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? 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. Providers who successfully report data can earn an additional 0.5 % of their total allowable Medicare charges in and 2014. In 2016, payment adjustments will be made to providers who choose not to report. This adjustment will be based upon participation in 2014.

Eligible & Able to Participate 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

Eligible BUT not able to Participate 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 Administrative claims option is no longer available to avoid payment adjustment

How is the data reported? To successfully report and receive the incentive, providers must select and submit at least nine measures. Submission of measures can be through claims, registry, a certified EHR or data submission vendor*, or a qualified clinical data registry*. 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 Group of 2 or more EPs under the same TIN Rates apply to All members of the TIN

Reporting Alignment PQRS EHR Incentive Program Value-Based Modifier

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.aspx Check eligibility for the PQRS program http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf

Eligible Providers Meaningful Use Medicare Medicaid MD DO Dentists and Oral Surgeons Podiatrists Optometrists Chiropractors MD DO NP Certified Nurse-Midwife Dentists Physician assistant (PA) who furnishes services in a Federally Qualified Health Center of Rural Health Clinic that is led by a physician assistant

Eligible Providers PQRS & VM Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic Nurse Practitioner Certified Nurse Midwife Physician Assistant Clinical Nurse Specialist Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant) Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists Physical Therapist Occupational Therapist Qualified 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

Choose Reporting Option 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 2014 The data submitted to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries.

Group Reporting (GPRO) 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

Value-based Modifier Cost data and Quality measures included Per-claim adjustment Applied at the Group Level CY 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. VM assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule. The VM is a new per-claim adjustment under the Medicare Physician Fee Schedule that is applied at the group (Taxpayer Identification Number “TIN”) level to EPs billing under the TIN.

Value-based Modifier Groups with 10-99 EPs Groups with 100+ Eps 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 Low Quality Average Quality High Quality Low Cost 0.0% +1.0x%* +2.0x%* Average Cost -0.5% High Cost -1.0% "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 setting Are 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 Engagement PQRS # 377 -Functional Status Assessment for Complex Chronic Conditions 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 Safety PQRS # 130 -Documentation of Current Medications in the Medical Record 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 Coordination PQRS # 374 - Closing the Referral Loop: Receipt of Specialist Report 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 Health PQRS # 226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 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 Resources PQRS # 312 -Use of Imaging Studies for Low Back Pain 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/Effectiveness PQRS # 236 - Controlling High Blood Pressure 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

Population Health Team Questions? Health Care Excel Population Health Team Don Gettinger, BS, Program Manager 812.234-1499 x336 dgettinger@inqio.sdps.org Stacy Colson, RN Clinical Advisor 812.234-1499 x314 scolson@inqio.sdps.org