What’s New in CMS Value-Based Purchasing and

VBM
2015
Physician Compare
2011
QRUR
What’s New in
CMS Value-Based Purchasing and
Why It’s Important to Participate in PQRS
2012
December 4, 2012
Joseph G. Cacchione, MD, FACC
Eileen Hagan
Brian Whitman
Overview of Today’s Webinar
Participants will be able to:
1. Appreciate the timelines and implications for valuebased payment.
2. Understand why it’s important to participate in PQRS.
3. Begin to understand the value-based modifier.
4. Describe the options and methods for successful
participation in PQRS in 2013.
5. Determine the best way for you and your practice to
participate in PQRS in 2013.
2
Timelines and Implications
for Value-Based Payment
Background
 Since 2006, Legislation has called for value-based purchasing
(VBP) to transform Medicare from a passive payer to an active
purchaser by using specific performance measures aimed at
improving quality and reducing overall cost.
 Value-based purchasing involves three major elements for
physicians:
Confidential feedback on performance and resource use
Public Reporting
Payment adjustment /value modifier
4
Confidential Feedback on
Performance and Resource Use
Quality and Resource Use Reports (QRURs) provide comparative
information so physicians can view the clinical care their patients
receive in relation to the average care and costs of other
physician’s Medicare patients:
 Physicians in IA, KS, MO, NE received them in March 2012
using 2010 data;
 Physicians in groups with > 25 eligible professionals (EPs)
in CA, IA, IL, KS, MI, MN, MO,NE, WI will receive them in
December 2012 using 2011 data;
 All groups with > 25 EPs will receive them in Fall 2013
using 2012 data; VBM information is expected to be
included in the reports.
5
Public Reporting
Physician Compare is a CMS website for publicly reporting
physician performance; similar to Hospital Compare
 Physician Compare currently reports:
That a physician has satisfactorily reported quality measures
through PQRS
That a physician received a bonus for electronic prescribing
 Physician Compare will publicly report data on those physician
groups that participated in PQRS using the GPRO web
interface in 2012
 CMS has not yet announced full details of future expansion of
this program, but expect to see PQRS performance and cost
measures in the future.
6
Payment Adjustment / Value Modifier
CMS is phasing in the use of value-based modifiers
(VBM) to provide differential payments based on
quality and cost of care.
The QRUR is intended as a precursor to the VBM and
currently includes cost of care measures for patients
seen by the physician and quality information
calculated using claims data and from PQRS.
For further information on the QRUR, go to:
http://www.cardiosource.org/~/media/Files/Advocacy/Physician%20Payment/CMSQu
alityandResourceUseReportsandImplicationsforValueBasedPayment.ashx
7
In the Meantime
Think about physicians and other eligible
professionals as the supply side of value-based
purchasing; your fee-for-service is subject to valuebased payment
Participation in CMS incentive programs (PQRS, e-Rx,
Meaningful Use) has been voluntary;
CMS has begun phasing in payment adjustments for
non-participation .
8
Payment adjustments for PQRS are moving from bonuses for
successful participation to penalties for non-participation.
2007 2008 2009
PQRS
Yes
No
Penalty
1.5% 1.5%
2%
2010
2011
2012
2013
2014
2%
1%
0.5%
0.5%
0.5%
2015
penalty
2016
penalty
2015
2016
2017
2018
2017
penalty
2018
penalty
2019
penalty
2020
penalty
-1.5%
-2%
-2%
-2%
2019
2020
-2%
-2%
Eligible professionals (EPs) who do not participate in PQRS in 2013 will
receive a -1.5% payment adjustment in 2015.
9
Payment adjustments for E-prescribing are moving from
bonuses for successful participation to penalties for nonparticipation.
2007
E- Rx
Yes
No
Penalty
2008
2009
2010
2011
2012
2013
2014
2015
2%
2%
1%
1%
0.5%
2012
penalty
2013
penalty
2014
penalty
2015
penalty
2016
penalty
-1%
-1.5%
-2%
-2%
2016
2017
2018
2019
2020
-2%
Eligible professionals (EPs) who did not participate in E-Rx in 2011 are
experiencing a -1% payment adjustment in 2012.
10
Payment adjustments for Meaningful Use are moving from
bonuses for successful participation to penalties for nonparticipation.
2007
2011
2012
2013
2014
2015
$18000
$12000
$8000
$4000
$2000
$18000
$12000
$8000
$4000
$2000
$15000
$12000
$8000
$4000
Start 2014
$12000
$8000
$4000
No
2015
penalty
2016
penalty
-1%
Start 2011
Meaningful Use
Start 2012
Start 2013
Projected
Penalty
2008
2009
2010
2016
2017
2018
2019
2017
penalty
2018
penalty
2019
penalty
2020
penalty
-2%
-3%
-4%
-5%
2020
-5%
Eligible professionals (EPs) who do not participate in Meaningful Use by 2014
will receive a -1% payment adjustment in 2015.
11
CMS is phasing in the use of a value-based modifier (VBM) to
provide differential payments based on quality and cost of care.
2013
No PQRS
2014
TBD
2015
TBD
2016
2017
2018
2019
2020
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
Additional PQRS
Penalty for NonParticipation
Tiered Payment
Adjustment
Value-Based Modifier
Groups of
100+:
2015
penalty
Groups
of 100+:
Opt-in
Groups
of 25+
All
Groups of
100+:
-1%
3%
0%
-1%
12
What Does It All Mean?
It will be important to understand how the valuebased modifier is calculated:

Quality and cost data will inform the VBM
It will be important to participate in PQRS:
 There will be payment and performance ranking
implications for non-participation
13
Value-Based Payment Modifier
 In 2015, Medicare will begin providing differential
payments to physicians based on quality and cost of
care:
 Services provided during 2013 will be used to
calculate the 2015 modifier;
 In 2015, the modifier will apply to payment for items
and services provided by physicians in groups of 100
or more EPs ;
 The modifier is expected to be phased in over a 2year period with full implementation in 2017.
14
Measures will be weighted equally within each domain;
Domains will be weighted equally to form composites;
Where a group does not report measures in a particular domain,
the remaining domains will be weighted equally.
15
Quality Domain: PQRS Measure Examples
Clinical Care
CAD: Lipid Control
Patient Experience--CG-CAHPS Measures
Getting timely care, appointments and information
How well your doctors communicate
Patient Safety
Medication Reconciliation
Care Coordination
Advance Care Plan
Efficiency
Cardiac Stress Imaging: Not Meeting Appropriate Use Criteria: PreOperative Evaluation in Low-Risk Surgery Patients
16
VBM Implementation
 Groups of 100 or more EPs will receive an additional
payment adjustment of -1% in 2015 if they do not
participate as a group in PQRS in 2013.
 If they successfully participate in PQRS as a group in 2013,
they can opt-in to participate in quality tiering using the
VBM to receive a payment adjustment in 2015 based on the
quality and cost of care they provided in 2013.
 These payment adjustments will range from -1% to as high
as ~3% in 2015.
 Although CMS is starting with a limited set of physicians for
this program in 2015, the law requires them to expand the
program to all physicians by 2017.
17
Value-Based Modifier Payment Adjustment Amount (2015)
In Group with more than
100 eligible
professionals
0% (no bonus or penalty)
NO
YES
Register by October 15, 2013 as
a group to participate in 2013
PQRS:
1) Under the Group Practice
Reporting Option (GPRO) OR
2) Under the administrative
claims option
1% penalty
NO
YES
Opt-in to participate in
2015 value-based
modifier (quality-tiering)
by October 15, 2013
0% (no bonus or penalty)
NO
YES
High quality, low cost, high risk ~3% bonus
Performance/Resource Use/
Risk Adjustment
Average quality, average cost, average risk 0%
(no bonus or penalty)
Low quality, high cost, average risk
1% penalty
18
Options and Methods for Successful
Participation in PQRS in 2013
In 2010: 37% of eligible cardiologists participated in PQRS;
78% of cardiologists who participated qualified for the incentive.
20
Frequency of PQRS Reporting Method
by Cardiologists in 2010
10,000
8,729
8,000
6,798
5,887
6,000
4,478
4,000
4,274
3,031
2,000
0
Total
Claims
Participating
Registry
Qualifying
In 2010: 67% of participating cardiologists reported via claims submission;
51% of participating cardiologists reported via registry submission
Note: Some reported via more than one option but were only counted once for total participating.
21
2013 PQRS Reporting Options
Report as an Individual Eligible Professional
Report as a Group Practice
Group Practice = a single Tax Identification Number
(TIN) with 2 or more eligible professionals, as
identified by their individual NPI, who have
reassigned their Medicare billing rights to the TIN
22
Reporting as an Individual Eligible Professional
Choose your reporting mechanism:






Claims
Registry
EHR direct product
EHR data submission vendor
Administrative Claims
Choose your measures:

Individual Measures OR Measures Groups
23
Individual Reporting Via Claims
Reporting
Period
Measure
Type
Reporting Criteria
Jan 1, 2013 –
Dec 31, 2013
Individual
Measures
Report at least 3 measures
AND
Report each measure for at least 50% of your Medicare
Part B FFS patients seen during the reporting period to
which the measure applies.
Jan 1, 2013 –
Dec 31, 2013
Measures
Groups
Report at least 1 measures group AND Report each
measures group for at least 20 Medicare Part B FFS
patients.
Measures groups containing a measure with a 0%
performance rate will not be counted.
24
Individual Reporting Via Registry
Reporting
Period
Measure
Type
Reporting Criteria
Jan 1, 2013 –
Dec 31, 2013
Individual
Measures
Report at least 3 measures AND Report each measure for at least
80% of your Medicare Part B FFS patients seen during the reporting
period to which the measure applies.
Jan 1, 2013 –
Dec 31, 2013
Measures
Groups
Report at least 1 measures group AND Report each measures group
for at least 20 patients, a majority (11) of which must be Medicare
Part B FFS patients, seen during the reporting period.
Measures groups containing a measure with a 0% performance rate
will not be counted.
July 1, 2013 – Measures
Dec 31, 2013 Groups
25
Individual Reporting Via
Direct EHR Product OR
EHR Data Submission Vendor
Reporting
Period
Measure
Type
Reporting Criteria
Jan 1, 2013 –
Dec 31, 2013
Individual
Measures
Option 1: Report on ALL 3 PQRS EHR measures that are also
Medicare EHR Incentive Program core measures.
If the denominator for one or more of the core measures is 0:
Report on up to 3 PQRS EHR measures that are also Medicare
EHR Incentive Program alternate core measures
AND
Report on 3 additional PQRS EHR measures that are also
measures available for the Medicare EHR Incentive Program.
====================================================
Option 2: Report at least 3 measures AND Report each measure
for at least 80% of your Medicare Part B FFS patients seen during
the reporting period to which the measure applies.
Measures with a 0% performance rate will not be counted.
26
Individual Reporting Via
Administrative Claims
An individual may elect the administrative claimsbased reporting mechanism for 2013 PQRS to avoid
the 2015 PQRS payment adjustment
You MUST affirmatively elect to be analyzed under
this reporting mechanism
27
Reporting as a Group Practice

Self-nominate to participate in the PQRS Group
Practice Reporting Option (GPRO):
 Submit a self-nomination statement via a CMS

developed website
Deadline to self-nominate: October 15, 2013
Choose your reporting mechanism:



GPRO Web Interface
Registry
Administrative Claims
28
Patient Experience of Care Survey: CG-CAHPS
 CMS will fund and administer the survey on behalf of the
groups participating in the GPRO Web Interface
 Clinician-Group Consumer Assessment of Health Plans and
Systems Survey (CG-CAHPS) Measures
Getting timely care, appointments and information
How well your doctors communicate
Patients rating of doctor
Access to specialists
Health promotion and education
Shared decision-making
Courteous and helpful office staff
Care coordination
Between visit communication
Educating patients about medication adherence
Stewardship of patient resources
29
Group Practice Reporting Via GPRO Web Interface
Reporting
Period
Group
Practice Size
Reporting Criteria
Jan 1, 2013 –
Dec 31, 2013
25-99 eligible Report on all measures included in the Web Interface
professionals AND Populate data fields for the first 218 consecutively
ranked and assigned beneficiaries in the order in which
they appear in the group’s sample for each module or
preventive care measure. If the pool of eligible
assigned beneficiaries is less than 218, report on 100%
of assigned beneficiaries.
Jan 1, 2013 –
Dec 31, 2013
100+ eligible
professionals
Report on all measures included in the Web Interface
AND Populate data fields for the first 411 consecutively
ranked and assigned beneficiaries in the order in which
they appear in the group’s sample for each module or
preventive care measure. If the pool of eligible
assigned beneficiaries is less than 411, report on 100%
of assigned beneficiaries.
30
Group Practice Reporting Via Registry
Reporting
Period
Group
Practice Size
Jan 1, 2013 – 2+ eligible
Dec 31, 2013 professionals
Reporting Criteria
Report at least 3 measures AND Report each measure
for at least 80% of the group practice’s Medicare Part B
FFS patients seen during the reporting period to which
the measure applies.
Measures with a 0% performance rate will not be
counted.
31
Group Practice Reporting Via
Administrative Claims
A group practice may elect the administrative claimsbased reporting mechanism for 2013 PQRS to avoid
the 2015 PQRS payment adjustment
The group practice will make this election when the
practice self-nominates to participate in PQRS via the
GPRO
32
What Is the Best Way for You and Your
Practice to Participate in PQRS in 2013?
ACC-Sponsored Submission Options
NCDR PINNACLE Registry:
Qualified EHR Data Submission Vendor
Individual Reporting of Individual Measures
23 measures available
PQRIwizard:
Qualified Registry
Individual Reporting of Measures Groups
26 measures groups available
34
NCDR PINNACLE Registry
2013 PQRS Individual Measures for
EHR Data Submission Vendor Reporting Option







Measure #1 (NQF 0059): Diabetes Mellitus: Hemoglobin A1c Poor Control in
Diabetes Mellitus
Measure #2 (NQF 0064): Diabetes Mellitus: Low Density Lipoprotein (LDL-C)
Control in Diabetes Mellitus
Measure #3 (NQF 0061): Diabetes Mellitus: High Blood Pressure Control in
Diabetes Mellitus
Measure #5 (NQF 0081): Heart Failure: Angiotensin-Converting Enzyme (ACE)
Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular
Systolic Dysfunction (LVSD)
Measure #6 (NQF 0067): Coronary Artery Disease (CAD): Antiplatelet Therapy
Measure #7 (NQF 0070): Coronary Artery Disease (CAD): Beta-blocker Therapy for
CAD Patients with Prior Myocardial Infarction (MI)
Measure #8 (NQF 0083): Heart Failure: Beta-Blocker Therapy for Left Ventricular
Systolic Dysfunction (LVSD)
35
 Measure #47 (NQF 0326): Advance Care Plan
 Measure #110 (NQF 0041): Preventive Care and Screening: Influenza
Immunization
 Measure #128 (NQF 0421): Preventive Care and Screening: Body Mass Index
(BMI) Screening and Follow-Up
 Measure #197 (NQF 0074): Coronary Artery Disease (CAD): Lipid Control
 Measure #200 (NQF 0084): Heart Failure: Warfarin Therapy for Patients with
Atrial Fibrillation
 Measure #201 (NQF 0073): Ischemic Vascular Disease (IVD): Blood Pressure
Management Control
 Measure #204 (NQF 0068): Ischemic Vascular Disease (IVD): Use of Aspirin or
Another Antithrombotic
 Measure #226 (NQF 0028): Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
 Measure #236 (NQF 0018): Hypertension (HTN): Controlling High Blood
Pressure
 Measure #237 (NQF 0013): Hypertension (HTN): Blood Pressure Measurement
36
 Measure #239 (NQF 0024): Weight Assessment and Counseling for Children
and Adolescents
 Measure #240 (NQF 0038): Childhood Immunization Status
 Measure #241 (NQF 0075):Ischemic Vascular Disease (IVD): Complete Lipid
Panel and Low Density
 Measure #308 (NQF 0027): Smoking and Tobacco Use Cessation, Medical
Assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing
Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and
Tobacco Use Cessation Strategies
 Measure #313 (NQF 0575): Diabetes Mellitus: Hemoglobin A1c Control (<8%)
 Measure #316: Preventive Care and Screening: Cholesterol – Fasting Low
Density Lipoprotein (LDL) Test Performed AND Risk-Stratified Fasting LDL
http://www.ncdr.com/webncdr/pinnacle/
37
PQRIwizard
https://acc.pqriwizard.com/default.aspx
38
Coronary Artery Disease (CAD) Measures Group
NQF/ PQRS
0067/
6
Measure Title
Coronary Artery Disease (CAD): Antiplatelet Therapy
0074/
197
Coronary Artery Disease (CAD): Lipid Control
0028/
226
Preventive Care and Screening: Tobacco Use: Screening and
Cessation Intervention
N/A/
242
Coronary Artery Disease (CAD): Symptom Management
39
Heart Failure (HF) Measures Group
NQF/ PQRS
Measure Title
0081/
5
Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor
or Angiotensin Receptor Blocker (ARB) Therapy for Left
Ventricular Systolic Dysfunction (LVSD)
0083/
8
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD
0079/
198
Heart Failure: Left Ventricular Ejection Fraction (LVEF)
Assessment
0028/
226
Preventive Care and Screening: Tobacco Use: Screening and
Cessation Intervention
40
Coronary Artery Bypass Graft (CABG) Measures Group
NQF/ PQRS
Measure Title
0134/
43
Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in
Patients with Isolated CABG Surgery
0236/
44
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with
Isolated CABG Surgery
Coronary Artery Bypass Graft (CABG): Prolonged Intubation
0129/
164
0130/
165
0131/
166
0114/
167
0115/
168
0116/
169
0117/
170
0118/
171
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
Coronary Artery Bypass Graft (CABG): Stroke
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge
Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge
Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge
41
Other Qualified Submission Vendors
Qualified 2013 EHR Vendors
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2013QualifiedEHRDirectVendors.pdf
Qualified Data Submission Vendors
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2012QualifiedDSVs.pdf
Qualified Registries
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/2012-Qualified-Registries-Posting-Phase2.pdf
42
Measures in the GPRO Web Interface for 2013












Diabetes: Hemoglobin A1c Poor Control
Heart Failure: Beta-Blocker Therapy for LVSD
Medication Reconciliation
Preventive Care and Screening: Influenza Immunization
Pneumococcal Vaccination Status for Older Adults
Preventive Care and Screening: Breast Cancer Screening
Colorectal Cancer Screening
Coronary Artery Disease: ACE/ ARB Therapy for Diabetes or LVSD
Adult Weight Screening and Follow-Up
Preventive Care and Screening: Screening for Clinical Depression
Coronary Artery Disease: Lipid Control
Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic
43
Measures in the GPRO Web Interface for 2013 cont’d
 Preventive Care and Screening: Tobacco Use Screening and Cessation
Intervention
 Hypertension: Controlling High Blood Pressure
 Ischemic Vascular Disease: Complete Lipid Panel and LDL Control
 Preventive Care and Screening: Screening for High Blood Pressure and
Follow-Up Documented
 Falls: Screening for Fall Risk
 Diabetes Composite: Optimal Diabetes Care: Patients who meet all the
numerator targets of this composite measure:
 A1c < 8.0%
 LDL < 100 mg/dL
 Blood pressure < 140/90 mmHg
 Tobacco non-user
 For patients with a diagnosis of ischemic vascular disease: Daily aspirin use unless
contraindicated
44
Measures in the 2013 Administrative Claims Option:
Process Measures













Follow-Up After Hospitalization for Mental Illness
Use of High-Risk Medications in the Elderly
Lack of Monthly INR Monitoring for Beneficiaries on Warfarin
Use of Spirometry Testing to Diagnose COPD
Statin Therapy for Beneficiaries with Coronary Artery Disease
Lipid Profile for Beneficiaries Who Started Lipid-Lowering Medications
Osteoporosis Management in Women > Who Had Fracture
Dilated Eye Exam for Beneficiaries < 75 with Diabetes
HbA1c Testing for Beneficiaries < 75 with Diabetes
Urine Protein Screening for Beneficiaries < 75 with Diabetes
Lipid Profile for Beneficiaries with Ischemic Vascular Disease
Antidepressant Treatment for Depression
Breast Cancer Screening for Women < 69
45
Measures in the 2013 Administrative Claims Option:
Outcome Measures
 Composite of Acute Prevention Quality Indicators (PQIs)
Bacterial Pneumonia--Admissions per 100,000
UTI--Discharges per 100,000
Dehydration--Admissions per 100,000
 Composite of Chronic Prevention Quality Indicators (PQIs)
Diabetes Composite
 Uncontrolled Diabetes--Discharges per 100,000
 Short-Term Diabetes Complications--Discharges per 100,000
 Long-Term Diabetes Complications--Discharges per 100,000
 Lower-Extremity Amputation for Diabetes--Discharges per 100,000
 COPD--Admissions per 100,000
 Heart Failure--Percent of population with admissions
 All Cause Readmissions
46
Questions?
47
What Now? What Next?
There is still time to participate in PQRS 2012 using
the PQRIwizard
Note:
2012 CAD measures group is different from 2013
More webinars to come in 2013
48
ACC Contacts:
Eileen Hagan
ehagan@acc.org
(202) 375-6475
(800) 253-4636, ext 6475
Brian Whitman
bwhitman@acc.org
(202) 375-6396
(800) 253-4636, ext 6396
Advocacy Division
800-435-9203
49