reporting period to which the
measure applies
b. Report at least 9 measures covering 3 NQS domains
c. Measures with a 0% performance rate would not be counted
2) Measure Applicability Validation (MAV) Process
a. Claims-based MAV: applies to EPs reporting less than 9
measures OR 9 or more measures with less than 3 domains
b. Registry-based MAV: applies to EPs and group practices
reporting less than 9 measures OR 9 or more measures with
less than 3 domains
Value-Based Payment Modifier
Value-Based Payment Modifier
1)
2)
3)
4)
5)
Aligned with and is based on participation in PQRS
Assesses both quality of care furnished and the cost of that care
under the Medicare Physician Fee Schedule (PFS)
Payment adjustment made on a per claim basis to Medicare
payments for items & services furnished
Applied at TIN level & applies to all physicians billing under that TIN
Phased in:
Performance
Year
VM Payment
Adjustment
Year
Group Size Affected
EPs affected by
penalty
CY 2013
CY 2015
Physician Groups ~ 100+ EPs
Physician EPs
CY 2014
CY 2016
Physician Groups ~ 10+ EPs
Physician EPs
CY 2015
CY 2017
Physician Groups & Solo Practices ~
2+ EPs
Physician EPs
CY 2016
CY 2018
Physician Groups & Solo Practices ~
2+ EPs
Physician and NonPhysician EPs
Value Modifier Outcome Measures
The quality measurement component of the Value Modifier
includes three outcome measures that CMS calculates from
FFS Medicare claims:
1) two composite measures of hospital admissions for
ambulatory care-sensitive conditions
a. acute conditions (bacterial pneumonia, urinary tract
infection, dehydration)
b. chronic conditions (chronic obstructive pulmonary
disease, heart failure, diabetes)
2) one measure of 30-day all-cause hospital readmissions.
3) CAHPS surveys required in some cases
Value Modifier Cost Measures
The cost measures include:
1) Total per capita costs measure (annual payment
standardized and risk-adjusted Part A and Part B costs)
2) Total per capita costs for beneficiaries with four chronic
conditions (chronic obstructive pulmonary disease, heart
failure, coronary artery disease, diabetes)
3) Medicare spending per beneficiary for all A and B costs
during the 3 days before and 30 days after a Medicare
inpatient hospital stay
Incentives and Payment Adjustments: VM
2017 Calculation
Groups of 2-9 Eligible Professionals and Solo Practitioners
Cost/Quality
Low Quality
Average
Quality
High Quality
Low Cost
+0.0%
+1.0x
+2.0x
Average Cost
+0.0%
+0.0%
+1.0x
High Cost
+0.0%
+0.0%
+.0.0%
PQRS/Value-Based Payment Modifier: What Medicare Professionals Need to Know in 2015 5/18/2015
https://www.youtube.com/watch?v=Ww0oH-FhaYM
30
Incentives and Payment Adjustments: VM
2017 Calculation
Groups of 10 or More Eligible Professionals
Cost/Quality
Low Quality
Average
Quality
High Quality
Low Cost
+0.0%
+2.0x
+4.0x
Average Cost
-2.0%
+0.0%
+2.0x
High Cost
-4.0%
-2.0%
+0.0%
PQRS/Value-Based Payment Modifier: What Medicare Professionals Need to Know in 2015 5/18/2015
https://www.youtube.com/watch?v=Ww0oH-FhaYM
31
Quality & Resource Use Report
1)
QRUR - annual reports that provide physicians and physician groups
with:
a. Comparative information about the quality of care furnished and
the cost of that care to the practice’s Medicare FFS patients –
based on PQRS and claims data
b. Beneficiary-specific information to help coordinate and improve
the quality and efficiency of care furnished
c. Displays your performance related to the CMS Value-Based
Payment Modifier - Value Modifier (VM) program
2) Access report via CMS secure portal - must first sign up for IACS
account. Instructions at: http://www.cms.gov/Medicare/Medicare-
Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013QRUR.html
Summary Incentives and Payment Adjustments
Eligibility for All Programs
PQRS
Medicare Physicians
Doctor of Medicine
Doctor of Osteopathy
Doctor of Podiatric Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental Medicine
Doctor of Chiropractic
Practitioners
Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified RN Anesthestist
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologists
Therapists
Physical
Occupational
Qualified Speech-Language
Value Modifier
Eligible for
Incentive
Subject to
Payment
Adjustment
Included in
Definition of
"Group"
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
EHR Incentive Program
Subject to VM
Eligible for
Medicare
Incentives
Eligible for
Medicaid
Incentive
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Subject to
Medicare
Payment
Adjustment
X
X
X
X
X
X
X
Incentives and Payment Adjustments: MU
1) Incentives for Meaningful Use end in 2015
2) Medicare eligible professionals who do not meet
the requirements for meaningful use by 2015
and in each subsequent year are subject to
payment adjustments to their Medicare
reimbursements that start at 1% per year, up to
a maximum 5% annual adjustment.
35
Incentives and Payment Adjustments: PQRS
1) Phased-in approach
2) Two year look back period
3) By 2017, all solo practitioners and eligible professionals in
groups of any size will be subject to a 2% downward
adjustment if they do not report PQRS data for 2015
4) Failure to report PQRS data automatically results in a
downward adjustment in the value modifier for physicians for
2017 in groups with 10 or more eligible professionals
5) Solo practitioners and groups of 2-9 eligible professionals who
report PQRS data in 2015 will only receive a neutral or
upward adjustment in the value modifier in 2017, since 2015
is their first performance year
Incentives and Payment Adjustments: VM
1)
2)
3)
4)
5)
37
Phased-in approach
Groups of 100 or more eligible professionals are subject to an
upward, neutral or downward adjustment in 2015 based upon
performance year 2013
Groups of 10 or more eligible professionals are subject to an
upward, neutral or downward adjustment in 2016 based upon
performance year 2014
Solo practitioners and groups of 2-9 are only subject to a neutral or
upward adjustment in 2017, since 2015 is their first performance
year
In any size group, failure to report PQRS will result in an automatic
downward adjustment in PQRS and the Value Modifier in 2017
based upon performance year 2015
Payment Adjustment Example
Performance Year 2015, Payment Adjustment Year 2017
Meaningful
Use
-3%
PQRS
-2%
Value
Modifier
-4%
-9%
Payment
Adjustment
Based on this example: For every $100,000 in Medicare funds,
your practice risks losing up to $9,000 in payment adjustments.**
**Calculation is based on estimate for the 2017 payment year.
The Value Modifier adjustment is dependent upon group size
38
Help Desk Resources
1) QualityNet Help Desk:
a.
b.
c.
d.
e.
f.
866-288-8912 or qnetsupport@hcqis.org 8:00 am – 8:00 pm EST M-F
IACS registration questions
IACS login issues
PQRS portal password issues
PQRS feedback report availability and access
PQRS Program questions
2) VM Help Desk:
a.
b.
888-734-6433 ~ option 3 or pvhelpdesk@cms.hhs.gov
Value-Based Payment Modifier Program questions
3) EHR Incentive Program Information Center:
a.
b.
888-734-6433 or pvhelpdesk@cms.hhs.gov
EHR Incentive Program (Meaningful Use)
Stay Connected
Connect with us for the latest, up-to-date information.
@MD_VAQIN
www.qin.vhqc.org
Questions
Contact VHQC
Jennifer Chenault-Walker
Manager, Program Operations
Jchenault-walker@vhqc.org
804.289.5334
Sandra Gaskins
Improvement Consultant
QIN QIO
sgaskins@vhqc.org
804.289.5346
This material was prepared by VHQC, the Medicare Quality Innovation Network Quality Improvement Organization for Maryland and Virginia,
under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
The contents presented do not necessarily reflect CMS policy. VHQC/11SOW/6/17/2015/2177