Disclaimer This webinar may be recorded. This webinar ... · • Clinical quality measures, or CQMs, are tools that help measure and track the quality of healthcare services provided

DisclaimerThis webinar may be recorded. This webinar presents a sampling of best practices and overviews, generalities, and some laws. This should not be used as legal advice. Itentive recognizes that there is not a “one size fits

all” solution for the ideas expressed in this webinar; we invite you to follow up directly with us for more personalized information as it pertains

to your specific practice and issues.

Thank you, and enjoy the webinar.

About Us

Our passion is to provide solutions for our healthcare provider partners which help them improve patient care, enhance the patient experience and maintain a financially healthy practice.

Since 2003 we have specialized in NextGen Healthcare services including:

• Consulting

• Hosting

• Customization

• And productivity tools such as ChartGuard® and RefundManager®

Upcoming Webinars:

3 part series:

Improving NextGen Efficiencies with Itentive Products and Services

• May 18th – iCare Server Health

• June 1st – Patient Portal Auto Enrollment

• June 15th – Unapplied Utilities and Balance Control Scripting

Quality Care Program Reporting: So Many Choices,

So Little Time

Introductions

Kathy Thompson

Managing Consultant

Cindi Kincade

Vice President, Consulting Solutions

Lindsey Lanning

Healthcare Informatics Coordinator

Quality Care Program Reporting: So Many Choices,

So Little Time

Today’s Webinar

• Introduction to Quality Reporting

• EHR Incentive Program

Meaningful Use

Clinical Quality Measures (CQMs)

• Physician Quality Reporting System (PQRS)

• Value Modifier (VM)

• How they all go together

Introduction to Quality Reporting

Improving the quality of healthcare is a core function of the Centers for Medicare & Medicaid Services (CMS).

For over a decade, the U.S. Department of Health and Human Services (HHS) and CMS have launched quality initiatives to improve quality healthcare for all Americans through accountability and public disclosure.

CMS supports healthcare providers in achieving better outcomes for beneficiaries and communities by driving care improvement through quality initiatives.

What is Quality Reporting?

Healthcare providers report quality measures to CMS about healthcare services provided to Medicare beneficiaries.

Quality measures are tools that help CMS assess various aspects of care such as health outcomes, patient perceptions, and organizational structure.

The measures reported by healthcare professionals give the ability to provide high-quality healthcare and relate to the goal of effective, safe, efficient, patient-centered, equitable, and timely care.

How Does Quality Reporting Affect You?

By reporting quality measures, clinicians can:

• Assess the quality of care they provide to their patients

• Quantify how often they are meeting a particular quality metric

• View their published quality metrics alongside that of their peers on the Physician Compare website

• Avoid Physician Quality Reporting System (PQRS) negative payment adjustments

• Receive Medicare Electronic Health Record (EHR) Incentive Program incentive payments and avoid the program’s payment adjustments

• Avoid the automatic downward Value Modifier payment adjustment and be eligible for an upward, neutral, or downward payment adjustment based on performance

What EPs Need to Know in 2016• MACRA condenses quality reporting into one program – 2016 is a year

of transition from PQRS, VM, and MU which all sunset and then MIPS and APM take over

• To clarify, 2016 is the final year PQRS, VM, and MU will all be individual programs with individual payment adjustments. These programs will sunset on December 31, 2018 with new incentives through MIPS and APMS on Jan 1, 2019

• Since 2018 is the final year for payment adjustment for these individual programs its important to note 2016 is the performance year to determine payment adjustment in 2018

Defining An EP Across Quality Reporting Programs

EHR Incentive Program

Meaningful UsePart I

of EHR Incentive Program

Meaningful Use Updates

• Failure to successfully attest would result in a negative 3% payment adjustment in 2018

• We’ve already covered everything you need to know regarding MU in previous webinars. Two topics that have been updated since we last talked are:

Hardship Exception Deadline

Alternate exclusions for public health reporting

Hardship Exception Application

• Eligible professionals who can participate in either the Medicare or Medicaid EHR Incentive Programs will be subject to payment adjustments unless they are meaningful users under one of the EHR Incentive Programs.

• Eligible professionals may apply for hardship exceptions to avoid these payment adjustments.

• The application is now available on CMS’ website with instructions.

• This application will allow groups of healthcare providers to apply for a hardship exception together instead of each doctor applying individually.

• The deadline to submit a hardship application has been extended to July 1, 2016

Extreme and Uncontrollable Circumstances

CMS Public Health Reporting FAQs

NextGen On Alternate Exclusion

“NextGen Healthcare always errs on the side of caution when it comes to advising clients on regulatory requirements. While these FAQs seem to signal the intent of CMS to allow providers to claim exclusions for both measure #2 and measure #3, NextGen Healthcare urges clients to carefully review the FAQs linked to this message.”

“…we recommend limiting the use of the exclusion to specialties for which there is no available registry with applicable clinical measures, and/or situations where software upgrades or interfaces pose a challenge.”

Clinical Quality Measures

Part II of EHR Incentive Program

CQM Basics

• Clinical quality measures, or CQMs, are tools that help measure and track the quality of healthcare services provided by eligible professionals, eligible hospitals and critical access hospitals (CAHs) within our healthcare system. These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality healthcare. CQMs measure many aspects of patient care.

• To participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and receive an incentive payment, providers are required to submit CQM data from certified EHR technology.

What Do You Report?

• You must select and report 9 from a list of 64 approved CQMs over 3 different domains for the EHR Incentive Programs. The 6 domains are:

1. Patient and Family Engagement

2. Patient Safety

3. Care Coordination

4. Population/Public Health

5. Efficient Use of Healthcare Resources

6. Clinical Process/Effectiveness

• CMS has a recommended core set for adults and children

Adult Recommended Core Measures

• Controlling High Blood Pressure

• Use of High-Risk Medications in the Elderly

• Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

• Use of Imaging Studies for Low Back Pain

• Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

• Documentation of Current Medications in the Medical Record

• Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

• Closing the referral loop: receipt of specialist report

• Functional status assessment for complex chronic conditions

CQM Reporting Options

• Eligible professionals and eligible hospitals can report clinical quality measures (CQMs) several ways. Reporting options are listed below.

• Options that only apply for the EHR Incentive Program:

Option 1: Attest to CQMs through the EHR Registration & Attestation System

Option 2: eReport CQMs through Physician Quality Reporting System (PQRS) Portal

• Options that Align with Other Quality Programs:

Option 3: Report individual eligible professionals’ CQMs through PQRS Portal

Option 4: Report group’s CQMs through PQRS Portal

Option 5: Report group’s CQMs through Pioneer ACO participation or Comprehensive Primary Care Initiative participation

Aligned Reporting

• To reduce the burden on providers participating in multiple quality reporting programs, CMS has aligned several reporting requirements for those reporting electronically using an EHR.

• The criteria for satisfactory reporting under PQRS using an EHR are aligned with the Medicare EHR Incentive Program.

• Satisfactory reporting of PQRS EHR quality measures will allow EPs and PQRS group practices to qualify for the clinical quality measures (CQM) component of Meaningful Use.

• If it is your first year of meaningful use your reporting period is 90 days for both PQRS and CQMs only for aligned reporting. If it is beyond your first year for meaningful use reporting is one full year for both PQRS and MU. If you are not participating in aligned reporting PQRS reporting is always a full year.

Physician Quality Reporting System

PQRS

PQRS

• The Physician Quality Reporting System (PQRS) is a voluntary quality reporting program that applies a negative payment adjustment to promote the reporting of quality information by eligible professionals (EPs), and group practices.

• Those who do not satisfactorily report data on quality measures for covered Medicare Physician Fee Schedule (MPFS) services furnished to Medicare Part B beneficiaries will be subject to a negative payment adjustment under PQRS. Medicare Part C–Medicare Advantage beneficiaries are not included.

2016 PQRS Updates

• There are a total of 281 measures in the PQRS measure set, 18 measures in the GPRO Web Interface, and 23 cross-cutting measures

• For those that are using the registry reporting option and are using measure groups, 3 new groups have been added: Multiple Chronic Conditions; Cardiovascular Prevention; and Diabetic Retinopathy

• New this year is the Qualified Clinical Data Registry reporting option, previously only available to individuals is now available for group reporting

• 2018 PQRS payment adjustment (based off of the 2016 reporting year) is the last adjustment that will be issued under PQRS

Starting in 2019, adjustments for quality reporting will be made under MIPS

PQRS: Getting Started

• Step 1: Determine Eligibility

• Step 2: Determine if you want to participate as an individual EP or as part of a group practice

• Step 3: Choose reporting method

• Step 4: Choose quality measures

• Step 5: Be aware of payment adjustment information

• Step 6: Review PQRS timeline

Step 1: Determine Eligibility

Find out whether you are eligible to participate in 2016 PQRS to avoid the 2018 negative payment adjustment. View CMS’ PQRS List of Eligible Professionals to determine your eligibility.

Step 2: Determine Participation

Determine whether you want to participate in PQRS as an individual eligible professional (EP) or as part of a group practice

• Individual: Individual EPs are identified on claims by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN).

• Group Practice: A group practice under 2016 PQRS is defined as a single Tax Identification Number (TIN) with 2 or more individual EPs who have reassigned their billing rights to the TIN. Group practices can register to participate in PQRS via the group practice reporting option (GPRO) to be analyzed at the group (TIN) level. Note that group practices participating via GPRO are referred to as PQRS group practices.

Step 3: Choose Reporting Method

• Reporting electronically using an electronic health record (EHR)

• Qualified Registry

• Qualified Clinical Data Registry (QCDR)

• PQRS group practice via GPRO Web Interface

• CMS-Certified Survey Vendor

• Claims- based reporting

Reporters may choose from the following reporting mechanisms to submit their quality data:

Universal Reporting Criteria• Report on at least 9 individual measures covering at least 3

NQS domains for at least 50% of the EP’s Medicare Part B FFS patients

Measures with a 0% performance rate will not be counted.

• When submitting CQMs via Meaningful Use attestation 0 numerator/0 denominator is acceptable. When submitting PQRS that is not the case. Data for both numerator and denominator need to be submitted and at best at high numerator values.

• Individual EPs or PQRS group practices are also required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter.

• Measure-applicability validation (MAV) process will be used if a provider reports less than 9 measures to determine if the EP could have reported 9 measures covering at least 3 domains.

• Reporting period is 1 year

Individual – Claims Reporting

• Based on claims data

• Report quality data codes listed in the individual measure you have selected on Medicare part B claims

• Make sure to report the QDC on each eligible claim – failure to do so will be a missed opportunity and can’t resubmit

Individual – Qualified Registry Reporting

• Can report either individual measures or measures groups

This is the only reporting method where measures groups can be used

• Registries may now attest that quality measure results and all associated data are accurate via web (in lieu of written attestation statement)

• NextGen is a qualified registry

Individual – CEHRT Reporting

For PQRS EHR Reporting CMS requires 2014 CEHRT. NextGenEHR is 2014 CEHRT. HQM is a data submission vendor for PQRS EHR reporting extracting quality measures data from CEHRT and submitting to CMS. As required by CMS, HQM uses the most recent eCQMsJuly 2014 version for EHR reporting.

Individual – Qualified Clinical Data Registry Reporting

A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. A QCDR will complete the collection and submission of PQRS quality measures data on behalf of EPs.

Group – Qualified Registry Reporting

• Group practices will be able to register for the PQRS GPRO between April 1, 2016 and June 30, 2016

• Size of group will determine the GPRO options

• Size is the total number of practitioners under one TIN in a group

Group – CEHRT Reporting

Group – Qualified Clinical Data Registry Reporting

Group – GPRO Web Interface Reporting

• Beneficiary sample size remains 248 beneficiaries for groups of all sizes

• If there are less than 248 patients in the group practice, group would report on 100% of assigned beneficiaries

• If a group does not have any Medicare patients for any of the GPRO measures in the Web Interface, another reporting option must be chosen

• 18 measures have been finalized for GPRO web interface for 2016

• If a practice picks GPRO then they should be reporting on all 18 measures

Step 4: Choose Quality Measures• Quality measures are indicators of the quality of care provided by

physicians.

• Individual EPs and PQRS group practices should choose at least 9 individual measures across 3 NQS domains OR 1 measures group as an option to report on measures to CMS

A measures group is defined as a subset of 6 or more PQRS measures that have a particular clinical condition or focus in common

All applicable measures within the group must be reported for all patients in the sample seen by the EP during the reporting period

• Individual measures consist of two major components: denominators and numerators

• Calculating the PQRS reporting rate (dividing the number or reported numerator outcomes by denominator-eligible encounters) identifies the percentage of a defined patient population that was reported for the measure

Measure Selection

Step 1: Review

Measures

•Review the 2016 Physician Quality Reporting System

(PQRS) Measures List, available on the Measures Codes section of the CMS PQRS website, to determine

which measures, associated domains, and reporting

mechanism(s) may be of interest and applicable to the EP or group practice participating in PQRS via

GPRO.

Step 2: Consider Certain Factors

•Consider clinical conditions

usually treated, types of care provided, settings where care

is delivered, and quality

improvement goals.

Step 3: Review

Specifications

•After making a selection of

potential measures, review the specifications for the selected

reporting mechanism for each

measure under consideration. Select those measures that

apply to services most

frequently provided to Medicare patients by the EP or PQRS

group practice.

The types of quality measures reported under PQRS change from year to year. The measures generally vary by specialty, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health. They can also vary by reporting method.

Inverse Quality Measures

Most measures you want to have a high percentage to show a high performance rate, but there are inverse measures where the lower the numerator the better the performance. Therefore if you have a 0 for an inverse measure it would be considered high performance, and 100% would indicate poor performance. The table below shows some of the inverse measures to look out for:

Program Measure # Description

PQRS INDV 001 Diabetes: Hemoglobin A1c Poor Control

PQRS INDV 238 Use of High-Risk Medications in the Elderly

PQRS INDV 331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis

PQRS PQRS 001 Diabetes: Hemoglobin A1c Poor Control

CMS 75 v3 Children Who Have Dental Decay or Cavities

CMS 122 v3 Diabetes: Hemoglobin A1c Poor Control

CMS 156 v3 Use of High-Risk Medications in the Elderly

CMS 166 v3 Low back pain

Specialty Measure Sets

Cardiology

Emergency medicine

Gastroenterology

Family Practice

Internal Medicine

Multiple Chronic Conditions

OB/Gynecology

Oncology/Hematology

Ophthalmology

• CMS is collaborating with specialty societies to ensure that the measures represented within Specialty Measure Sets accurately illustrate measures associated within a particular clinical area.

These are suggested not required

• 17 specialties listed have a suggested measure set to aid an EP in these fields.

• 5 new sets in orange were added for 2016 PQRS

Pathology

Radiology

Surgery

Dermatology

PT/OT

Mental Health

Hospitalist

Urology

Step 5: Be Aware of Payment Adjustment Information

Step 6: Review PQRS Timeline

CAHPS for PQRS

• A CMS-certified survey vendor is a new reporting mechanism that began in 2014 and is available to group practices participating in the PQRS Group Practice Reporting Option (GPRO). This reporting mechanism is available to group practices of 2 or more eligible professionals (EPs) wishing to supplement their 2016 PQRS reporting with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

• CAHPS for group practices participating in PQRS GPRO was developed to collect information about patient experience and care within that group practice.

• Although required for group practices of 100 or more EPs, this is an extra reporting option for groups with 2-99 EPs and for EHR and registry reporting.

CAHPS Survey

• The CAHPS for PQRS Survey measures 12 key domains of beneficiaries’ experiences of care that we refer to as summary survey measures (SSMs). The CMS-certified survey vendor will administer and collect 12 SSMs modules on behalf of the group practice’s patients. These results may be posted on the CMS Physician Compare website.

• The 12 summary survey modules for use with the PQRS program include those listed below:

Health Status/Functional Status Courteous and Helpful Office Staff Care Coordination Between Visit Communication Helping You to Take Medication as

Directed Stewardship of Patient Resources

Getting Timely Care, Appointments and Information

How Well Providers Communicate Patient’s Rating of Provider Access to Specialists Health Promotion and Education Shared Decision Making

CAHPS Reporting• The CAHPS for

PQRS survey is equal to 3 individual measures and 1 NQS domain. So if reporting CAHPS only 6 measures over 2 domains will be required in addition to CAHPS.

• Beginning in 2016, the CAHPS for PQRS survey will have 4 options for group practices to satisfactorily report:

CAHPS and VM• Groups with 2+ Eligible Professionals (EPs) may elect to have

CAHPS for PQRS included in their VM quality composite calculation.

• The quality of care composite score determines one-half of the VM calculation. The CAHPS for PQRS Survey falls into one of six domains that contribute to the quality of care composite score.

• 11 of the 12 SSMs contribute to the Person and Caregiver-Centered Experience and Outcomes domain in the quality of care composite

PQRS and VM

• For PQRS, an EP is only required to submit nine measures covering three National Quality Strategy domains. If an EP chooses to submit more than 9 measures special care should be taken to avoid reporting measures showing poor performance, thereby subjecting providers to negative payment adjustments under the value-based modifier.

• A potential downward adjustment under Value Based Modifier (VM) quality-tieringapplies to all providers this year.

The Value Modifier

VM

Value Modifier Basics• The VM assesses the quality of care and the cost of care

furnished to Medicare Fee-for-Service (FFS) beneficiaries during a performance period

• The VM is an adjustment made on a per-claim basis to Medicare payments for items and services furnished under the Medicare Physician Fee Schedule (MPFS)

• The VM is applied at the Taxpayer Identification Number (TIN) level

• Additional reporting outside of the PQRS is not required under the VM

• CMS began phase-in of the VM in 2015 based on 2013 reporting for groups of 100+ EP. Phase-in will be completed in 2017 when the VM will be applied to solo practitioners and groups of two or more EPs. Implementation of the VM is based in part on participation in Physician Quality Reporting System (PQRS).

Phased- In Approach to Payment Adjustment

• In CY 2018, Medicare will apply the Value Modifier to all physicians and non-physicians who are solo practitioners or in groups of 2 or more EPs. This policy expands the application of the Value Modifier to include all non-physician EPs.

• In CY 2017, Medicare will apply the Value Modifier to physician payments under the Medicare PFS for physician solo practitioners and physicians in groups of 2 or more EPs

• In CY 2016, Medicare will apply the Value Modifier to payments under the Medicare PFS for physicians in groups of 10 or more EPs.

• Beginning in calendar year (CY) 2015, Medicare applies the Value Modifier to payment under the Medicare PFS for physicians in groups of 100 or more EPs.

Please Note: VM is applied two years after actual performance year

2018 VM: What You Need to Know• 2016 is the performance year for application of the 2018 VM,

and 2018 is the final year for VM

• Applies to all physicians and also to:

Physician Assistants (PAs)

Nurse Practitioners (NPs)

Clinical Nurse Specialists (CNSs)

Certified Registered Nurse Anesthetists (CRNAs)

• In groups of 2+ EPs and those who are solo practitioners, as identified by their TIN

• Quality-tiering is mandatory; TINS consisting of non-physician EPs ONLY will be held harmless from downward payment adjustments (if they successfully report PQRS measures); all other TINS will be subject to upward, neutral, and downward payment adjustments

How the VM Works?

Quality Measures Used to Calculate 2018 VM Under Quality-Tiering

Quality Measures:

• Groups with 2 or more EPs: Measures reported through the PQRS Group Practice Reporting Option (GPRO) selected by the group OR individual PQRS measures reported by at least 50% of the EPs in the group (50% threshold option)

• Physician solo practitioners: Individual PQRS measures reported by the solo practitioner

• Three claims-based outcome measures: All-Cause Hospital Readmissions, Composite of Preventable Hospitalizations for Acute Conditions, and Composite of Preventable Hospitalizations for Chronic Conditions

• CAHPS for PQRS survey measures (Applicable only for groups that elected to use their 2016 CAHPS results in the calculation of their 2018 VM)

Quality-Tiering

The VM is calculated for a group using a quality composite score and a cost composite score.

The quality composite scores are derived from six quality domain scores; each domain score is based on performance scores for PQRS measures reported, using its associated domain. Quality-tiering will determine if group performance is statistically better, the same, or worse than the national mean, based on standard deviation calculations.

Quality-Tiering• Qualty-tiering approach for 2018 VM for physicians, PAs, NPs, CNSs, &

CRNAs in Groups with 10+ EPs

• Qualty-tiering approach for 2018 VM for physicians, PAs, NPs, CNSs, & CRNAs in Groups with 2-9 EPs & Solo Practitioners

• Qualty-tiering approach for 2018 VM for PAs, NPs, CNSs, & CRNAs who are Solo Practitioners or in Groups consisting of Non-Physician EPs only

VM and Other Initiatives

CMS provides specific policies through rulemaking regarding application of the Value Modifier to TINs participating in Medicare Shared Savings Program ACOs, Pioneer ACOs, the CPC initiative, and other similar initiatives.

How It All Relates

2018 Payment Adjustments-Physicians

2018 Payment Adjustments-Practitioners

2018 Payment Adjustments-Practitioners and Therapists

How Does 2016 PQRS Participation Affect VM in 2018?

This flowchart serves as a guide to individual eligible professionals wishing to report quality measures one time during the 2015 program year in order to avoid the 2017 Physician Quality Reporting System (PQRS) negative payment adjustment, satisfy the clinical quality measure (CQM) component of the Medicare Electronic Health Record (EHR) Incentive Program, and satisfy requirements for the 2017 Value-Based Payment Modifier (VM).

This flowchart serves as a guide to group practices wishing to report quality measures one time during the 2015 program year in order to avoid the Physician Quality Reporting System (PQRS) 2017 negative payment adjustment, satisfy the clinical quality measure (CQM) component of the Electronic Health Record (EHR) Incentive Program, and satisfy requirements for the 2017 Value-Based Payment Modifier (VM).

CMS Resources

• For PQRS Help

QualityNet Help Desk

866-288-8912

• For VM Help

Physician Value Help Desk

888-734-6433, press 3

• For MU Help

888-734-6433

Uncertain Where Your Practice Stands?

Let Itentive help:

• By assessing your current readiness

• Providing recommendations

• Implementation of new processes and procedures

Next Steps

• Visit us Itentive.com

• Sign-up for our informative webinars and blog

• Consider our 3-day, fixed price on-site consultations:

Clinical Workflow

Revenue Cycle and Front Office

Technology and Performance

• Test Drive our Products

Questions

• Lindsey Lanning

Healthcare Informatics Coordinator

[email protected]

224-220-5621

• Cindi Kincade

Vice President, Client Solutions

[email protected]

224-220-5575

Thank you