PQRS 101: Meeting Requirements, Avoiding Penalties
•Download as PPTX, PDF•
1 like•408 views
Learn about what upcoming legislative changes in Medicare and Medicaid mean for practices and how to navigate incentives and penalties under PQRS.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to PQRS 101: Meeting Requirements, Avoiding Penalties
Similar to PQRS 101: Meeting Requirements, Avoiding Penalties (20)
Recently uploaded
Recently uploaded (20)
PQRS 101: Meeting Requirements, Avoiding Penalties
- 1. This event is live as of XYZ PQRS 101: Meeting Requirements, Avoiding Penalties Raymond Mariano Manager Small Group Sales
- 2. 2
- 3. Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf; Projected Medicare Fee-for- service Payment Cuts per the ACA 2014 2015 2016 2017 2018 2019 2020 Projected number of Medicare beneficiaries 54M 56M 57M 59M 61M 63M 64M -14B -21B -25B -32B -42B -53B -64B Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf
- 4. 2018: 90% of Medicare payments tied to quality. 2020: 75% of commercial plans will be value-based. Jan 2015. http://www.hhs.gov/news/press/2015pres/01/20150126a.html
- 5. FFS versus FFV Eliminates incentive to increase volume Eliminates incentive to provide high-cost services over equally effective low-cost services Quality-based incentives Shared risk Emphasizes the role of primary care providers Encourages coordination of care Fees billed per units of service Income maximized through volume No penalty for poor quality Providers lose money if they reduce unnecessary services Volume Driven Health Care Value Driven Health Care Fee-for-service Value-based payments
- 8. 8 The Evolution of PQRS 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 74 measures 119 measures 119 measures 175 measures 198 measures 225 measures 260 measures 287 measures +2.0% +1.0% +0.5% +0.5% +0.5% -1.5% -2.0% BONUS PENALTY 2016 participation affects penalty in 2018. 254 measures 280 measures
- 9. 9
- 10. PQRS Meaningful Use MEDICARE PHYSICIANS Doctor of Medicine X X Doctor of Osteopathy X X Doctor of Podiatric Medicine X X Doctor of Optometry X X Doctor of Oral Surgery X X Doctor of Dental Medicine X X Doctor of Chiropractic X X PRACTITIONERS Physician Assistant X Nurse Practitioner X Clinical Nurse Specialist X Certified Registered Nurse Anesthetist X Certified Nurse Midwife X Clinical Social Worker X Clinical Psychologist X Registered Dietician X Nutrition Professional X Audiologists X THERAPISTS Physical Therapist X Occupational Therapist X Qualified Speech-Language Therapist X PQRS and MU eligible providers 10
- 11. • Federally Qualified Health Centers (FQHCs) • Patient Centered Medical Homes (PCMH) • Hospitals • Independent Labs • Rural Health Clinics • Ambulance providers • Ambulatory Surgical Centers (ASCs) Who is not eligible for PQRS?
- 12. In the Medicare EHR Incentive Program so providers demonstrate meaningful use of the capabilities of their EHRs to achieve benchmarks. 1 To calculate the 2018 Value Modifier based on quality of care and cost data to select those eligible for payment adjustments.2 It will be publicly posted on the Physician Compare website allowing patients and other practices to view performances of all. 3 How is 2016 PQRS data used?
- 13. The Evolution of Meaningful Use 13 Stage 1: Data capture and sharing Stage 2: Advanced processes Stage 3: Improved outcomes
- 14. In the Medicare EHR Incentive Program so providers demonstrate meaningful use of the capabilities of their EHRs to achieve benchmarks. 1 To calculate the 2018 Value Modifier based on quality of care and cost data to select those eligible for payment adjustments.2 It will be publicly posted on the Physician Compare website allowing patients and other practices to view performances of all. 3 How is 2016 PQRS data used?
- 15. Value Modifier uses reported PQRS data to rate practices on cost & quality 15 (above average) COST (below average) QUALITY
- 16. 0% +2% +4% -2% 0% +2% -4% -2% 0% Rewards and penalties are based on how practices perform relative to the nation 16 (above average) COST (below average) QUALITY
- 17. In the Medicare EHR Incentive Program so providers demonstrate meaningful use of the capabilities of their EHRs to achieve benchmarks. 1 To calculate the 2018 Value Modifier based on quality of care and cost data to select those eligible for payment adjustments.2 It will be publicly posted on the Physician Compare website allowing patients and other practices to view performances of all. 3 How is 2016 PQRS data used?
- 18. 18
- 19. PQRS and MU Program Comparison
- 20. PQRS versus MU Upcoming Medicare Penalties Program 2016 2017 2018 Physician Quality Reporting System (PQRS) -2% -2% -2% Value Based Modifier Program (VM) -2%** -2%*** or -4%**** -4% Meaningful Use/EHR Incentive Program -2% -3% -4% Penalty -6% -7% or -9% At least -10% * -2% in 2015 only applies to providers who failed Meaningful Use and eRx thresholds ** -2% applies to practices with 100+ EPs only *** -2% is only for practices with 1-9 EPs **** -4% only applies to practices with 10+ EPs
- 21. 20 out of 23 measures MUPQRS 9 out of 280 measures PQRS versus MU Reporting Measures
- 22. Report first. Then, performance against your peers. Measure against thresholds. MUPQRS PQRS versus MU Measurement style
- 23. 23 PQRS 40% MU 30% of eligible providers faced a payment reduction in 2015 for not reporting in 2013. were penalized in 2015 for not meeting requirements in 2013 and 2014. National Penalty Results PQRS versus MU
- 24. 2007 PQRI starts 2011 Meaningful Use Stage 1 2014 Meaningful Use Stage 2 2019 Start MIPS or APM 2015 Meaningful Use penalties begin 2015 ICD-10 2015 PQRS penalties begin 2017 VM applies to all HCPs 2016 VM applies to groups of 10 or more EPs based on 2014 performance
- 25. 25 MU PQRS VMMIPS 2019 2022 Fully implemented with a much greater range of adjustments -4% penalty +12% incentive MIPS takes over and replaces penalties from current programs -9% penalty +27% incentive
- 27. 27
- 34. 34 PQRS Success with athenahealth 1 For enrollment, we look at our network data to determine the best 9 measures for each specialty. 2 Once enrolled, our rules engine tracks the performance of each HCP and adjusts enrollment based on performance. 3 Our software provides real-time visibility into performance to ensure you are on track.
- 35. We navigate regulatory change so you don’t have to Meaningful Use Stage 2 attestation % of HCPs avoiding PQRS penalties in 2015 NATIONAL AVERAGE 33% ATHENAHEALTH CLIENTS 98.2% NATIONAL AVERAGE 60% ATHENAHEALTH CLIENTS 93.6%
- 37. Ask a few key questions of your EHR vendor 37 Is your vendor able to deploy the 2016 Certified Edition to all clients at once?1 How is your vendor monitoring your PQRS and MU performance? 2 Does the vendor provide MU/PQRS support and training as part of the regular pricing without additional fees?3 Do they provide the required interfaces for free and without interruption? How many connections? When will they be available?4
- 39. Thank You
Editor's Notes
- Welcome and introduction 1. Discuss governmental changes and new legislative updates to the VBR system for Medicare and Medicaid processes that will dramatically affect your practice if you are not informed or prepared 2. Diving deeper into PQRS and MU and offering a refreshing look at the programs to answer any questions on confusing measures and processes 3. Offers reassurance to providers in consideration of the tumultuous times ahead especially framed by what adopting an EHR vendor like athenahealth can do
- It’s pretty clear that the government has fundamentally shifted the way our country provides health care since the arrival of the Affordable Care Act in 2010. Within recent years, these changes are specifically felt in how providers are reimbursed for giving care. But, what is the real reason prompting all these changes?
- Well, the number of Medicare beneficiaries continues to grow, payer reimbursements are a huge target for Medicare cuts to try and offer a solution to a cumulating financial problem. Rather than cutting public payer programs altogether, the government has decided to tie payments to the demonstration of quality rather than just cut public payer programs altogether. It is by the Affordable Care Act, the government continues to move toward a consistent delivery of quality care. Hospital payment cuts will represent : 260B As you can see the number of Medicare beneficiaries has been and will continue to increase exponentially over the next five to ten years, mostly driven by the “baby-boomers” hitting the retirement age. So as to not bankrupt the country, the Medicare fee cuts have to be cut just as much to compensate. As a result the payment system is shifting from fee-for-service to fee-for-value
- In fact, as of 2018, CMS has committed at least 90% of their Medicare payments will be tied to quality. Commercial payers have followed suit and stated around 75% of their plans will be value-based by 2020.
- The big shift is moving from what is known as a “fee-for-service” environment to a “fee-for-value” environment, or “value based”. These value based payments are very different in that they really incentivize quality based care. Instead of high volume where money is made form providing more care, it is all about high quality, where payments come from the type of care that is provided.
- It can feel like trying to run your practice is like walking a tightrope, trying to balance all this change while you keep getting handed more to juggle, more things that can upset your balance – this illustrates why physicians can’t do it yourself anymore. As we have seen with many programs in the past such as ANSI, MU and ICD-10 all experiencing delays, change is inevitable. There is a lot coming at providers and juggling it all can make the providers life difficult. You need a good partner that is willing to take on some of this burden and help you navigate this landscape and manage change.
- PQRS stands for the Physician Quality Reporting System
- PQRS like we said before started back in 2007 but has only gotten immensely more complicated since. In 2007 there were only 74 measures but now, in 2016, we recently heard that there are going to be over 300. There also used to be a bonus associated with the program but as of this year there is a penalty of over a % just for not reporting. At the beginning, PQRS was relatively easy and was composed of paper based claims. Increasingly the program has become more and more complicated as well as transitioning away from providing bonuses into a penalty only program. Today, especially with MIPS on the horizon, PQRS is more complicated than ever and the stakes for penalties are much higher.
- 2015 is a year of intense change. New legislation, rulings, announcements, proposals, and constant changes from the government surrounding the healthcare community have been especially noticeable this year just by the sheer amount coming from the capitol. Much of the changes are pushing aggressively toward reworking payment systems into exclusively quality based programs and unfortunately a lot of the resulting work will fall at the feet of healthcare professionals. Keeping up with all these recent developments can feel a bit like hiking out into uncharted territory, especially now that you’re put in the position of needing to know more about new reporting and documentation measures than ever before. Image source: https://www.flickr.com/photos/33346716@N03/8036177029
- In order to participate in 2016 PQRS to avoid the 2018 negative payment adjustment, you must first determine eligibility. About 1.25 million providers are eligible for PQRS, making this system the largest governmental pay for performance program available, even larger than MU. Meaningful Use has about 392,800 providers eligible for that program. While the penalties aren’t as steep as PQRS, it is still essential to understand what is expected within MU. Many more providers are eligible for PQRS, to which CMS refers as “EP’s” or “eligible providers”, a slight misnomer as reporting for PQRS and MU isn’t exactly optional, given the weight of the penalties. Because so many more providers must report PQRS, it is important to know where you fall within both PQRS and MU. Under PQRS, covered professional and institutional services are those paid under or based on Medicare Physician Fee Schedule (MPFS). Only those EPs who render denominator- eligible, Part B MPFS professional and/or institutional services are considered able to participate in PQRS and will be analyzed for future PQRS negative payment adjustments. PQRS and MU as you saw in the timeline have been around for a couple of years. MU is for Medicare is almost entirely for physicians whereas PQRS is all providers, so it affects everyone and not just the 300,000 or so medicare physicians out there.
- Why is the government introducing this program and what are the objectives The EHR Incentive Program provides incentive payments for certain healthcare providers to use EHR technology in ways that can positively impact patient care. It’s important to know that the EHR Incentive Program is NOT a reimbursement program for purchasing or replacing an EHR. Providers have to meet specific requirements in order to receive incentive payments. In other words, it’s not enough just to own a certified EHR. Providers have to show CMS that they are using their EHRs in ways that can positively affect the care of their patients. To do this, providers must meet all of the objectives established by CMS for this program. Then they will be able to demonstrate MEANINGFUL USE of their EHRs and receive an incentive payment.
- Meaningful Use has evolved as well, it was originally intended to have three stages. Most providers are in Stage 2 now, because of the recent announcements from the CMS about MU stage 3 is that it will be replaced very soon The Stage 1 final rule set the foundation for the Medicare and Medicaid EHR Incentive Programs by establishing requirements for the electronic capture of clinical data, including providing patients with electronic copies of health information. The Stage 2 final rule expanded upon the Stage 1 criteria with a focus on ensuring that the meaningful use of EHRs supported the aims and priorities of the National Quality Strategy. Stage 2 criteria encouraged the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible. http://www.healthcare-informatics.com/article/federal-health-it-officials-say-mu-stage-3-still-effect
- Why is the government introducing this program and what are the objectives To make matters even more interesting, CMS recently added a performance layer to providers’ PQRS data under what they call the “Value-based modifier program” or “VM” for short. Under VM, providers will be evaluated using their PQRS data as well as other readmissions and claims data, to determine their quality performance and their cost performance relative to their peers – and they will be reimbursed accordingly. For example, providers who are determined to have provided low quality care at high cost, will have their Medicare payments reduced by 4% for poor performance. Providers who are determined to have provided low quality care at average cost will have their Medicare payments reduced by 2%, and providers who are determined to have provided average quality care at high cost will also have their payments reduced by 2%. There is some potential upside the good performers, though the exact amount is determined by CMS that year based on available incentive dollars to distribute. Again, the additional performance later increasing in impact over the years as part of the shift towards actual quality and utilization performance and away from fee-for-service or even simple reporting of tech capabilities. Those practices that simply failed to report PQRS will see an automatic 2% penalty – for practices of more than 10 providers, this number is 4%. So the combined automatic penalty between PQRS and VM for failing to report PQRS is 4% for practices of fewer than 10 eligible providers and 6% for those practices of more than 10 eligible providers. The reason a performance measure as been added in is to force practices to manage utilization of risk. You have to operate as if you're under a risk based contract even if you aren’t.
- To explain how the PQRS value based modifier works, this is your patient panel. Some of your patients cost more, some cost less, some received really great quality, some maybe didn’t which puts you at an average, about where that red dot is.
- CMS then takes your data and compares you to other practices, or the other red dots on this grid. In this case, looks like you did about average which means that you won’t get hit with a payment reduction but you also won’t get an additional payment incentive. If you had done better and ended up in the upper right quadrant you might have seen as much as 4% bump on your Medicare payments.
- Why is the government introducing this program and what are the objectives
- When you preview your measures in PQIP, they will appear as they will be publicly reported on Physician Compare. Quality measure data are displayed on Physician Compare in plain language. The performance rates are displayed as stars and percentages. The plain language measure titles, descriptions, and display are tested with consumers to ensure that they are accurately interpreted. The Centers for Medicare and Medicaid Services (CMS) was required by Section 10331 of the Patient Protection and Affordable Care Act (ACA) of 2010 to establish the Physician Compare website. As a result, the site was launched on December 30, 2010. In its first iteration, Physician Compare utilized the existing Healthcare Provider Directory already part of Medicare.gov. Since that time, CMS has been working continually to enhance the site and its functionality, improve the information available, and include more and increasingly useful information about physicians and other healthcare professionals who take part in Medicare. This effort, along with the eventual addition of quality measures on the site, will help it serve its two-fold purpose To provide information for consumers to encourage informed healthcare decisions; and To create explicit incentives for physicians to maximize performance.
- Taking a further look at what penalties are to come, not just for PQRS and VM but both combined with MU paints a concerting picture. PQRS is a bit more complicated from a performance management and reporting perspective than other programs and it also has greater implications revenue-wise, especially when combined with the impact of VM performance. Penalties for failing to report MU range from 1-2% to only 3% in 2017 and then on up to 4% in 2018. Whereas penalties for failing to report PQRS range from -2.5% starting this payment year to 6% in 2017 payment year (which is based on 2015 performance data). Altogether, providers could be seeing up to a 9% reduction to their 2017 Medicare payments for failing to report MU and PQRS this year.
- PQRS does require providers to report fewer measures than MU, but that doesn’t make managing and optimizing your performance simpler. With PQRS, your practice could being doing much better on a different set of possible measures, but with out proper insight into all likely good measures, all 287 of them, it’s hard to know which to select, monitor, and ultimately report on as to optimize your performance. PQRS success is also determined differently from success with MU. Under MU, providers must meet certain performance thresholds. Under PQRS, providers must successfully report their data to show that it is data they are capable of tracking and reporting. And then, under VM, providers will be assessed for actual performance relative to their peers and reimbursed accordingly.
- When it comes to how you get measured, with PQRS you submit a report with all your data and then CMS measures you against your peers to see how you did so essentially you’re measured on a curve. With Meaningful Use you just have to hit thresholds so you have to be good enough at the measures you selected to hit the thresholds set out by CMS With PQRS you report them and then later on with the VBR modifier it will benchmark your reported scores against your peers. With MU you’re just checking the boxes to meet the thresholds
- As of right now, providers aren’t performing well and are facing penalties. Approximately 37% of eligible providers face a payment reduction for not reporting PQRS in 2013, and more than 30% of providers were penalized for not meeting MU requirements in 2013 and 2014. This means serious cuts to provider reimbursement. Those on PQRS as reported here is from when the program only asked for submitted quality measures. Next year submitting is just the first step, the second is proving these quality measures have been implemented and utilized. For the data showing on MU, most who failed were only in stage 1, containing less-stringent quality measures in comparison to stages 2 and 3. A good EHR vendor helps make sure the reporting is finished and mailed in (an important step many providers miss), to ensure that VM layer is met. In all likelihood when updated numbers are released from this year, the percentage of providers suffering penalties will have increased.
- As stated before, 2015 is a tumultuous year. Quality-incentive programs have much changed from their origins, especially PQRS and MU, which now carry penalties at a staggering rate. More changes are still to come out of MACRA: a consolidation of three programs established under the ACA: MU (the EHR incentive program), the Physician Quality Reporting System (PQRS), and the value-based payment modifier (VM). On top of all this, ICD-10 is slated to finally start later this year. The increased strain upon already burdened professionals in the healthcare community is all too visible and unfortunately is converging all at once. In 2016, we will apply the Value Modifier to groups of physicians with 10 or more EPs based on 2014 performance. The Affordable Care Act requires CMS to apply the Value Modifier to all physicians and groups of physicians starting in 2017. This law repeals the flawed Medicare sustainable growth rate (SGR) formula that calculated payment cuts for physicians. MACRA establishes an alternative set of predictable annual baseline payment updates and two payment tracks: the alternative payment model (APM) track and the Merit-Based Incentive Payment System (MIPS) track. The following is a timeline for MACRA implementation: July 2015 through December 2015: Medicare physician payments increase by 0.5 percent. 2016 through 2019: Medicare physician payments increase by 0.5 percent each year. January 2019: Based on eligibility, physicians enter either the APM track or the MIPS track. 2020 through 2025: Medicare physician fee-for-service payments remain at 2019 levels with no updates.
- Two new systems of payment have been outlined in MACRA to begin in 2019. Both methods allow practices to be awarded incentives for providing improved care, whichever model is chosen. The first option is MIPS, or the merit-based incentive payment system, is a whole new version of physician value-based purchasing completely altering how you and your practice are paid. MIPS is one of the biggest changes coming out of the MACRA legislature though it is only a small part of the very large law. Beginning in 2017 as the reporting year, the MU, PQRS, and VM programs will all merge into the one system of MIPS with adjustments for that year implemented in 2019. This new program comes with new sets of incentives and penalties, supplanting the existing penalties and bonuses under the current EHR incentive program. With PQRS, Meaningful Use, and VM combined, practices of 10 or more eligible providers face potential cuts of up to 9% on their Medicare payments, and up to 7% for practices of fewer than 10 eligible providers. While starting with the reporting year of 2017, this date isn’t as far off on the horizon as it sounds. As more information emerges, it is becoming clear that much of the coming hurdles cannot be crossed without preparing for them in the present. Having the right workflows and tools in place is imperative.
- So those are all the programs which might be slightly overwhelming. I’d like to spend the rest of my time just quickly talking about what a partner can look like in order to avoid penalties and secure incentives. At athenahealth, this is our approach:
- We at athena have three teams that are tracking over 100 different reimbursement programs Government affairs team go down to Washington D.C. to monitor changes Payer performance team, tracking every measure in every program to make sure we are embedding it in the right way in our software
- We have a quality management engine that sorts though more that 1,700 clinical rules that works for you
- Those measures are surfaced at a point that is not disruptive but it is specific to the patient that comes into the office that is most appropriate to so you can satisfy those measures at the moment of care
- We provide real time visibility into how you’re doing
- Value-based payments (MU, PQRS/VBM, MSSP, MIPS, etc.) are here to stay and, for better or for worse, we have you covered. Our combined approach of software, knowledge, and services makes being successful with PQRS – a complicated program with heavy penalties for failure – simpler. We have determined the 9 best measures in which to enroll a specialty based on network knowledge. Once enrolled, we track performance and adjust enrollment to optimize performance. And our QM tools within the software give you real-time visibility into performance at the point of care to it clearer which measures need to be met and when to meet them. Like we do with MU, clients simply have to sign off on their data and we submit it on their behalf.
- Meaningful Use drove widespread adoption of EHRs Stage 1 the bar was very low but stage 2 bar was higher and was harder for our clients to attest and right out of the gate we were able to solve this problem for our clients ahead of the curb Network intelligence and experience rest of the industry was really struggling A lot of change when it comes to regulatory programs (MU, PQRS) – our model is flexible and can adopt to changes, “future proof” We apply our Software/Knowledge/Services approach to MU Take much of the MU burden off of providers – for example we do all of the attestation work on behalf of our clients Our approach works… we have a proven track record of success We apply our Software/Knowledge/Services approach to MU Take much of the MU burden off of providers – for example we do all of the attestation work on behalf of our clients Our approach works… we have a proven track record of success As long as your are with us, we’ve got you covered. Here’s all of the things we are doing… - how we are handling PQRS, etc - all of the services that go into that When we start asking you to do things… it’s because of all these VBR changes – please keep that in mind.
- As you continue to prepare yourself for success with value-based reimbursement programs, like MU and PQRS, so as to avoid hits to your Medicare revenue, here are a few key questions we recommend you ask your EHR vendor to make sure they are ready to support you in the way they need to for your to succeed: First, are they able to deploy the 2016 certified edition of their software to all clients at once? Or is it likely that as they roll out updates to prepare for these quality and payer program changes that you’ll have to wait your turn for an update? Second, how are they monitoring and working to improve your PQRS and MU performance? Third, do they offer MU and PQRS support and training as part of their regular pricing? Or do they charge an additional fee? And finally, do they provide any of the required interfaces for free and without interruption? If yes, how many connections, and when will they be available? This is certainly not the full list of things to keep in mind as you evaluate your readiness for the shift away from fee-for-service towards value-based reimbursement, but it’s a start, and we hope to hear from you to be able to tell you more about how athena is uniquely able and motivated to drive your success with these payment programs.