The Latest Regulations, Simplified: MU, PQRS & MIPS
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Changing governmental regulations for the advancement of healthcare is more than difficult and we have simplified these changes to keep you up to date.
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The Latest Regulations, Simplified: MU, PQRS & MIPS
- 1. This event is live as of XYZ The Latest Regulations, Simplified: MU, PQRS & MIPS Catherine Chuter Product Marketing
- 2. 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
- 3. Shift Toward Quality 3 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. 5
- 6. April 16th MACRA, H.R. 2, made law • Medicare Access and CHIP Reauthorization Act • Replaced SGR formula • EHR Incentive Programs to be streamlined into one new payment system • Incentivizes the shift to alternative, value-based payment models News from Washington:
- 7. 7 MACRA represents a continuation in the shift toward value.
- 8. 8 MIPS 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
- 9. 9
- 10. 2007 PQRI starts 2011 Meaningful Use Stage 1 2014 Meaningful Use Stage 2 2017 Start MIPS or APM 2015 Meaningful Use penalties hit 2015 ICD-10 2015 PQRS penalties hit 2016 PQRS VM applies to all HCPs
- 12. 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 12
- 13. • 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?
- 15. The Evolution of PQRS and Beyond 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 • 74M • Claims • 119 M • 4 MG • Claims • Registry • 119 M • 4 MG • Claims • Registry • 175 M • 13 MG • Claims • Registry • EHR • GPRO • 198 M • 14 MG • Claims • Registry • EHR • GPRO • 225 M • 22 MG • Claims • Registry • EHR • GPRO • 260 M • 22 MG • Claims • Registry • DSV • HER • GPRO • 287 M • 25 MG • Claims • Registry • EHR • GRPO • CSV • CDR +2.0% +1.0% +0.5% +0.5% +0.5% -1.5% -2.0% BONUS PENALTY 2017 MIPS participation affects penalty beginning in 2019. 2017 • MIPS -9.0% M – Measures MG – Measure Groups
- 16. Stage 1: Data capture and sharing Stage 2: Advanced processes Stage 3: Improved outcomes 2015 The Evolution of MU and Beyond Meaningful Use is designed to create infrastructure that supports reform.
- 18. PQRS versus MU Upcoming Medicare Penalties Program 2015 2016 2017 2018 Physician Quality Reporting System (PQRS) -1.5% -2% -2% -2% Value Based Modifier Program (VM) -1% -2%** -2%*** or -4%**** -4% Meaningful Use/EHR Incentive Program -1% or -2%* -2% -3% -4% Penalty -3.5% or - 4.5% -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
- 19. 20 out of 23 measures MUPQRS 9 out of 287 measures PQRS versus MU Reporting Measures
- 20. Report on patient- specific data. Then, measure against peers. PQRS Meaningful Use Fully demonstrate success within three types of measurement. PQRS versus MU Measurement Style
- 22. 22 PQRS 40% MU 30% Nearly 40% of eligible providers face a payment reduction for not reporting in 2013. More than 30% will be penalized for not meeting requirements in 2013 and 2014. National Penalty Results PQRS versus MU
- 23. 23
- 25. Ask a few key questions of your EHR vendor 25 Is your vendor able to deploy the 2014 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
- 26. 26 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.
- 27. Performance on Meaningful Use Stage 2 Behavioral measures Covering period: Q1 2014 27 100% 89% 99% 99% 99% 100% 99% 95% 80% 1. CPOE for Medication, Laboratory, and Radiology Orders 2. E-prescribing (eRx) 3. Record Demographics 4. Record Vital Signs 5. Record Smoking Status 6. Clinical Decision Support Rule 7. Patient Electronic Access 8. Clinical Summaries 9. Protect Electronic Health Information (N/A) 10. Clinical Lab Test Results 11. Patient Lists (N/A) 12. Preventive Care Reminders 13. Patient-Specific Education Resources 14. Medication Reconciliation 15. Summary of Care 16. Immunization Registry Data Submission 17. Use Secure Electronic Messaging 75% 92% 99% 89% 90% 33% 98% Providers who satisfied required 3 of 6 menu measures:
- 28. Performance on Meaningful Use Stage 2 Behavioral measures As of 12/31/2014 28 100% 100% 100% 100% 100% 99% 99% 1. CPOE for Medication, Laboratory, and Radiology Orders 2. E-prescribing (eRx) 3. Record Demographics 4. Record Vital Signs 5. Record Smoking Status 6. Clinical Decision Support Rule 7. Patient Electronic Access 8. Clinical Summaries 9. Protect Electronic Health Information (N/A) 10. Clinical Lab Test Results 11. Patient Lists (N/A) 12. Preventive Care Reminders 13. Patient-Specific Education Resources 14. Medication Reconciliation 15. Summary of Care 16. Immunization Registry Data Submission 17. Use Secure Electronic Messaging 99% 100% Providers who satisfied required 3 of 6 menu measures: 100% 100% 100% 100% 100% 100% 100%
- 29. We navigate regulatory change so practices don’t have to 29 Meaningful Use Stage 2 attestation National average: 33% 98.2% athenahealth clients: % of HCPs expecting PQRS penalties in 2015 National average: 40% 6.4% athenahealth clients:
- 30. 2014 Best in KLAS #1 Practice Management System (1-10, 11-75 physicians) #2 Practice Management System (Over 75 physicians) #2 EHR (1-10, 11-75 physicians) #2 Patient Portal #2 Overall Physician Practice Vendor “2014 Best in KLAS Awards: Software & Services,” January, 2015. © 2015 KLAS Enterprises, LLC. All rights reserved. www.KLASresearch.com
- 31. 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
- Because 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
- CMS stands behind this transition by no longer encouraging practices to adopt value-based care but by making it a requirement. CMS plans to tie 50% of all provider payments to quality initiatives by 2018. Additionally in 2018, all Medicare plans will be tied to quality in some way. On the other side of this, the total payment cut for Medicare fee-for-service reimbursement is expected to double between 2015 and 2018.
- Two such programs will be discussed today, drawing them out of the overwhelming white noise of the so called “acronym soup”. PQRS and MU are the only two penalty based programs that also affect the majority of healthcare professionals nationwide.
- 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
- On April 16th, the Medicare Access and CHIP Reauthorization Act (MACRA), H.R. 2 was signed into law, and is the basis for all of these recent changes. While this law permanently repealed the sustainable growth rate (SGR) formula, the new legislation also includes a small addition that has huge repercussions on the Medicare framework for paying physicians. Sources: http://www.familydocs.org/payment-reform/macra https://www.acponline.org/advocacy/where_we_stand/assets/macra_handout_need_to_know_2015.pdf Image source: http://www.healthcarefinancenews.com/news/icd-10-debate-hits-washington-most-prepared-worry-persists
- The main goal of the MIPS addendum within MACRA is to help support reaching the goal of cutting costs while improving the quality of health care in the country. This objective may seem clear and well intentioned on paper but the road getting there is starting to prove a bit rocky. As with any untested approach, it is as of yet unclear if MIPS will truly promote quality care, especially without further overburdening medical professionals.
- Two new systems of payment have been outlined in MACRA to begin in 2017. 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.
- MACRA and MIPS are here to stay, at least for now, and there is no turning back. Still, there is no use focusing all energy upon that 2017 starting date because you can’t build without a good foundation. There is much to keep up with in the meantime dealing with current value-based reimbursement programs, which will continue to very important until that 2017 marker. Image source: http://estesbuilders.com/foundations-of-quality/
- 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.
- About 1.25 million providers are eligible for PQRS, making this system, which focuses on promoting and measuring quality outcomes, the largest governmental pay for performance program available, even larger than MU. The Meaningful Use program is aimed at driving effective use of EHRs and ultimately improving outcomes and 392,800 providers are eligible for this program. While the penalties aren’t as steep as PQRS, it is still essential to understand what is expected within MU if you don’t already know or need a refresher. 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.
- 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.
- Stage 1 is focused on basic data capturing and sharing, Stage 2 focuses on advanced processes like patient engagement, and Stage 3 will focus more on interoperability and driving improved outcomes. Key differences with Stage 2: more core measures, fewer menu measures, and higher measure thresholds – Stage 2 demands more of the provider and their EHR Like other incentive programs, MU has gotten more complicated and challenging over time Not sure if stage 3 will even happen after the 2017 date
- 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.
- measurements 2016 apply to everyone against each other can’t opt out anymore understand how difficult this new program is
- Recent CMS mistake - 80% will be penalized 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.
- 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 will be 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.
- This is what is truly important. We can’t say for sure what will happen in the future but we can say for sure that we work really hard to make sure that, at the end of the day, the only thing occupying your mind are your patients.
- Value-based payments (MU, PQRS/VBM, MSSP, MIPS, etc.) are here to stay and, for better or for worse, we have you covered.
- 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 2014 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.
- Similarly, 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.
- Here’s how our clients were performing at the end of Q1 2014: Providers fared well with most of the measures, especially the carry-over measures from Stage 2 However providers were struggling with the Patient Engagement measures, especially the measure that required that patients log into the patient portal and send their provider a secure electronic message
- By year’s end, our clients were at or close to 100% for all Stage 2 measures—secure messaging finished at 99% (33% at the end of Q1) While Stage 2 is challenging, success is attainable with the right platform and resources at your disposal
- 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 always, we strive to offer you the best possible services, etc. 67,500+ providers on athenaNet® Clients ranging from 1 to 5,000+ providers 50 states and 112 medical specialties $14 billion in client collections per year 300k physicians on Epocrates Entry into the Inpatient Space – Jan, 2015