Overview of PQRS, VM, & the EHR

Incentive Programs

Angela M McCrea, MT, ASCP

Maureen Schwarzer, BSN, RN Lynn Page, BSN, RN

Atlantic Quality innovation network (AQIN)•The Carolinas Center for Medical Excellence CCME) is

part of AQIN, a Quality Innovation Network (QIN)

•We serve as the QIN-Quality Improvement organization

(QIO) for South Carolina–Known as AQIN South Carolina

•The CCME mission: “We help people by improving the

quality of health care”

Objectives• Provide a high level overview of CMS’s incentive

payment programs (PQRS, VM, MU EHR incentive

program).• Review how to earn incentive bonuses under the these

programs.• Review the payments adjustment associated with not

participating in these programs.

What is the Physician Quality Reporting

System (PQRS)?•CMS quality improvement program that uses a combination

of incentive payments and penalties to promote reporting of

quality data.

•The Foundation of Value Based Purchasing

Who is Eligible for PQRS?• Eligible providers who bill under the Medicare Physician

Fee Schedule (part B). •Includes therapist and NP.

•Excludes FQHC, RHC, independent labs or

diagnostic testing centers, etc.

PQRS Overview• 2007, Pay for Reporting • 2014 was the last incentive year of .05%• MOC earn an additional .05%• Calendar Year Reporting • 2014 Reporting Period – 01/01/15 – 02/28/15• Incentive Payments release in the Fall 2015• Penalty-for-Not-Reporting – (Medicare uses the term

Payment Adjustments)

Value Modifier Program•The Value Modifier (VM) program assesses both quality of

care furnished and the cost of that care under the Medicare

Physician Fee Schedule.

•Implementation of the VM is based on participation in the

PQRS Program.

•Medicare Pay for Performance

Value Modifier Program• 2015 - the VM applies to groups of 100+ EP based on

2013 PQRS reporting.

• 2016 – the VM applies to 10 – 99 EPs based on 2014

PQRS reporting.

• 2017 – the VM applies to solo practitioners and groups

of two or more EPs based on 2015 PQRS reporting.

VBM 2016 (2014 Year of Care) Groups of 10-99

Submit PQRS

NO

YES

2%VBM

Adjustment

VBM Quality Tiering

Groups of 100 or More

Low Quality

Avg Quality

High Quality

0 +1% +2% Low Cost

-1% 0 +1% Avg Cost

-2% -1% 0 High Cost

Groups of 10 - 99

Low Quality

Avg Quality

High Quality

0 +1% +2% Low Cost

0 0 +1% Avg Cost

0 0 0 High Cost

2%PQRS

Adjustment

On Top Of

For the 2016 value modifier, quality tiering is mandatory for groups with 10 or more EPs.

Physicians in groups of 10 to 99 EPs will be subject to an upward or neutral payment adjustment,

VBM 2017 (2015 Year of Care)

Submit PQRS

YES

VBM Quality Tiering

Groups of 10 or More

Low Quality

Avg Quality

High Quality

0 +1% +4% Low Cost

-2% 0 +2% Avg Cost

-4% -2% 0 High Cost

Groups of 1 - 9

Low Quality

Avg Quality

High Quality

0 +1% +2% Low Cost

0 0 +1% Avg Cost

0 0 0 High Cost

< 10

For the 2017 value modifier, quality tiering is mandatory for all EPs

Physicians in groups of 1 to 9 EPs will be subject to an upward or neutral payment adjustment,

GroupSize

2% PQRS Payment

AdjustmentNO

4% V BM Payment

Adjustment

2% VBM Payment

Adjustment

> 10

Composite Scores

Quality Score

Based off PQRS measures reported

Cost Score

a. Diabetes

b. COPD

c. Coronary Artery Disease

d. Heart Failure

Quality Resource Use Reports (QRURs)

Provides physician with their performance scores used in

calculating the value-based payment modifier (VBM).

Provides physicians with comparative information about the

quality and cost of the care delivered to their Medicare fee-

for-service patients.

Physician Compare Website

Information about physicians and other healthcare

professionals who satisfactorily participate in CMS

incentive payment programs.

EHR Incentive Programs

The Medicare and Medicaid EHR Incentive Programs

provide incentive payments to eligible professionals (EPs)

who demonstrate meaningful use of electronic health records

(EHRs).

EPs must demonstrate meaningful use and submit measures

for Stage 1, Stage 2, and Stage 3.

MU Goals

Use certified EHR technology to improve quality, safety,

efficiency, and reduce health disparities.

Engage patients and families in their health care.

Improve care coordination.

Improve population and public health.

Maintain privacy and security.

MU Payment Adjustments

2015 for Medicare EPs who decide not to participate in the

program.

No payment adjustments for providers who are only eligible

for the Medicaid program.

It’s not just PQRS Anymore

Payment adjustments for not participating in CMS Incentive Programs

Year CY Data PQRS Value Modifer Meaningful Use

Total Posible Payment

Adjustments2015 2013 -1.5 -1.0 -1.0 -3.5

Groups of 100+ 2016 2014 -2.0 -2.0 -2.0 -6.0

Groups of 10+ 2017 2015 -2.0 -2.0 3.0 – 5%** TBD

Groups of <10 (each year 2017 2015 -2.0 -4.0 3.0 – 5%** TBD

Groups of > 10 (each year ** Penalty amount could increase up to 5% depending on meaningful use success rates

(800) 922-3089 • (803) 212-7500 • www.atlanticquality.org

Questions?

This material was prepared by the Atlantic Quality Innovation Network (AQIN), the Medicare Quality Innovation Network-Quality Improvement Organization for New York State,

South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

Services. The contents do not necessarily reflect CMS policy. 11SOW-AQINSC- TskB.4- 15 03

Sources• http://

www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

• MLN Connects™ National Provider Call: “CY 2014 Medicare Physician Fee Schedule (PFS) Final Rule,” December 17, 2013. http://www.cms.gov/Outreach-and-Education/Outreach/NPC/ National-Provider-Calls-and-Events-Items/2013-12-17-PFS-NPC.html

• CMS Webinar: “CMS 2014 Physician Quality Reporting System (PQRS) Webinar”, January 7, 2014. http://www.qipa.org/getattachment/Materials/Prevention/2014-PQRS-Presentation-010714.pdf.aspx

• CMS Webinar: “2014 Value Modifier,” January 14 and 16, 2014. https://webinar.cms.hhs.gov/p1cx2h95k68