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Claims and the QCDR: Avoiding the Payment Adjustment

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Presentation on theme: "Claims and the QCDR: Avoiding the Payment Adjustment"— Presentation transcript:

1 Understanding PQRS and why reporting via an anesthesia QCDR is beneficial

2 Claims and the QCDR: Avoiding the Payment Adjustment
Presented by: Matthew T. Popovich, Ph.D. Quality Specialist American Society of Anesthesiologists 10/28/2014

3 Physician Quality Reporting System (PQRS)
What is the program? Incentives and Payment (Negative) Adjustments Reporting Options (Including the QCDR) CMS Rulemaking Process 2014 Physician Fee Schedule (PFS) 2015 Proposed PFS Final Rule (est. November 2014) 10/28/2014

4 Physician Quality Reporting System (PQRS)
Defining PQRS “Paid under or based on the Physician Fee Schedule” Eligible Professionals (EPs) Payment Incentives (ending in 2014) v. Payment Adjustments Common Measures Reported by Anesthesiologists #30 (NQF #0269): Timing of Prophylactic Antibiotic #44 (NQF #0236): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery #76 (NQF #0464): Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol #193 (NQF #0454): Perioperative Temperature Management 10/28/2014

5 Satisfactorily Report = Avoid the Payment Adjustment
Reporting Options (2014 & Proposed 2015) Claims Qualified Clinical Data Registry (QCDR) “Traditional” Qualified Registry Other Reporting Options Alignment of Measure Reporting Requirements Nine (9) quality measures Three (3) National Quality Strategy (NQS) domains 10/28/2014

6 Satisfactorily Report = Avoid the Payment Adjustment
National Quality Strategy Domains Patient Safety Person and Caregiver-Centered Experience and Outcomes Communication and Care Coordination Effective Clinical Care Community / Population Health Efficiency and Cost Reduction Anesthesia Measures (Claims) Patient Safety (PQRS #30, #76 and #193) Effective Clinical Care (PQRS #44) 10/28/2014

7 Satisfactorily Report = Avoid the Payment Adjustment
Satisfactorily Reporting – Claims (2014): EPs must report ≥ 9 PQRS measures covering ≥ 3 NQS domains to qualify for an incentive payment for 50% of Medicare Part B patients for whom the measure applies If fewer than 9 measures, then EP is subject to the Measure-Applicability Validation (MAV) process EPs must report ≥ 3 measures in order to avoid the payment adjustment for 2016 Subject to MAV process 10/28/2014

8 Satisfactorily Report = Avoid the Payment Adjustment
Qualified Clinical Data Registry (QCDR) Use of Established Specialty Society Registries PQRS and non-PQRS Measures AQI/NACOR: 8 PQRS and 11 Non-PQRS Measures AQI/NACOR: 4 NQS Domains Available QCDR Responsibilities 10/28/2014

9 Satisfactorily Report = Avoid the Payment Adjustment
Claims-Based Reporting Challenges (Beyond 2014): PQRS Measures for Consideration PQRS #30, PQRS #109 Potentially fewer measures to report via claims 10/28/2014

10 Satisfactorily Report = Avoid the Payment Adjustment
QCDR Incentive Requirements (2014) Report at least 9 measures covering at least 3 NQS domains AND report each measure for at least 50% of EP’s applicable patients seen during reporting period One measure must be an outcome measure 10/28/2014

11 Satisfactorily Report = Avoid the Payment Adjustment
QCDR Reporting Requirements Avoid the payment adjustment (2016) [For CY 2014] Report at least 3 measures covering at least 1 NQS domain for at least 50 percent of the EP’s applicable patients seen during the participation period 10/28/2014

12 Satisfactorily Report = Avoid the Payment Adjustment
CMS PROPOSED: “For the 12-month reporting period [CY 2015] for the 2017 PQRS payment adjustment, the EP would report at least 9 measures available for reporting under a QCDR covering at least 3 of the NQS domains, AND report each measure for at least 50 percent of the eligible professional’s patients.” Report 3 outcome measures or 2 outcome measures and at least 1 resource use, patient experience or efficiency/appropriate use measure 10/28/2014

13 Resources Learn and Understand PQRS
CMS PQRS Website ( CMS QualityNet Help Desk ( or ASA & AQI Member Resources Quality and Regulatory Affairs Anesthesia Quality Institute ( ASA web site ( ) 10/28/2014

14 Presented by: Lance Mueller Director Anesthesia quality institute
The Qualified Clinical Data Registry Presented by: Lance Mueller Director Anesthesia quality institute 10/28/2014

15 The Challenge The government wants to know that Ma and Pa are getting the health care they deserve… and that our taxes pay for. 10/28/2014

16 Institute of Medicine report published in late 1999
Highlighted preventable errors in the US healthcare system “100,000 lives a year lost to preventable death” Anesthesiology cited as leaders in advancing patient safety 10/28/2014

17 The Physician Quality Reporting System
Individual physicians For public reporting Approved measures Submitted and maintained by ‘stewards’ Vetting through National Quality Forum “Claims made” reporting Scored by CMS Incentives >>> penalties 10/28/2014

18 “Pay for Performance” Federal programs to promote quality over quantity in the delivery of healthcare Based on measuring outcomes Public reporting Payment adjustments (penalties) >>> Incentives Hospitals Physicians 10/28/2014

19 Key Points Pay for Performance programs are evolving over time
What was true last year will not be true next year Complexity is increasing ASA (and all physician societies) must seize opportunities to guide this evolution ASA has worked hard to provide a solution for the profession 10/28/2014

20 The Evolution of P4P From Process Measures To Outcomes 10/28/2014

21 Small hospitals, surgery centers, clinics and offices
The Evolution of P4P From Big hospitals To Small hospitals, surgery centers, clinics and offices 10/28/2014

22 The Evolution of P4P From Inpatients To ALL patients 10/28/2014

23 Medicare Advantage, Medicaid
The Evolution of P4P From Medicare only To ALL payers including Medicare Advantage, Medicaid 10/28/2014

24 The Evolution of P4P From Incentives To Penalties 10/28/2014

25 Clinical Safety Focused
The Evolution of P4P From Clinical Safety Focused To Patient Centered 10/28/2014

26 The Evolution of P4P From Individuals To Teams 10/28/2014

27 The Evolution of P4P From Paper To Electrons 10/28/2014

28 A demonstration project
The Evolution of P4P From A demonstration project To The way we do business 10/28/2014

29 The QCDR Qualified Clinical Data Registry New in 2014
A reporting mechanism for registry participants Similar to the registry reporting option for PQRS / VM Can use PQRS measures Can use non-PQRS, specialty specific measures 10/28/2014

30 Why the QCDR is a big deal
Measure definition by the specialty, for the specialty Data collection and scoring moves from CMS to the registry “One stop shop” for all requirements Public reporting by the society 10/28/2014

31 The Anesthesiology Perspective
The National Anesthesia Clinical Outcomes Registry (NACOR) is certified as a QCDR Available measures for perioperative care increased from 4-8 in PQRS to 19 4 domains, multiple outcome measures 10/28/2014

32 Where Did New Anesthesia Measures Come From?
Existing in PQRS Solves the stewardship problem Existing in NQF New measures mostly developed by ASA’s Committee on Performance and Outcome Measures (CPOM) Developed, but never selected Developed, but never submitted Subspecialty possibilities Aspirational measures 10/28/2014

33 AQI as a QCDR The Centers for Medicare and Medicaid Services (CMS) introduced the Qualified Clinical Data Registry (QCDR) as a reporting option in 2014. 2015 Medicare Physician Fee Schedule Proposed Rule: To avoid future payment adjustments an EP will have to report on 9 measures including 3 outcomes across 3 NQS domains. The addition of QCDR reporting allows specialty societies to develop measures that reflect profession-specific priorities. 10/28/2014

34 Performance Reporting through the QCDR
2015 Anesthesia QCDR reporting is a product of ASA in partnership with AQI ASA sells the service AQI reports to CMS on behalf on the group and it’s EP’s AQI provides monthly PQRS feedback reports Groups must be participating in AQI and receive all benefits of participation Free to ASA members who are participating in AQI’s NACOR registry Additional charge for Eligible Professionals (EP) who are non-ASA members 10/28/2014

35 QCDR Reporting Requirements. You Must:
Be a NACOR participant If you are already participating – see next slide If you are not already participating in NACOR steps include: Completion of a Business Associate Agreement with the AQI Completion of the AQI practice survey Transmission of electronic data to the registry beginning in January 2015 Pay AQI membership dues 10/28/2014

36 QCDR Reporting – Steps to Report
Self-nomination with AQI for QCDR reporting in early 2015 (more details forthcoming) Work with AQI to ensure proper data is being sent AQI has staff to review your data and reports to ensure EP’s are reporting and have a reasonable expectation of satisfactorily reporting Approve the final transmission of EP performance data to CMS (early 2016) 10/28/2014

37 Presented by: Terri Howard, CAE Director of Member Services
ASA QCDR Service Presented by: Terri Howard, CAE Director of Member Services 10/28/2014

38 ASA QCDR Service Definition of the service
Costs associated with participating in QCDR Enrollment and membership processes Who to contact if interested in participating 10/28/2014

39 ASA QCDR ASA has partnered with AQI to provide PQRS reporting as a benefit of ASA membership. To participate in QCDR, the entire practice enrolls in AQI’s NACOR. ASA members: no cost to participate in NACOR Non-ASA member independent providers: $1000 annually to participate Non-physician providers in the care team: no cost to participate 10/28/2014

40 ASA Membership / QCDR Purchase
Group Membership / QCDR Invoice One invoice for all participating providers in the practice Membership: Both ASA and state component society dues are required ASA membership = $665 physicians, $335 CRNAs, AAs; state dues varies Non-ASA members purchase QCDR only = $295 per provider annually 10/28/2014

41 Enrollment Process Submit roster template of participating EPs
Practice may add/subtract providers throughout the year Sign AQI & ASA agreements Work with AQI to submit data to NACOR Submit new ASA member applications, as applicable Practice reviews the roster prior to annual renewal of membership and QCDR service 10/28/2014

42 Questions? 10/28/2014

43 Getting Started Contact ASA
Sara Moser, Director of Marketing & Corporate Development, Terri Howard, Director of Member Services, General questions: 10/28/2014

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