cap.org v. # 2014 PQRS and VBM Programs Jonathan L. Myles, MD FCAP Chair, CAP Economic Affairs Committee Pathology Advisor, AMA-RUC Diana Cardona, MD FCAP Chair, EAC Measures and Performance Assessment Sub- Committee January 14, 2014

PQRS and VBM Programs Background 2013 PQRS Reporting – There is still time! What’s new for the PQRS in 2014 Value-Based Payment Modifier (VBM) Program 2 © 2013 College of American Pathologists. All rights reserved.

Background: PQRS and VBM Physician Quality Reporting System (PQRS): A quality reporting program that provides incentive payments and payment adjustments to Medicare Part B reimbursement for eligible professionals based on whether or not they satisfactorily report data on quality measures for covered professional services. Value-Based Payment Modifier (VBM): A budget neutral payment adjustment applied to Medicare Part B reimbursement to physicians based on a measure of the cost and quality of the services provided to Medicare patients. 2 © 2013 College of American Pathologists. All rights reserved.

Background: Definitions Eligible Professionals (EPs): (1) A physician; (2) a practitioner described in the Act; (3) a physical or occupational therapist or qualified speech-language pathologist; or (4) a qualified audiologist. Group Practices for the purpose of the PQRS: A single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by their National Provider Identifier (NPI), who have reassigned their Medicare billing rights to the TIN. 3 © 2013 College of American Pathologists. All rights reserved.

Pathology Measures in the 2013 and 2014 PQRS Breast Cancer Resection Pathology Reporting Colorectal Cancer Resection Pathology Reporting Barrett’s Esophagus Radical Prostatectomy Pathology Reporting Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor 2 Testing (HER2) for Breast Cancer Patients Measures available at online at CAP PQRS Advocacy CAP PQRS Advocacy 3 © 2013 College of American Pathologists. All rights reserved.

2013 Physician Quality Reporting System Eligible Professionals who are not yet participating in the 2013 PQRS may still participate as individuals in the 2013 PQRS through a registry. Benefits of participation via registry in 2013 include: – 0.5% incentive payment on Part B allowed charges – Avoid the % payment adjustment A list of CMS approved registries that include pathology measures can be found at CAP PQRS Advocacy. Here you’ll also find or CAP’s Advocacy news and resources and important PQRS Updates. CAP PQRS Advocacy 5 © 2013 College of American Pathologists. All rights reserved.

2013 Physician Quality Reporting System There may still be time to avoid the 2015 penalty via claims reporting! – Eligible professionals can still report on 1 measure, 1 time in early 2014, if they have 1 patient in 2013 for which a measure is applicable (and they have not yet filed the claim). – The reporting code must be included on the CMS 1500 form at the time the service is billed. 6 © 2013 College of American Pathologists. All rights reserved.

What’s new for 2014 PQRS - Highlights – 2014 Payment Incentive: 0.5% incentive payment on Part B allowable charges for successful reporting – 2016 Payment Adjustment: EPs who do not successfully report on measures in 2014 are subject to a -2% penalty on Part B allowable charges in 2016 – Successful reporting requirements have been increased – Group Reporting Options: Group practices with 2 or more members may report as a group via registries on applicable measures regardless of the number of applicable measures 7 © 2013 College of American Pathologists. All rights reserved.

2014 PQRS – Incentive for Individual EPs Criteria and mechanisms for Individual EP satisfactory reporting for the 2014 PQRS incentive have increased: – Claims Based Reporting: o Report on 9 measures* in 3 National Quality domains on 50% of EP’s Medicare Part B patients to which the measures apply – Registry Reporting: o Report on 9 measures* in 3 National Quality domains on 50% of EP’s Medicare Part B patients to which the measures apply * If fewer than 9 measures apply to the EP, report on all applicable measures; measures with 0% performance rate are not counted. 8 © 2013 College of American Pathologists. All rights reserved.

2014 PQRS – Incentive for Group Practices Registry mechanism for Group Practice satisfactory reporting for the 2014 PQRS incentives: – Report on all applicable measures (up to 9*) through a registry on 50% of the entire group practice’s Medicare Part B patients to which the measures apply – CMS eliminated the minimum of reporting 3 measures – All Members of the group practice (2 or more Member who bill under the same TIN) receive PQRS credit regardless of who provided the service * Note: Groups must elect to participate in the Group Practice Reporting Option (GPRO) by notifying CMS through its Web interface by September 30, © 2013 College of American Pathologists. All rights reserved.

2014 PQRS – Incentive for Multi-Specialty Groups Multi-Specialty Group Practices may also report through the PQRS GPRO web interface: – CMS provides the group practice (25-99 and 100 or more Members) with a list of attributed patients – The group must report on 22 measures (or any of the 22 measures that are applicable to the patients) – All Members of the group practice receive PQRS credit regardless of who provided the service Note: Group must elect to participate in the GPRO web interface by notifying CMS through its Web interface by September 30, © 2013 College of American Pathologists. All rights reserved.

What’s New for 2014 PQRS – 2016 Penalty – CMS will apply a -2% penalty on 2016 Medicare Part B payments for eligible professionals who fail to successfully participate in the 2014 PQRS – Eligible Professionals may avoid the -2% penalty by either – Successfully reporting to receive the incentive* – Successfully reporting on 3 measures for 50% of their patients for whom the measure is applicable * If fewer than 9 measures apply to the EP, report on all applicable measures; measures with 0% performance rate are not counted. © 2013 College of American Pathologists. All rights reserved. 11

How to Avoid the 2016 PQRS Penalty EPs who successfully report PQRS measures in 2014 either as an individual or group through any mechanism will avoid the 2016 payment adjustment Note that CMS has eliminated both the Administrative Claims option and reporting on one measure one time as a way to avoid the penalty EPs with no PQRS measures to report will not receive the -2% 2016 PQRS payment adjustment. CMS recommends you double check with the CMS Quality Help desk to be sure that no measures apply 12 © 2013 College of American Pathologists. All rights reserved.

What’s new in 2014? Value-Based Payment Modifier In addition to the PQRS, the Value-Based Payment Modifier (VBM) will be applied in 2016 to physicians in group practices with 10 or more members billing under the same TIN The VBM will be set at -2% of all Medicare Part B allowable charges for physicians in group practices with 10 or more members who do not successfully participate in the 2014 PQRS Note: CMS must by law (Affordable Care Act) apply the VBM to all physicians by © 2013 College of American Pathologists. All rights reserved.

How to Avoid the VBM Payment Adjustment Group practices with Members may avoid the % VBM adjustment by successfully reporting PQRS measures in 2014 – either as an individual* or group – through the claims or registry Groups with Members who successfully report will not receive a negative VBM adjustment but will be subject to Quality Tiering steps and may receive a positive VBM adjustment if they provide high quality and low cost care *In certain circumstances 14 © 2013 College of American Pathologists. All rights reserved.

How to Avoid the VBM Payment Adjustment If Members of a group practice with members report through claims as individuals, CMS will consider the group to have successfully reported if 50% of the group’s members meet the PQRS successful reporting criteria CMS will consider those EPs with no PQRS measures to have successfully reported for the purpose of the VBM success calculation As a result, an EP may receive the PQRS incentive but still be subject to the VBM payment adjustment if 50% of your group practice fails to successfully report The reverse is also true, an EP can fail to report PQRS measures but avoid the VBM payment adjustment if more than half of the group practice successfully reports PQRS measures 15 © 2013 College of American Pathologists. All rights reserved.

Positive Adjustments are Possible with the VBM –All practices with 100 or more EPs are subject to the VBM Quality Tiering process in 2016 and may receive a positive or negative VBM adjustment The VBM is then based on quality of care (performance on PQRS measures) and cost of care Upward adjustment or -2% downward adjustment to 2016 Medicare Part B allowable charges are possible 16 © 2013 College of American Pathologists. All rights reserved.

Case Study 1 17 © 2013 College of American Pathologists. All rights reserved. A pathology practice with 10 members would like to participate in the 2014 PQRS. Only three members of the practice have applicable measures in the PQRS. How can this practice qualify for the 2014 PQRS incentive and avoid the 2016 PQRS and VBM penalties?

Case Study 1 ANSWER: The 3 members with measures report through claims or the Group Practice can elect the Registry Group Practice option through the CMS web interface* by September 30, 2014 Registry Option: o The Group Practice enters into an appropriate Business Associate agreement with a qualified registry that provides for the registry’s receipt of patient–specific data and disclosure of the data to CMS on behalf of EPs o The registry successfully submits PQRS quality data to CMS on behalf of eligible professionals by February 2015 Note: The web interface will be available in the Spring of 2014 on the CMS website 18 © 2013 College of American Pathologists. All rights reserved.

Case Study 2 19 © 2013 College of American Pathologists. All rights reserved. A pathologist in solo practice would like to participate in the 2014 PQRS. How can this pathologist qualify for the 2014 PQRS incentive and avoid the 2016 PQRS penalty?

Case Study 2 ANSWER: The solo practitioner may participate through claims or a registry for bonus/avoid penalty Registry Reporting: EP must report on 50% of eligible cases on all measures that apply Claims Reporting: EP must report on 50% of eligible cases on all measures that apply (EPs with fewer than 9 applicable measures must report on all measures that apply; EPs with no measures will not be penalized but will not receive the incentive) 20 © 2012 College of American Pathologists. All rights reserved.

Case Study 3 21 © 2013 College of American Pathologists. All rights reserved. A large academic multi-specialty group (billing under the same TIN) with 180 practitioners would like to earn the 2014 PQRS incentive and avoid the 2016 PQRS penalty and VBM downward adjustment. What should they do?

Case Study 3 ANSWER: The group practice can elect one of two GPRO reporting options through the CMS web interface by September 30, The group practice then must report on patients via the mechanism elected. o Registry reporting: Report on 9 measures in 3 National Quality Domains for 50% of the group’s patients by Feb 2015 o GPRO web interface, report on 22 measures on patients attributed to the group by CMS in early 2015 o VBM adjustment will be determined by the cost and quality of care provided – an upward or downward adjustment are possible 22 © 2013 College of American Pathologists. All rights reserved.

Medicare Shared Savings Program Eligible Professionals who participate in an ACO in the CMS Medicare Shared Savings Program will avoid the -2% PQRS payment adjustment and -2% VBM adjustment when… An ACO, on behalf of its ACO provider/suppliers who are eligible providers satisfactorily reports quality metrics to CMS on behalf of the ACO participant TIN(s) The ACO providers’ TIN(s) under which the ACO provider/suppliers bill will receive an incentive payment based on allowed charges of those ACO providers/suppliers Note that EPs should report PQRS measures on patients billed under a different TIN from that of their ACO patients 23 © 2013 College of American Pathologists. All rights reserved.

PQRS Maintenance of Certification Incentive In 2014 CMS will offer an additional 0.5% bonus on Medicare Part B allowable charges for physicians who successfully report PQRS measures AND participate in a CMS qualified MOC program “more frequently” than is required to maintain board certification The American Board of Pathology (ABP) is recognized as a Qualified MOC program for the purposes of the CMS PQRS: MOC Incentive Those interested in the additional incentive should visit the ABP website or contact ABP in January 2014 for details on how to qualify for this additional bonuswww.abpath.org 24 © 2013 College of American Pathologists. All rights reserved.

2014 PQRS 25 © 2013 College of American Pathologists. All rights reserved. CAP developed and submitted three additional measures to CMS for inclusion in the 2014 PQRS: Proposed New Measure #1 – Lung cancer reporting (biopsy/cytology specimens) Proposed New Measure #2 – Lung cancer reporting (resection specimens) Proposed New Measure #3 – Melanoma reporting These measures were not accepted for the 2014 PQRS but may be included in the 2015 PQRS

ADDITIONAL RESOURCES ONLINE – The Centers for Medicare and Medicaid Services released the final 2014 Physician Fee Schedule (PFS) Rule and the Hospital Outpatient Payment Rule. CAP has provided lists of frequently asked questions to offer additional information on the ruling. released the final 2014 Physician Fee Schedule (PFS) Rule and the Hospital Outpatient Payment Rulefrequently asked questions – CAP PQRS Advocacy for CAP’s Advocacy news and resources and important PQRS Updates CAP PQRS Advocacy 26 © 2013 College of American Pathologists. All rights reserved.

Thank You! Questions? Laura Diamond, Director, Advocacy Communications CMS QualityNet help desk at: , TTY at (Monday - Friday 8am to 8pm EST) or via at 27 © 2013 College of American Pathologists. All rights reserved.