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Overview of Medicare’s Regulatory Programs Bob Jasak Deputy Director, Regulatory & Quality Affairs American College of Surgeons.

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Presentation on theme: "Overview of Medicare’s Regulatory Programs Bob Jasak Deputy Director, Regulatory & Quality Affairs American College of Surgeons."— Presentation transcript:

1 Overview of Medicare’s Regulatory Programs Bob Jasak Deputy Director, Regulatory & Quality Affairs American College of Surgeons

2 Data Collection Pay-For-Reporting Public Reporting Pay-for-Performance/ Value-Based Purchasing

3 Overview

4

5 Physician Compare (Public Reporting) Physician Compare (Public Reporting) PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) CLAIMS EHRs Registries QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

6 Physician Compare (Public Reporting) Physician Compare (Public Reporting) Group Practice Performance Rates on quality measures (2014 target) Patient Experience of Care Data: (2014 target) Specialty Society Specific Data Individual performance data (target 2015)

7 Physician Compare (Public Reporting) Physician Compare (Public Reporting) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

8 Bonuses: Beginning in 2015 Budget neutral program (amounts of bonuses unknown until penalties determined) Penalties: 2015: -2% for non-PQRS participants (combined VBPM and PQRS penalty) 2015: up to -1% even if PQRS compliant 2016: -4% for non-PQRS participants 2016: up to -2 percent even if PQRS compliant Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

9 Physician Compare (Public Reporting) Physician Compare (Public Reporting) PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

10 PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) Incentives Bonuses Expiring Separate Penalties (increasing to 2%) Quality Measures Specific Menu of Measures Heavy favor toward NQF-endorsement Year long submission process Predominately Process Measures Limited Measures for some Specialties Low Participation All EPs: 32% General Surgery: 20% Vascular: 32.4% Colon/Rectal: 28.2% Increasing Requirements Elimination of “low bar” reporting mechanisms to avoid penalty Increasing from 3 to 9 individual measures

11 Measure Groups: Perioperative Care Measure NameNQS Domain 1. Timing of Prophylactic Parenteral Antibiotic – Ordering PhysicianPatient Safety 2. Selection of Prophylactic Antibiotic – First OR Second Generation CephalosporinPatient Safety 3. Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)Patient Safety 4. Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)Patient Safety CMS had proposed expanding Measures Groups to include a minimum of “at least 6 measures,” but withdrew the proposal and will continue to allow a Measures Group to consist of 4 or more measures.

12 Measure Groups: General Surgery** Measure NameNQS Domain 1. Anastomotic Leak InterventionEffective Clinical Care 2. Unplanned Reoperation within the 30 Day Postoperative PeriodEffective Clinical Care 3. Unplanned Hospital Readmission within 30 Days of Principal ProcedureEffective Clinical Care 4. Surgical Site Infection (SSI)Effective Clinical Care 5. Patient-Centered Surgical Risk Assessment and Communication (Patient-Specific Risk Calculator) Person and Caregiver- Centered Experience and Outcomes ** Measure includes: Ventral Hernia, Appendectomy, AV Fistula, Cholecystectomy, Thyroidectomy, Mastectomy +/- Lymphadenectomy or SLNB, Partial Mastectomy or Breast Biopsy/Lumpectomy +/- Lymphadenectomy or SLNB Bariatric Laparoscopic or Open Roux-en Y Gastric Bypass, Bariatric Sleeve Gastrectomy, and Colectomy  CMS had originally proposed two separate groups (one for general surgery; one for gastrointestinal surgery) but combined into a single Measures Group  Working the CMS to refine the Measures Group ASAP because the inclusion of the Anastomotic Leak measure would limit the entire Measures Group to ONLY gastric bypass and colectomy surgeries.

13 Additional Individual Measures of Note Measure NameNQS Domain Participation in a Systematic Clinical Database Registry That Includes Consensus Endorsed Quality Measures Communication and Care Coordination Patient-Centered Surgical Risk Assessment and Communication (Patient-Specific Risk Calculator) Person and Caregiver- Centered Experience and Outcomes Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionCommunity/Population Health

14 Physician Compare (Public Reporting) Physician Compare (Public Reporting) PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) CLAIMS EHRs Registries QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

15 CLAIMS Future of Claims-Based Reporting: Limited to mostly process measures High administrative burden 2014: CMS eliminated the claims- based reporting option for reporting Measures Groups CMS has been explicit about desire to eliminate this as an option

16 Physician Compare (Public Reporting) Physician Compare (Public Reporting) PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) CLAIMS EHRs Registries QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

17 EHRs EHR Quality Measure Reporting Lower administrative burden Only 63 PQRS approved EHR reportable quality measures (2014) None of the measures in the Perioperative or General Surgery Measures Groups is specified for EHR-based PQRS reporting Pilot project to streamline PQRS EHR Reporting and EHR Meaningful Use Reporting- but without applicable measures there is nothing to streamline ACS work with Epic

18 Physician Compare (Public Reporting) Physician Compare (Public Reporting) PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) CLAIMS EHRs Registries QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

19 Registries ACS Surgeon Specific Registry Approved for participation in PQRS beginning in 2012 Online for 2013 Reporting Also built on platform collecting information for ABS MOC and Caselog Current Limitations on this point-of-entry: Limited to collecting information on PQRS approved measures Only available for an individual to report on Measures Groups (which only requires reporting the Measures Group across 20 patients (including 11 Medicare patients) Not currently available for group practice reporting (unless each surgeon reports separately as an individual Not available to report individual measures outside of a measure group (which in 2014 will require reporting a measure across 50% of patients who are eligible to be reported on for a given measure)

20 Physician Compare (Public Reporting) Physician Compare (Public Reporting) PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) Registries QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

21 QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) QCDR Quick Facts Concept mandated by Congress (at ACS and others’ requests) in the “Fiscal Cliff Bill” to be implemented by January 1, 2015 Theory was to provide a PQRS bypass for physicians participating in clinical registries that provide more value and quality improvement opportunities than the measures currently approved in PQRS. ACS responded to early 2013 CMS request for comments and again in official proposed rule CMS qualification criteria finalized in CY 2014 Physician Fee Schedule Final Rule (released by CMS on November 27, 2013)

22 QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) QCDR Criteria Only available for individual physician participation (no group practice reporting) and must be physician specific Measure Sources: CG-CAHPS, NQF-endorsed measures, measures used by boards or specialty societies, and measures used in a quality collaborative Report on at least 9 measures (across 3 National Quality Strategy domains) Report on at least 50% of patients eligible for each measure selected Report on at least 1 outcome measure (example: unplanned readmission) At least quarterly feedback reports

23 Physician Compare (Public Reporting) Physician Compare (Public Reporting) PQRS (Pay-for-Reporting) PQRS (Pay-for-Reporting) CLAIMS EHRs Registries QCDRs (Qualified Clinical Data Registries) QCDRs (Qualified Clinical Data Registries) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance) Value-Based Payment Modifier (Value-Based Purchasing/ Pay-for-Performance)

24 Value-Based Modifier Scoring Clinical care Patient experience Efficiency Patient Safety Care Coordination Total overall costs Total costs for beneficiaries with specific conditions Quality of Care Composite Score Cost Composite Score VALUE- BASED MODIFIER AMOUNT

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