VBM 2015 Physician Compare 2011 QRUR What’s New in CMS Value-Based Purchasing and Why It’s Important to Participate in PQRS 2012 December 4, 2012 Joseph G. Cacchione, MD, FACC Eileen Hagan Brian Whitman Overview of Today’s Webinar Participants will be able to: 1. Appreciate the timelines and implications for valuebased payment. 2. Understand why it’s important to participate in PQRS. 3. Begin to understand the value-based modifier. 4. Describe the options and methods for successful participation in PQRS in 2013. 5. Determine the best way for you and your practice to participate in PQRS in 2013. 2 Timelines and Implications for Value-Based Payment Background Since 2006, Legislation has called for value-based purchasing (VBP) to transform Medicare from a passive payer to an active purchaser by using specific performance measures aimed at improving quality and reducing overall cost. Value-based purchasing involves three major elements for physicians: Confidential feedback on performance and resource use Public Reporting Payment adjustment /value modifier 4 Confidential Feedback on Performance and Resource Use Quality and Resource Use Reports (QRURs) provide comparative information so physicians can view the clinical care their patients receive in relation to the average care and costs of other physician’s Medicare patients: Physicians in IA, KS, MO, NE received them in March 2012 using 2010 data; Physicians in groups with > 25 eligible professionals (EPs) in CA, IA, IL, KS, MI, MN, MO,NE, WI will receive them in December 2012 using 2011 data; All groups with > 25 EPs will receive them in Fall 2013 using 2012 data; VBM information is expected to be included in the reports. 5 Public Reporting Physician Compare is a CMS website for publicly reporting physician performance; similar to Hospital Compare Physician Compare currently reports: That a physician has satisfactorily reported quality measures through PQRS That a physician received a bonus for electronic prescribing Physician Compare will publicly report data on those physician groups that participated in PQRS using the GPRO web interface in 2012 CMS has not yet announced full details of future expansion of this program, but expect to see PQRS performance and cost measures in the future. 6 Payment Adjustment / Value Modifier CMS is phasing in the use of value-based modifiers (VBM) to provide differential payments based on quality and cost of care. The QRUR is intended as a precursor to the VBM and currently includes cost of care measures for patients seen by the physician and quality information calculated using claims data and from PQRS. For further information on the QRUR, go to: http://www.cardiosource.org/~/media/Files/Advocacy/Physician%20Payment/CMSQu alityandResourceUseReportsandImplicationsforValueBasedPayment.ashx 7 In the Meantime Think about physicians and other eligible professionals as the supply side of value-based purchasing; your fee-for-service is subject to valuebased payment Participation in CMS incentive programs (PQRS, e-Rx, Meaningful Use) has been voluntary; CMS has begun phasing in payment adjustments for non-participation . 8 Payment adjustments for PQRS are moving from bonuses for successful participation to penalties for non-participation. 2007 2008 2009 PQRS Yes No Penalty 1.5% 1.5% 2% 2010 2011 2012 2013 2014 2% 1% 0.5% 0.5% 0.5% 2015 penalty 2016 penalty 2015 2016 2017 2018 2017 penalty 2018 penalty 2019 penalty 2020 penalty -1.5% -2% -2% -2% 2019 2020 -2% -2% Eligible professionals (EPs) who do not participate in PQRS in 2013 will receive a -1.5% payment adjustment in 2015. 9 Payment adjustments for E-prescribing are moving from bonuses for successful participation to penalties for nonparticipation. 2007 E- Rx Yes No Penalty 2008 2009 2010 2011 2012 2013 2014 2015 2% 2% 1% 1% 0.5% 2012 penalty 2013 penalty 2014 penalty 2015 penalty 2016 penalty -1% -1.5% -2% -2% 2016 2017 2018 2019 2020 -2% Eligible professionals (EPs) who did not participate in E-Rx in 2011 are experiencing a -1% payment adjustment in 2012. 10 Payment adjustments for Meaningful Use are moving from bonuses for successful participation to penalties for nonparticipation. 2007 2011 2012 2013 2014 2015 $18000 $12000 $8000 $4000 $2000 $18000 $12000 $8000 $4000 $2000 $15000 $12000 $8000 $4000 Start 2014 $12000 $8000 $4000 No 2015 penalty 2016 penalty -1% Start 2011 Meaningful Use Start 2012 Start 2013 Projected Penalty 2008 2009 2010 2016 2017 2018 2019 2017 penalty 2018 penalty 2019 penalty 2020 penalty -2% -3% -4% -5% 2020 -5% Eligible professionals (EPs) who do not participate in Meaningful Use by 2014 will receive a -1% payment adjustment in 2015. 11 CMS is phasing in the use of a value-based modifier (VBM) to provide differential payments based on quality and cost of care. 2013 No PQRS 2014 TBD 2015 TBD 2016 2017 2018 2019 2020 TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD Additional PQRS Penalty for NonParticipation Tiered Payment Adjustment Value-Based Modifier Groups of 100+: 2015 penalty Groups of 100+: Opt-in Groups of 25+ All Groups of 100+: -1% 3% 0% -1% 12 What Does It All Mean? It will be important to understand how the valuebased modifier is calculated: Quality and cost data will inform the VBM It will be important to participate in PQRS: There will be payment and performance ranking implications for non-participation 13 Value-Based Payment Modifier In 2015, Medicare will begin providing differential payments to physicians based on quality and cost of care: Services provided during 2013 will be used to calculate the 2015 modifier; In 2015, the modifier will apply to payment for items and services provided by physicians in groups of 100 or more EPs ; The modifier is expected to be phased in over a 2year period with full implementation in 2017. 14 Measures will be weighted equally within each domain; Domains will be weighted equally to form composites; Where a group does not report measures in a particular domain, the remaining domains will be weighted equally. 15 Quality Domain: PQRS Measure Examples Clinical Care CAD: Lipid Control Patient Experience--CG-CAHPS Measures Getting timely care, appointments and information How well your doctors communicate Patient Safety Medication Reconciliation Care Coordination Advance Care Plan Efficiency Cardiac Stress Imaging: Not Meeting Appropriate Use Criteria: PreOperative Evaluation in Low-Risk Surgery Patients 16 VBM Implementation Groups of 100 or more EPs will receive an additional payment adjustment of -1% in 2015 if they do not participate as a group in PQRS in 2013. If they successfully participate in PQRS as a group in 2013, they can opt-in to participate in quality tiering using the VBM to receive a payment adjustment in 2015 based on the quality and cost of care they provided in 2013. These payment adjustments will range from -1% to as high as ~3% in 2015. Although CMS is starting with a limited set of physicians for this program in 2015, the law requires them to expand the program to all physicians by 2017. 17 Value-Based Modifier Payment Adjustment Amount (2015) In Group with more than 100 eligible professionals 0% (no bonus or penalty) NO YES Register by October 15, 2013 as a group to participate in 2013 PQRS: 1) Under the Group Practice Reporting Option (GPRO) OR 2) Under the administrative claims option 1% penalty NO YES Opt-in to participate in 2015 value-based modifier (quality-tiering) by October 15, 2013 0% (no bonus or penalty) NO YES High quality, low cost, high risk ~3% bonus Performance/Resource Use/ Risk Adjustment Average quality, average cost, average risk 0% (no bonus or penalty) Low quality, high cost, average risk 1% penalty 18 Options and Methods for Successful Participation in PQRS in 2013 In 2010: 37% of eligible cardiologists participated in PQRS; 78% of cardiologists who participated qualified for the incentive. 20 Frequency of PQRS Reporting Method by Cardiologists in 2010 10,000 8,729 8,000 6,798 5,887 6,000 4,478 4,000 4,274 3,031 2,000 0 Total Claims Participating Registry Qualifying In 2010: 67% of participating cardiologists reported via claims submission; 51% of participating cardiologists reported via registry submission Note: Some reported via more than one option but were only counted once for total participating. 21 2013 PQRS Reporting Options Report as an Individual Eligible Professional Report as a Group Practice Group Practice = a single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by their individual NPI, who have reassigned their Medicare billing rights to the TIN 22 Reporting as an Individual Eligible Professional Choose your reporting mechanism: Claims Registry EHR direct product EHR data submission vendor Administrative Claims Choose your measures: Individual Measures OR Measures Groups 23 Individual Reporting Via Claims Reporting Period Measure Type Reporting Criteria Jan 1, 2013 – Dec 31, 2013 Individual Measures Report at least 3 measures AND Report each measure for at least 50% of your Medicare Part B FFS patients seen during the reporting period to which the measure applies. Jan 1, 2013 – Dec 31, 2013 Measures Groups Report at least 1 measures group AND Report each measures group for at least 20 Medicare Part B FFS patients. Measures groups containing a measure with a 0% performance rate will not be counted. 24 Individual Reporting Via Registry Reporting Period Measure Type Reporting Criteria Jan 1, 2013 – Dec 31, 2013 Individual Measures Report at least 3 measures AND Report each measure for at least 80% of your Medicare Part B FFS patients seen during the reporting period to which the measure applies. Jan 1, 2013 – Dec 31, 2013 Measures Groups Report at least 1 measures group AND Report each measures group for at least 20 patients, a majority (11) of which must be Medicare Part B FFS patients, seen during the reporting period. Measures groups containing a measure with a 0% performance rate will not be counted. July 1, 2013 – Measures Dec 31, 2013 Groups 25 Individual Reporting Via Direct EHR Product OR EHR Data Submission Vendor Reporting Period Measure Type Reporting Criteria Jan 1, 2013 – Dec 31, 2013 Individual Measures Option 1: Report on ALL 3 PQRS EHR measures that are also Medicare EHR Incentive Program core measures. If the denominator for one or more of the core measures is 0: Report on up to 3 PQRS EHR measures that are also Medicare EHR Incentive Program alternate core measures AND Report on 3 additional PQRS EHR measures that are also measures available for the Medicare EHR Incentive Program. ==================================================== Option 2: Report at least 3 measures AND Report each measure for at least 80% of your Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate will not be counted. 26 Individual Reporting Via Administrative Claims An individual may elect the administrative claimsbased reporting mechanism for 2013 PQRS to avoid the 2015 PQRS payment adjustment You MUST affirmatively elect to be analyzed under this reporting mechanism 27 Reporting as a Group Practice Self-nominate to participate in the PQRS Group Practice Reporting Option (GPRO): Submit a self-nomination statement via a CMS developed website Deadline to self-nominate: October 15, 2013 Choose your reporting mechanism: GPRO Web Interface Registry Administrative Claims 28 Patient Experience of Care Survey: CG-CAHPS CMS will fund and administer the survey on behalf of the groups participating in the GPRO Web Interface Clinician-Group Consumer Assessment of Health Plans and Systems Survey (CG-CAHPS) Measures Getting timely care, appointments and information How well your doctors communicate Patients rating of doctor Access to specialists Health promotion and education Shared decision-making Courteous and helpful office staff Care coordination Between visit communication Educating patients about medication adherence Stewardship of patient resources 29 Group Practice Reporting Via GPRO Web Interface Reporting Period Group Practice Size Reporting Criteria Jan 1, 2013 – Dec 31, 2013 25-99 eligible Report on all measures included in the Web Interface professionals AND Populate data fields for the first 218 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 218, report on 100% of assigned beneficiaries. Jan 1, 2013 – Dec 31, 2013 100+ eligible professionals Report on all measures included in the Web Interface AND Populate data fields for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 411, report on 100% of assigned beneficiaries. 30 Group Practice Reporting Via Registry Reporting Period Group Practice Size Jan 1, 2013 – 2+ eligible Dec 31, 2013 professionals Reporting Criteria Report at least 3 measures AND Report each measure for at least 80% of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate will not be counted. 31 Group Practice Reporting Via Administrative Claims A group practice may elect the administrative claimsbased reporting mechanism for 2013 PQRS to avoid the 2015 PQRS payment adjustment The group practice will make this election when the practice self-nominates to participate in PQRS via the GPRO 32 What Is the Best Way for You and Your Practice to Participate in PQRS in 2013? ACC-Sponsored Submission Options NCDR PINNACLE Registry: Qualified EHR Data Submission Vendor Individual Reporting of Individual Measures 23 measures available PQRIwizard: Qualified Registry Individual Reporting of Measures Groups 26 measures groups available 34 NCDR PINNACLE Registry 2013 PQRS Individual Measures for EHR Data Submission Vendor Reporting Option Measure #1 (NQF 0059): Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus Measure #2 (NQF 0064): Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus Measure #3 (NQF 0061): Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus Measure #5 (NQF 0081): Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Measure #6 (NQF 0067): Coronary Artery Disease (CAD): Antiplatelet Therapy Measure #7 (NQF 0070): Coronary Artery Disease (CAD): Beta-blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Measure #8 (NQF 0083): Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 35 Measure #47 (NQF 0326): Advance Care Plan Measure #110 (NQF 0041): Preventive Care and Screening: Influenza Immunization Measure #128 (NQF 0421): Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Measure #197 (NQF 0074): Coronary Artery Disease (CAD): Lipid Control Measure #200 (NQF 0084): Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation Measure #201 (NQF 0073): Ischemic Vascular Disease (IVD): Blood Pressure Management Control Measure #204 (NQF 0068): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Measure #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Measure #236 (NQF 0018): Hypertension (HTN): Controlling High Blood Pressure Measure #237 (NQF 0013): Hypertension (HTN): Blood Pressure Measurement 36 Measure #239 (NQF 0024): Weight Assessment and Counseling for Children and Adolescents Measure #240 (NQF 0038): Childhood Immunization Status Measure #241 (NQF 0075):Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Measure #308 (NQF 0027): Smoking and Tobacco Use Cessation, Medical Assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies Measure #313 (NQF 0575): Diabetes Mellitus: Hemoglobin A1c Control (<8%) Measure #316: Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL) Test Performed AND Risk-Stratified Fasting LDL http://www.ncdr.com/webncdr/pinnacle/ 37 PQRIwizard https://acc.pqriwizard.com/default.aspx 38 Coronary Artery Disease (CAD) Measures Group NQF/ PQRS 0067/ 6 Measure Title Coronary Artery Disease (CAD): Antiplatelet Therapy 0074/ 197 Coronary Artery Disease (CAD): Lipid Control 0028/ 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention N/A/ 242 Coronary Artery Disease (CAD): Symptom Management 39 Heart Failure (HF) Measures Group NQF/ PQRS Measure Title 0081/ 5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 0083/ 8 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD 0079/ 198 Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment 0028/ 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 40 Coronary Artery Bypass Graft (CABG) Measures Group NQF/ PQRS Measure Title 0134/ 43 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery 0236/ 44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery Coronary Artery Bypass Graft (CABG): Prolonged Intubation 0129/ 164 0130/ 165 0131/ 166 0114/ 167 0115/ 168 0116/ 169 0117/ 170 0118/ 171 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate Coronary Artery Bypass Graft (CABG): Stroke Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge 41 Other Qualified Submission Vendors Qualified 2013 EHR Vendors http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2013QualifiedEHRDirectVendors.pdf Qualified Data Submission Vendors http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2012QualifiedDSVs.pdf Qualified Registries http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2012-Qualified-Registries-Posting-Phase2.pdf 42 Measures in the GPRO Web Interface for 2013 Diabetes: Hemoglobin A1c Poor Control Heart Failure: Beta-Blocker Therapy for LVSD Medication Reconciliation Preventive Care and Screening: Influenza Immunization Pneumococcal Vaccination Status for Older Adults Preventive Care and Screening: Breast Cancer Screening Colorectal Cancer Screening Coronary Artery Disease: ACE/ ARB Therapy for Diabetes or LVSD Adult Weight Screening and Follow-Up Preventive Care and Screening: Screening for Clinical Depression Coronary Artery Disease: Lipid Control Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic 43 Measures in the GPRO Web Interface for 2013 cont’d Preventive Care and Screening: Tobacco Use Screening and Cessation Intervention Hypertension: Controlling High Blood Pressure Ischemic Vascular Disease: Complete Lipid Panel and LDL Control Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Falls: Screening for Fall Risk Diabetes Composite: Optimal Diabetes Care: Patients who meet all the numerator targets of this composite measure: A1c < 8.0% LDL < 100 mg/dL Blood pressure < 140/90 mmHg Tobacco non-user For patients with a diagnosis of ischemic vascular disease: Daily aspirin use unless contraindicated 44 Measures in the 2013 Administrative Claims Option: Process Measures Follow-Up After Hospitalization for Mental Illness Use of High-Risk Medications in the Elderly Lack of Monthly INR Monitoring for Beneficiaries on Warfarin Use of Spirometry Testing to Diagnose COPD Statin Therapy for Beneficiaries with Coronary Artery Disease Lipid Profile for Beneficiaries Who Started Lipid-Lowering Medications Osteoporosis Management in Women > Who Had Fracture Dilated Eye Exam for Beneficiaries < 75 with Diabetes HbA1c Testing for Beneficiaries < 75 with Diabetes Urine Protein Screening for Beneficiaries < 75 with Diabetes Lipid Profile for Beneficiaries with Ischemic Vascular Disease Antidepressant Treatment for Depression Breast Cancer Screening for Women < 69 45 Measures in the 2013 Administrative Claims Option: Outcome Measures Composite of Acute Prevention Quality Indicators (PQIs) Bacterial Pneumonia--Admissions per 100,000 UTI--Discharges per 100,000 Dehydration--Admissions per 100,000 Composite of Chronic Prevention Quality Indicators (PQIs) Diabetes Composite Uncontrolled Diabetes--Discharges per 100,000 Short-Term Diabetes Complications--Discharges per 100,000 Long-Term Diabetes Complications--Discharges per 100,000 Lower-Extremity Amputation for Diabetes--Discharges per 100,000 COPD--Admissions per 100,000 Heart Failure--Percent of population with admissions All Cause Readmissions 46 Questions? 47 What Now? What Next? There is still time to participate in PQRS 2012 using the PQRIwizard Note: 2012 CAD measures group is different from 2013 More webinars to come in 2013 48 ACC Contacts: Eileen Hagan [email protected] (202) 375-6475 (800) 253-4636, ext 6475 Brian Whitman [email protected] (202) 375-6396 (800) 253-4636, ext 6396 Advocacy Division 800-435-9203 49
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