Transcript Document
Turn Data Into Knowledge → Knowledge Into Improvement
T HE W HY , W HAT O F THE 2013 P HYSICIAN Q UALITY & H OW R EPORTING S YSTEM
Barbara Bole, MPA Research & Communication Debra Reis Senior Architect
DISCLOSURE
NetHealth is a CMS qualified PQRS registry, hosting submission through a public-facing PQRSPRO 2013 Registry as well as portals co-branded through organizations such as ASH .
Agenda
1. WHY PQRS? History of the quality movement 2. WHAT IS PQRS? Current State of PQRI/PQRS 3. HOW TO PARTICIPATE IN PQRS? 4. ASH PQRSPro 5. CMS PQRS Resources
Why PQRS?
1992 Efficiency
Osborne, D. & Gaebler, T. (1992). Reinventing Government: How the Entrepreneurial Spirit Is Transforming the Public Sector. Reading, MA: Addison-Wesley.
1999 Patient Safety
Committee on the Quality of Health Care, Institute of Medicine (IOM). (1999). To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press.
2000 / 2001 Health System Reform
Committee on the Quality of Health Care, Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press.
Why PQRS?
Change to Structures and Processes
Applying evidence to Health Care Delivery (pp. 145-163)
Using Information Technology (pp. 164-180)
Aligning Payment Policies with Quality Improvement (pp. 181-206)
Preparing the Workforce (pp. 207-224)
Committee on the Quality of Health Care, Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press.
Why PQRS?
Change to Structures and Processes
Aligning Payment Policies with Quality Improvement
• Reexamine payment policies and remove barriers that impede quality improvement (pp. 182-199) • Build in stronger
incentives
for quality enhancement (pp. 184-204) • Allow consumers to
recognize quality
differences (Physician Compare) (p. 182) • Align
financial incentives
with adherence to best practice and better patient outcomes (pp.199-206) Committee on the Quality of Health Care, Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press.
Why PQRS?
Change to Structures and Processes
Preparing the Workforce
1. Redesign the way health professionals are trained, integrating
evidence-based practice
and interdisciplinary training (pp. 208-214) 2. Modify the ways in which health professionals are
regulated and accredited
to facilitate needed changes in care delivery (pp. 214-218) 3. Use the
liability system
to support changes in care delivery (pp. 218-221) Committee on the Quality of Health Care, Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press.
What is PQRS?
CMS.gov
Centers for Medicare & Medicaid Services
http://www.cms.gov/Medicare/Quality-Initiatives Patient-Assessment-Instruments/PQRS 2007-2009 PQRI – Physician Quality Reporting Initiative 2010-present PQRS – Physician Quality Reporting System
What is PQRS?
Mandated by Federal legislation the Physician Quality Reporting System (Physician Quality Reporting or PQRS) “is a reporting program that uses a combination of
incentive payments and payment adjustments
to promote reporting of quality information by eligible professionals (EPs).”
(para. 1) • •
Incentive payments available until 2014 ‘Payment adjustments’ (penalties/reductions) begin in 2015 (based on 2013 nonparticipation)
Centers for Medicare & Medicaid Services (CMS). (2013). Physician Quality Reporting System: Physician Quality Reporting System (Physician Quality Reporting or PQRS) formerly known as the Physician Quality Reporting Initiative (PQRI). Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
What is PQRS?
“The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B
Fee-for-Service (FFS) beneficiaries (including
Railroad Retirement Board and Medicare Secondary Payer).” (para. 2) Centers for Medicare & Medicaid Services (CMS). (2013). Physician Quality Reporting System: Physician Quality Reporting System (Physician Quality Reporting or PQRS) formerly known as the Physician Quality Reporting Initiative (PQRI). Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
Year
2013 2014 2015 2016
What is PQRS?
Incentives and Penalties
PQRS Incentive PQRS Payment Adjustment (penalty)
+ 0.5% Penalty, 2015 based on 2013 participation + 0.5% Penalty, 2016 based on 2014 participation N/A
- 1.5%
(based on 2013 participation) N/A
- 2.0%
(based on 2014 participation)
What is PQRS?
Part of an overall, initially incentivized,
CMS
program to promote QI in health care including…
ePrescribing (eRx) Meaningful Use (MU) EHR Incentive Program Value Based Payment Modifier (VBPM) Maintenance of Certification Program Incentive (MOCP)
What is PQRS?
Eligible Professionals
Medicare Physicians
Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry
Practitioners
Physician Assistant Nurse Practitioner Clinical Nurse Specialist
Therapists
Physical Therapist Occupational Therapist Qualified Speech Language Therapist Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant) Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Nutrition Professional Audiologist Centers for Medicare & Medicaid Services (CMS). (2013).Physician Quality Reporting System (PQRS): List of Eligible Professionals. Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment Instruments/PQRS/index.html?redirect=/PQRS/ Confidential Presentation by NetHealth LLC
What is PQRS?
Number of Eligible Professionals Who Qualified for an Incentive: PQRS (2007 to 2011) (p vii)
Centers for Medicare & Medicaid Services (CMS). (2013). 2011 Reporting Experience Including Trends (2008-2012): Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program. Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
What is PQRS?
Participation & Incentives Summary
More than one million eligible professionals
could have
participated (1,101,773) (pp. v, 12) Only 320,442 participants (only 29%!) (p. xii) Quality information was submitted for nearly 14 million Medicare beneficiaries (p. xvii) $261,733,236 in PQRS incentive payments distributed (p. vii) Average incentive, individual: $1,059 (p. viii) Average incentive, practice: $9,863 (p. viii) Centers for Medicare & Medicaid Services (CMS). (2013). 2011 Reporting Experience Including Trends (2008-2012): Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program. Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
What is PQRS?
Participation & Incentives
Across all reporting options, more than eight in ten participants (83%) in the 2011 Physician Quality Reporting System met the criteria for incentive eligibility (p. xv).
Centers for Medicare & Medicaid Services (CMS). (2013). 2011 Reporting Experience Including Trends (2008-2012): Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program. Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
What is PQRS?
Participation – Hematology/Oncology
Most commonly used PQRS individual measures Oncology/Hematology (2011, in order of usage) (p. 22)
#124 – Health Information Technology (HIT)
now retired
#69 – Hematology: Multiple Myeloma: Treatment with Bisphosphonates #70 – Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry #72 – Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients #71 – Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer Centers for Medicare & Medicaid Services (CMS). (2013). 2011 Reporting Experience Including Trends (2008-2012): Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program. Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
What is PQRS?
Public Reporting CMS
Physician Compare
website
www.medicare.gov/physiciancompare Initial phase in 2010 included posting names of EPs that satisfactorily submitted quality data for 2009 PQRS Now includes 2010 PQRS information and EPs who were successful under eRx and EHR incentive programs Hospital performance is now posted and individual provider quality measure performance information is forthcoming!
What is PQRS?
Physician Compare
www.medicare.gov/physiciancompare Information primarily from the Provider, Enrollment, Chain, and Ownership System (PECOS) and other sources, checked against Medicare claims data.
Includes…
• Addresses where the professional sees patients • Primary and secondary specialties • • Medicare Assignment status Whether the individual or group
participates in select CMS quality programs
• Gender, • Medical school education and residency information, • Groups that individuals work with (individual profile) or individuals who work with the group (group profile), and • Hospital affiliation Physician Compare, Centers for Medicare & Medicaid Services (CMS). (2013). Information Available on Physician Compare. Retrieved from: http://www.medicare.gov/physiciancompare/staticpages/aboutphysiciancompare/informationavailable.html
HOW to report PQRS?
3 Options for meeting criteria for satisfactory reporting to avoid 2015 payment adjustment
• Satisfactory submission for the 2013 PQRS incentive (
Avoidance and incentive
) 1 • Report 1 applicable measure, one patient (
Avoidance only, no incentive
) 2 • Elect to be analyzed under the administrative claims-based reporting mechanism (
Avoidance only, no incentive
)
3
HOW to report PQRS?
Getting Started
http://www.cms.gov/Medicare/Quality-Initiatives-Patient Assessment-Instruments/PQRS/How_To_Get_Started.html
1 • Determine Eligibility (NPI number(s),
allowed claims)
2 • Determine Measures to Report (at least 3
individual measures or 1 measures group)
3 • Determine Reporting Method (claims,
registry, EHR)
HOW to report PQRS?
PQRS Quality Measures
1. Individual Measures – Reporting 80% of all Medicare patient visits for at least 3 measures 212 measures for 2013 2. Group Measures –
2010 – 30 consecutive patient visits, 2 of which had to be Medicare Part B 2011-2012 – 30 Medicare Part B patient visits
2013 – 20 patient visits, a majority of which (11) must be Medicare Part B
HOW to report PQRS?
1.
Measures available in ASH PQRSPro
Individual Measure Categories (pick 3 measures): a.
Breast Cancer (71, 99, 251, 263, 264) b. Colon Cancer (72, 100) c.
General Oncology (194, 265) d. Falls (154, 155) e.
Hematology (67, 68, 69, 70) f.
g.
Lung Cancer (157, 233) Oncology and Radiation (143, 144, 156) h. Preventive (39, 46, 47, 48, 76, 110, 111, 112, 113, 128, 130, 131, 173, 226, 317, 321, 326) i.
Prostate Cancer (102, 104) 2.
CMS Measures Groups: Hypertension, Oncology, Prevention
HOW to report PQRS?
PQRS Quality Measures
http://cms.gov/Medicare/Quality-Initiatives-Patient Assessment-Instruments/PQRS/MeasuresCodes.html
2013 PQRS Measure List Implementation Guide 2013 PQRS Measure Specification Manual, Release Notes 2013 PQRS Measure Groups Specification Manual
ASH PQRSPro Measures List! www.pqrspro.com/ASH
1
HOW to report PQRS?
Four Reporting Options
• On Medicare Part B Claims 2 • Through a qualified PQRS Registry • Through a qualified electronic health record (EHR) 3
4
• Through a qualified Physician Quality Reporting Data Submission Vendor (DSV)
HOW to report PQRS?
Reporting Mechanism
Claims Qualified Registry
Reporting Mechanism Characteristics
• Available to use for reporting for the PQRS incentives and avoiding payment adjustment • Available for use by eligible professionals; not available for group practice/GPRO reporting • Available to use for reporting for the PQRS incentives and avoiding payment adjustments • Available for use by eligible professionals and CMS-selected group practices of 2-99 eligible professionals using the GPRO •Also available for groups of 100 or more EPs using GPRO • Eligible professionals and group practices MUST use a registry that has been qualified by CMS for the applicable reporting period • Qualified registries that submit grossly inaccurate data will be subject to disqualification
HOW to report PQRS?
Reporting Mechanism
Direct EHR Product and EHR Data Submission Vendor
Reporting Mechanism Characteristics
• Available to use for reporting for the PQRS incentives and avoiding payment adjustments • Available for use by eligible professionals •Available for CMS-selected group practices of 2-99 eligible professionals and groups of 100 or more EPs using the GPRO for 2014 and beyond • Although CMS has previously required direct EHR products and EHR data submission vendors to undergo a qualification process, beginning 2014, CMS is discontinuing the qualification process and requiring that a direct EHR product be certified by ONC as CEHRT (certified EHR technology) to align with the EHR incentive program
Reporting Mechanism
GPRO Web- interface
option is no longer available
Administrative Claims
HOW to report PQRS?
Reporting Mechanism Characteristics
• Available to use for reporting for the PQRS incentives and payment adjustments • ONLY available for CMS-selected group practices of 25 or more eligible professionals using the GPRO • Temporary reporting option; ONLY available to use for reporting for the 2015 PQRS payment adjustments (2016 will be considered) • Available for use by all eligible professionals and CMS-selected group practices using the GPRO • Eligible professionals and group practices must elect to use this reporting mechanism •
Deadline for electing the administrative claims-based reporting mechanism will be October 15
of the applicable reporting period for both EPs and group practices; • Reporting will be via the web with U.S. mail as a backup option • Unlike the traditional claims-based reporting option, an eligible professional or group practice would not be required to submit quality-data codes (QDCs) on claims to CMS for analysis. Rather, CMS would analyze every eligible professional’s or CMS selected group practice’s Medicare billing data to determine whether the eligible professional or group practice has performed any of the clinical quality actions indicated in the proposed PQRS quality measures in Table 123 of the CY2013 PFS final rule (limited measure set)
HOW to report PQRS?
Group Practice Reporting Option (GPRO)
Registry option available for GPRO in 2013!
A Group is defined as 2 or more eligible professionals (EPs) submitting claims under the same TIN The Value Based Payment Modifier (VBM) does not apply to practices of 2-100 Groups of 100+ EPs MUST self-nominate and report through GPRO to avoid the 1% VBM in 2015 (for nonparticipation in 2013) Self nomination for GPRO is accomplished through the QualityNet Help Desk web portal
by October 15, 2013
HOW to report PQRS?
Group Practice Reporting Option (GPRO)
Group reports on 3 or more individual measures and 80% the eligible instances for the entire group.
Applies to all providers in the group (even those with no applicable patients for a measure).
No provider in the group (under the same TIN) should submit individually to PQRS.
The GPROs are considered a group for incentive purposes.
If the GPRO does not successfully report, nobody within the group will receive an incentive – but the group WILL avoid the ‘payment adjustment.’
http://pqrspro.com/ASH Tutorial video http://www.pqrspro.com/ash/tutorial/player.html
Confidential Presentation by NetHealth LLC
4 Easy Steps
Complete Profile Choose Measures Enter Data Submit!
Confidential Presentation by NetHealth LLC
What’s New in 2013 for PQRS
• Qualify for the
0.5% incentive
reimbursement on all eligible Medicare Part B FFS charges • Not reporting in 2013 will result in 2015 payment reduction of 1.5% on all Medicare reimbursement claims • To avoid the penalty, but not report for the incentive, there is an avoidance option available • GPRO option allows two or more individuals to report under one Tax ID Number (TIN)
If You Selected a Measure Group
• A measures group is composed of 3 to 10 measures • Measures cannot be added or omitted from a measures group • You must report at least 20 patients from 2013 • 11 of the 20 patients must be Medicare Part B FFS
If You Selected a Specialty Measure Set
• 80% of all 2013 Medicare Part B FFS patient visits must be reported • At least 3 measures must be selected and reported
If You Selected the Avoidance Option
1. Follow the same steps as though you were reporting for incentive 2. Except, you only need to select one measure to report and you only need to enter one patient visit 3. Once you have entered that one patient visit, then you are ready to submit.
Regarding Measure Calculations
PQRS is a Pay-for-Reporting program, not YET a Pay-for-Performance program You must do the quality action at least once whenever possible If reporting for avoidance, you need not meet the measure.
HOW to report PQRS?
PQRS Tip
In the 2011 Reporting Experience, the most common reasons for not obtaining an incentive payment were incorrect reporting rates, invalid measures, and submission of an invalid TIN and/or NPI (submitting data for TIN/NPI that had no Part B MPFS allowed charges).
Be sure to use the Individual NPI (the one entered on claims as the ‘Rendering Physician’), not the Group NPI Be sure to enter all of the TIN digits correctly with no dashes You will also FAX a sample claim form to NetHealth to verify the correctness of your TIN/NPI submission.
Source: 2011 Reporting Experience Including Trends (2008-2012): Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program
HOW to report PQRS?
CMS Resources
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment Instruments/PQRS How to Get Started http://www.cms.gov/Medicare/Quality-Initiatives-Patient Assessment-Instruments/PQRS/How_To_Get_Started.html
Medicare Learning Network - Monthly CMS National Provider Calls http://www.cms.gov/Outreach-and Education/Outreach/NPC/National-Provider-Calls-and-Events.html
HOW to report PQRS?
CMS QualityNet Help Desk https://www.qualitynet.org
Phone: 866-288-8912 Email:
[email protected]
Feedback Reports
1. TIN-level (all providers under one TIN) requires IACS account (TIN representative) 2. NPI-level reports 2008-2011 available no IACS account required
Questions?
http://pqrspro.com/ASH
Barbara Bole, MPA [email protected]
610.590.2229 x 3