Dr. Dan Mingle's Overview of the 2015 Medicare Final Rule

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12/4/2014 ©Copyright Mingle Analytics 2
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People, Processes, and Technology

Dr. Dan Mingle, MD, MS
• Family Physician and Educator
• Knows the business & practice of medicine
• Reporting PQRS since 2008
• Principle Architect for nine registries
• Feature in Healthcare Informatics magazine
Nobody knows PQRS the way we do
Gay De Hart
• Ten years in healthcare
• Practice Manager
• Business Writer – Grant Writer
• Working with Dr. Mingle since 2011
Kash Basavappa
• Thirty years in healthcare and healthcare
informatics
• Recipient of multiple awards as Chief
Information Officer
• Directed development of commercial
healthcare information technology products
• Working with Dr. Mingle since 2000
Scott Larsen
• 27 years in Information Technology
• 6 years in healthcare informatics
• Web Applications, Software as a Service
• Security Infrastructures
• Building environments that scale
Assisted By
• PQRS Consultants providing
• Client Support
• Account Management
• Project Management
• Data Analysts
• Development Staff

Review of the 2015 Medicare Final Rule
Revisions to Payment Policies under the Physician Fee
Schedule, Clinical Laboratory Fee Schedule, Access to
Identifiable Data for the Center for Medicare and
Medicaid Innovation Models & Other Revisions to Part B
for CY 2015

Federal Register Document 2014-26183
Filed 10/31/2014
Publication Date: 11/13/2014

Focus on the Sections
J. Physician Compare Website
K. Physician Payment, Efficiency, and Quality Improvements – Physician Quality
Reporting System
N. Value-Based Payment Modifier and Physician Feedback Program

Logistics
• Ask Questions Anytime
• Type your questions into the GoToWebinar dialog box
• Email questions to us after the Webinar
• We will distribute a link to the slides and a recording of the
Webinar

PHYSICIAN COMPARE
Pause to check
Any problems hearing or seeing the presentation?
Before moving on to:

Physician Compare Website
Required by the Affordable Care Act – 2010
To the extent that scientifically sound measures are developed and are available,
we are required to include, to the extent practicable, the following types of
measures for public reporting:
• Measures collected under PQRS
• Assessment of patient health outcomes and functional status of patients
• Assessment of the continuity and coordination of care and care transitions
• Assessment of efficiency
• Assessment of patient experience and patient, caregiver, and family engagement
• Assessment of the safety, effectiveness, and timeliness of care
• Other information as determined appropriate by the Secretary

Physician Compare Resources
• Website URL:
– http://www.medicare.gov/physiciancompare
• Data on Physician Compare comes from PECOS
– https://pecos.cms.hhs.gov/pecos/login.do
• Specialty is as reported on your Medicare Enrollment Form
• Physician Compare support team
– PhysicianCompare@Westat.com
• Physician Compare information and updates
– http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/physician-compare-initiative/

Physician Compare Milestones
SrvYear Publish Method To be Reported
2009 2010 Reg, Claims Site launch in December 2010 listing PQRS Participants
2012 2013 Web, EHR, Reg, Claims Checkmarks for PQRS, eRx, EHR
2012 2014 Web 5 DM and CAD Measure Performance
2013 2014 Web, EHR, Reg, Claims Add Checkmarks for MOC, CV Prevention MG
2013 2014 Web 6 DM and 2 CAD Measure Performance
2013 2014 Web 5 CG-CAHPS summary Measure Performance for groups ≥
100 (6 for ACO)
2014 2015 Web, GPRO-EHR, GPRO-Reg,
Administrative Claims
All Web, 13 EHR, and 16 Registry Measure Performance
2014 2015 Web, Survey Vendor 12 CAHPS for PQRS Summary measure Performance (6 for
ACO)
2014 2015 Ind-EHR, Ind-Reg, Claims Performance for 20 measures that align with Web Measures
2014 2015 Reg Performance for Measures from CV Prevention MG

Physician Compare 2015
2015 Reporting Year Publish in 2016
Groups ≥ 2 participating
in GPRO
All PQRS Measures by all
Methods
Shared Savings Program
(SSP) ACO
All Measures (Web)
All Groups ≥ 2 and SSP 12 CAHPS for PQRS
Summary Scores
Individual Reporting by
Reg, EHR, Claims, QCDR
All PQRS Measures by all
Methods
Prerequisites
• 20 Patient Minimum Sample
• Measures beyond Year 1 of
Distribution
• Measures deemed to be
– statistically comparable
– Statistically valid and reliable
– Understood by Consumers
• Practices given 30d Preview
Period

PHYSICIAN QUALITY REPORTING SYSTEM
Pause for Questions about Physician Compare

Remember Medicare’s Naming Conventions
Incentive
Is Named for the Service Year
• Your 2014 Incentive (The Last
Incentive)
• Is based on your 2014 Year of Patient
Services
• That you report in 2015
• Is paid in 2015
Adjustment (Penalty)
Is Named for the Adjustment Year
• Your 2016 Adjustment
• Is based on your 2014 Year of Patient
Service
• That you report in 2015
• The Adjustment is taken out of
payments for 2016 Patient Services

2017 PQRS and VBM Program Years
• VBM Naming conventions match
PQRS Adjustment Naming
Conventions
• Quality Tiering adjustments apply
to payments for claims for
patient services provided in the
program year
This 2015 Final Rule applies
primarily to:
• Patient Services Provided in 2015
• PQRS Reporting Completed in
2016
• Adjustments to Payments made
for services provided in 2017

0.5%
-2%
-3.0%
-2.0%
-1.0%
0.0%
1.0%
2.0%
3.0%
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Incentive Adjustment Earned Adjustment Applied
We
Are
(almost)
Here
Adjustment
will be
Avoided
No More Incentive
Adjustment stable at 2%
First Adjustments Showing up
Service Year

MOC
There is still a 0.5% Incentive
When PQRS is combined with a
Specialty Specific
Maintenance of Certification Program (MOC)

Individual Group
Claims
Registry
2015 Reporting Options
Qualified Clinical Data Registry
EHR
Measure Groups
Web Interface Tool
GPRO Registry
GPRO EHR
Certified Survey Vendor
Available Methods are Unchanged

Claims Measures De-emphasized
Measure Selection Reduced for 2015
Will be eliminated at a later date TBD
Cited reason: high failure rate

Submission Deadline
March 31 annually

GPRO Election Deadline
June 30 Annually
Elect GPRO and Commit to Method

Reporting Basics Unchanged
• 9 measures
• 3 Domains
• ≥ 50 % of eligible Medicare patients
• Any measure with 0% performance will not be counted

Not enough Measures?
• Measure Applicability Validation (MAV) is back for Claims and
Registry Reporting
• New for EHR Reporting:
“If the CEHRT does not contain data for 9 measures in 3 domains”
– Report all measures for which Medicare Patient Data exists
– Must have ≥ 1 measure

Cross-Cutting Measures
Groups and EPs with at least 1 face to face encounter
must submit 1 measure from the cross-cutting set

Cross-Cutting Measures
# Topic Mthd
1 Hemoglobin A1c control C,R,E
46 Medication Reconciliation C,R
47 Care Plan C,R
110 Influenza C,R,E
111 Pneumovax C,R,E
128 BMI and Plan C,R,E
130 Current Medications C,R,E
131 Pain Assessment and Plan C,R
134 Screen for Depression and Plan C,R,E
182 Functional Outcome Assessment
and Plan
C,R
# Topic Mthd
226 Tobacco Use and Plan C,R,E
236 Controlling High Blood Pressure C,R,E
240 Childhood Immunization Status E
317 Screen for HTN and Plan C,R,E
318 Screen for Fall Risk E
321 CAHPS for PQRS Survey S
374 Receipt of Specialist Report E
400 Hepatitis C Screening R
402 Tobacco Use and Plan in
Adolescents
R,MG

Consumer Assessment of Healthcare Providers and Systems
CG-CAHPS Survey
1. Renamed CAHPS for PQRS
2. CMS no longer Pays for Survey
3. Required for All GPRO submissions for groups ≥ 100
Optional in all other cases

Critical Access Hospitals
• When hospitals use billing method II, EP who assign billing to
the CAH previously unable to participate
• Hospital must include individual NPI on Claim to Qualify for
reporting
• 2014:
– Able to participate in all methods other than claims
• 2015:
– Able to participate in all methods including claims

Advice to Critical Access Hospitals
(Method 2 UB Billing)
• Get involved with lobbying efforts for 2014 Reporting (2016
Adjustment Program Year) Relief
– Regional Medicare Representative
– Federal Legislators
• 2015
– Get the rendering Provider NPI on the UB Form
– Choose the GPRO Option by June 30 (if appropriate)

Measure Groups Requirements
• Only through Registry
• Submit 1 measure group
≥ 20 Patients
≥ 11 Medicare Patients
• If any measure has 0% performance the Measure Group will
not be counted

Measure Group Changes
Discontinued Measure Groups
• Perioperative care
• Back pain
• Cardiovascular prevention
• Ischemic Vascular Disease (IVD)
New Measure Groups
• Acute Otitis Externa
• Sinusitis
New Measures added
to bring Measure count
per measure group ≥ 6

• Report ≥ 50 % of eligible patients (NOTE: All Patients are Eligible,
not just Medicare)
• Must include 1 outcome measure
• Must Include one additional measure of the type:
– Outcome
– resource use
– patient experience of care
– efficiency/appropriate use
– Safety
• QCDR May support up to 30 non-PQRS measures
• Must post data to QCDR Website by April 30

Web Interface Tool
• Only applicable to GPRO submissions for ≥ 25 Providers
• Must have one measure with Medicare Patient Data
• Groups ≥ 100 Providers must also submit CAHPS for PQRS
• Measures reduced 22  17
• For all size practices ≥ 25 Providers:
– Report on first consecutive 248 eligible patients for each measure
– Or all patients if < 248

Individual and GPRO Measure Changes
49 Measures Discontinued
20 New Measures
23 Measure Domains Recategorized

Reasons for Measure Retirement
1. Consistent and Universal near-100% Performance
2. Preference for Outcome instead of Process Measures
3. Failure to Identify a “Measure Steward”

Discontinued Measures
20 Timing of Prophylactic Antibiotic, Order
28 ASA on Arrival for acute AMI
30
Timing of Prophylactic Antibiotics,
Administration
31 VTE Prophylaxis in Stroke
35 Screening for Dysphagia in Stroke
36 Rehabilitation Services Ordered in Stroke
45 Discontinuation of Prophylactic Antibiotics
49 Characterizing Urinary Incontinence
55 EKG for Syncope
56 Vital Signs in CAP
59 Empiric Antibiotics in CAP
64 Assessment of Asthma Control
83 Confirmation of Hepatitis C Viremia
106 Depression Diagnosis and Severity
123 Hemoglobin levels in ESA
142 Assess use of OTC in Osteoarthritis
148 Back Pain, Initial Visit
149 Back Pain, Physical Exam
150 Back Pain, Advice for Normal Activity
151 Back Pain, Advice against bed rest
157
Cancer Staging prior to Thoracic
Surgery
159 AIDS, CD4+ count
169 CABG, APA at Discharge
170 CABG, BB at Discharge
171 CABG, Lipid Tx at Discharge
197 CAD, Lipid Control
198 HF, LVEF Assessment
228 HF, LVF Testing
231 Tobacco Use Screening
232 Tobacco Use Intervention
233
Performance Status prior to Thoracic
Surgery
234 PFT prior to lung resection
245 Wound Surface Culture
246 Wet to Dry Dressings
247 Substance abuse Tx Options
248
Screening for Depression in Substance
Abuse
266 Seizure type and frequency
267 Epilepsy, documentation of etiology
269 IBD Characterization
272 Flu shots in IBD
273 Pneumovax in IBD
296 HTN, lipid profile
297 HTN, Proteinuria
298 HTN, Serum Creatinine
299 HTN, Diabetes Screening
300 HTN, BP Control
301 HTN, LDL Control
302 HTN, lifestyle modifications
341 HIV Visit Gaps

Informal Review
• Must be requested within 60 days following publication of the
feedback report
• Data can be RESUBMITTED
– Not submitted for the first time
– Must be by a third party. Not available for claims, EHR Direct, or web
interface

PQRS MEASURE APPLICABILITY VALIDATION (MAV)
When a group or individual reports
• fewer than nine PQRS measures
• fewer than 3 Domains
• no Cross-Cutting Measures
• MAV will be applied
• Only applies to Registry or Claims
submissions
Passing MAV Means
• Avoiding the Adjustment
• With as few as one Measure

MAV Clusters
• Measures that share
– a common theme
– denominator criteria
• 2 to 7 Measures per MAV
– Many Measures Stand Alone
• If you submit one measure in a cluster
• You are expected to be able to submit all
• Medicare will analyze claims to understand if there are eligible
instances for other measures in the cluster

PQRS 2015
Submit 9
Measures
3 Domains
1CC
No
Adjustment
2%
PQRS
Adjustment
YES
NO
Other applicable Measures
not submitted
2%
VBM
Adjustment
VBM Quality Tiering
MAV
CMS test
for other
applicable
measures
No other
Applicable measures
+2%+4%
No
Adjustment
-2% -4%
4%
VBM
Adjustment
Group
Size
< 10
≥ 10

VALUE BASED MODIFIER
Pause for Questions about PQRS

Long Term Plan for VBM
• Gradual Implementation – Expect
– More Measures
– Quality expressed in comparative terms
– Increased stratification into Provider Peer Groups
– Finer payment distinctions
– Greater Rewards (Penalties)

VBM Applies to all groups ≥ 2 Physicians
and to Solo Physicians
for the 2017 Program Year
(2015 performance year)
Physician = doctors of medicine, osteopathy, dental
surgery, dental medicine, podiatric medicine,
optometry, and chiropracty

VBM Applies to Non-Physicians
in Groups and in solo practice
in the 2018 Program Year
(2016 performance year)

Mandatory Quality Tiering for All
Groups of 1-9 exempt from downward adjustment
for first year

Payment-at-risk to double
2%  4%
for groups of 10 or more
Solo Physicians and groups < 10 subject to
2% for 2017

Informal Review for VBM
• To be synchronized with PQRS Informal Review dates and
processes
• For VBM Program Year 2015, requests accepted through Feb
28, 2015
– Only possible action is to classify Quality as Average
• For subsequent years, requests due 60 days after publication of
QRUR
– Classify as average OR
– Resubmit/recalculate quality metrics

VBM 2017 (2015 Year of Care)
Submit
PQRS
NO
YES
4% VBM
Adjustment
VBM Quality Tiering
Groups of 10 or More
Low
Quality
Avg
Quality
High
Quality
0 +2% +4%
Low
Cost
-2% 0 +2%
Avg
Cost
-4% -2% 0
High
Cost
Groups of 1 - 9
Low
Quality
Avg
Quality
High
Quality
0 +1% +2%
Low
Cost
0 0 +1%
Avg
Cost
0 0 0
High
Cost
2% PQRS
Adjustment
Group
Size
2% VBM
Adjustment
< 10
≥ 10
+

Statistically Speaking
High and Low Defined as 1 Standard
Deviation above or below the mean
5% 90% 5%
Low
Quality
Avg
Quality
High
Quality
0 +2% +4%
Low
Cost
5%
-2% 0 +2%
Avg
Cost
90%
-4% -2% 0
High
Cost
5%
10% of
Participants
10% of
Participants80% of
Participants

PHYSICIAN FEEDBACK PROGRAM
Pause for Questions about VBM

Quality and Resource Use Report (QRUR)
• Annual report for TIN Practices
• Get it at the CMS Enterprise Portal (PV-PQRS)
– Cost performance
– Quality Performance
– Specialty Adjusted Benchmarks
– PQRS Measure Performance
– Episode Costs (Episode Groupers)
• Existing: CHF, Chronic COPD/Asthma, Acute COPD/Asthma, Permanent Pacemaker,
Bilateral Cataract/IOLI
• New: Pneumonia(all, IP, OP), Acute Coronary Syndrome(alone, PCI, CABG), Ischemic
Heart Disease(with ACS, without ACS, CABG without ACS, PCI without ACS),

12/4/2014 52
Individual Group
Claims
Registry
2015 Reporting Options
EHR
Measure Groups
Web Interface Tool
GPRO Registry
GPRO EHR
Certified Survey Vendor
Submit 9
Measures
3 Domains
1CC
No
Adjustment
2% PQRS
Adjustment
YES
NO
4% VBM
Adjustment
VBM Quality Tiering
MAV
CMS test
for other
applicable
measures
Pass
+2%
+4%
No
Adjustment
-2% -4%
2% VBM
Adjustment
Group
Size
< 10 ≥ 10
Fail
2015 PQRS Outcome Tree
Ask Questions
or Contact us:
(866)359-4458
www.PQRSsolutions.com
Daniel.Mingle@PQRSsolutions.com
Gay.DeHart@PQRSsolutions.com
Kash.Basavappa@PQRSsolutions.com

Dr. Dan Mingle's Overview of the 2015 Medicare Final Rule

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