Presentation on theme: "Conflict of Interest Disclosures"— Presentation transcript:
1 PQRS: An Overview of the Physician Quality Reporting System Don Gettinger, BS, CHTS-IM
2 Conflict of Interest Disclosures No Conflicts to Disclose
3 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.
4 Eligible & Able to Participate Who is Eligible?Eligible & Able to ParticipateMedicare 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
5 Eligible BUT not able to Participate Who is Eligible?Eligible BUT not able to ParticipateProfessionals 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
6 Significant Changes for 2014 Reporting Last year to receive incentive and avoid 2016 payment adjustmentMust report nine measures representing three of the six National Quality Strategy domainsKilling 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 ModifierNew reporting methods addedAdministrative claims option is no longer available to avoid payment adjustment
7 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
8 Reporting Methods Claims-Based Reporting Individual EPs only Report on 9 measures across at least three NQS domainsMust report on at least 50% of applicable Medicare part B fee for service (FFS) patients
9 Reporting Methods Registry-Based Reporting Individual or Group Report on 9 measures across at least three NQS domainsMust report on at least 50% of applicable Medicare part B fee for service (FFS) patients
10 Reporting Methods EHR-Based reporting Certified Direct EHR-Based Product or Certified Data Submission VendorIndividual or GroupReport on 9 measures across at least three NQS domains
11 Reporting Methods Qualified Clinical Data Registry-Based Individual EPs onlyReport on 9 measures across at least three NQS domainsMust report on at least 50% of applicable Medicare part B fee for service (FFS) patientsThe list of QCDRs should be available on the CMS PQRS website by the end of May, 2014
12 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, 2014GPRO Web InterfaceMust have 25 or more eligible professionalsReport on assigned patient sampleCertified Survey Vendor (CG-CHAPS)Optional for groups of EPsRequired for groups of 100+ EPsGroup of 2 or more EPs under the same TINRates apply to All members of the TIN
14 Step 1 - Am I an eligible professional for both programs? Check eligibility for the Meaningful Use programCheck eligibility for the PQRS program
15 Eligible Providers Meaningful Use MedicareMedicaidMDDODentists and Oral SurgeonsPodiatristsOptometristsChiropractorsMDDONPCertified Nurse-MidwifeDentistsPhysician assistant (PA) who furnishes services in a Federally Qualified Health Center of Rural Health Clinic that is led by a physician assistant
16 Eligible Providers PQRS & VM Doctor of MedicineDoctor of OsteopathyDoctor of Podiatric MedicineDoctor of OptometryDoctor of Oral SurgeryDoctor of Dental MedicineDoctor of ChiropracticNurse PractitionerCertified Nurse MidwifePhysician AssistantClinical Nurse SpecialistCertified Registered Nurse Anesthetist (and Anesthesiologist Assistant)Clinical Social WorkerClinical PsychologistRegistered DieticianNutrition ProfessionalAudiologistsPhysical TherapistOccupational TherapistQualified Speech-Language Therapist
17 MU and PQRS Alignment9 Clinical Quality Measures that cover at least 3 of the 6 Nation Quality Strategy (NQS) DomainsPatient and Family EngagementPatient SafetyCare CoordinationPopulation/Public healthEfficient Use of Healthcare ResourcesClinical Process/Effectiveness
18 Choose Reporting Option PQRS EHR Based ReportingQualified Clinical Data RegistrySubmit 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 VendorNew for 2014The data submitted to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries.
19 Group Reporting (GPRO) Option AOption BEPs in an ACO (Medicare Shared Savings Program or Pioneer ACO) who satisfy requirements of the Medicare Shared Savings Program using Certified EHR TechnologyEPs who satisfy the requirements of PQRS GPRO option using Certified EHR Technology
20 Value-based Modifier Cost data and Quality measures included Per-claim adjustment Applied at the Group LevelCY 2015 – CMS will apply the VM to groups of physicians with 100 or more eligible professionals (EPs) based on 2013 performance.CY 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.
21 Value-based Modifier Groups with 10-99 EPs Groups with 100+ Eps PQRS ReportersNon-PQRS ReportersGroups with EPsUpward or no VM based on quality tieringGroups with 100+ EpsUpward, 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.
22 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%
23 Why CQMs?Clinical Quality Measures support achievement of health care goals (Triple Aim)Better HealthBetter Health CareLower Cost
24 Selecting CQMs To Report 3 questions to ask about your practice settingAre there any existing quality improvement efforts in place?What is the patient population served?What is my EHR capable of reporting?
25 Examples of Measures for Each Domain Patient and Family EngagementPQRS # 377 -Functional Status Assessment for Complex Chronic ConditionsPercentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments
26 Examples of Measures for Each Domain Patient SafetyPQRS # 130 -Documentation of Current Medications in the Medical RecordPercentage 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
27 Examples of Measures for Each Domain Care CoordinationPQRS # Closing the Referral Loop: Receipt of Specialist ReportPercentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
28 Examples of Measures for Each Domain Population/Public HealthPQRS # Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionPercentage 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
29 Examples of Measures for Each Domain Efficient Use of Healthcare ResourcesPQRS # 312 -Use of Imaging Studies for Low Back PainPercentage of patients 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
30 Examples of Measures for Each Domain Clinical Process/EffectivenessPQRS # Controlling High Blood PressurePercentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90mmHg) during the measurement period
31 Resources PQRS reporting options and measures Value-based Modifier informationEHR Incentive ProgramInstitute for Healthcare Improvement
32 Population Health Team Questions?Health Care ExcelPopulation Health TeamDon Gettinger, BS,Program Managerx336Stacy Colson, RNClinical Advisorx314