Overview of Medicare’s Regulatory Programs

Bob JasakDeputy Director, Regulatory & Quality Affairs

American College of Surgeons

Data Collection

Pay-For-Reporting

Public Reporting

Pay-for-Performance/Value-Based Purchasing

Overview

Overview

Physician Compare(Public Reporting)

PQRS(Pay-for-Reporting)

CLAIMS EHRs RegistriesQCDRs(Qualified

Clinical Data Registries)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

Physician Compare(Public Reporting)

• Group Practice Performance Rates on quality measures (2014 target)

• Patient Experience of Care Data: (2014 target)

• Specialty Society Specific Data

• Individual performance data (target 2015)

Physician Compare(Public Reporting)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

Bonuses:

• Beginning in 2015

• Budget neutral program (amounts of bonuses unknown until penalties determined)

Penalties:

• 2015: -2% for non-PQRS participants (combined VBPM and PQRS penalty)

• 2015: up to -1% even if PQRS compliant

• 2016: -4% for non-PQRS participants • 2016: up to -2 percent even if PQRS compliant

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

Physician Compare(Public Reporting)

PQRS(Pay-for-Reporting)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

PQRS(Pay-for-Reporting)

Incentives

Bonuses Expiring

Separate Penalties (increasing to 2%)Quality Measures

Specific Menu of Measures

Heavy favor toward NQF-endorsement

Year long submission process

Predominately Process Measures

Limited Measures for some Specialties

Low Participation

All EPs: 32%

General Surgery: 20%

Vascular: 32.4%

Colon/Rectal: 28.2%

Increasing Requirements

Elimination of “low bar” reporting mechanisms to avoid penalty

Increasing from 3 to 9 individual measures

Additional Individual Measures of Note

Measure Name NQS Domain

Participation in a Systematic Clinical Database Registry That Includes Consensus Endorsed Quality Measures

Communication and Care Coordination

Patient-Centered Surgical Risk Assessment and Communication (Patient-Specific Risk Calculator)

Person and Caregiver-Centered Experience and Outcomes

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Community/Population Health

Physician Compare(Public Reporting)

PQRS(Pay-for-Reporting)

CLAIMS EHRs RegistriesQCDRs(Qualified

Clinical Data Registries)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

CLAIMS

Future of Claims-Based Reporting:

• Limited to mostly process measures

• High administrative burden

• 2014: CMS eliminated the claims-based reporting option for reporting Measures Groups

• CMS has been explicit about desire to eliminate this as an option

Physician Compare(Public Reporting)

PQRS(Pay-for-Reporting)

CLAIMS EHRs RegistriesQCDRs(Qualified

Clinical Data Registries)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

EHRs

EHR Quality Measure Reporting

• Lower administrative burden

• Only 63 PQRS approved EHR reportable quality measures (2014)

• None of the measures in the Perioperative or General Surgery Measures Groups is specified for EHR-based PQRS reporting

• Pilot project to streamline PQRS EHR Reporting and EHR Meaningful Use Reporting- but without applicable measures there is nothing to streamline

• ACS work with Epic

Physician Compare(Public Reporting)

PQRS(Pay-for-Reporting)

CLAIMS EHRs RegistriesQCDRs(Qualified

Clinical Data Registries)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

Registries

ACS Surgeon Specific Registry

• Approved for participation in PQRS beginning in 2012

• Online for 2013 Reporting

• Also built on platform collecting information for ABS MOC and Caselog

• Current Limitations on this point-of-entry:• Limited to collecting information on PQRS approved measures• Only available for an individual to report on Measures Groups (which only requires reporting the

Measures Group across 20 patients (including 11 Medicare patients)• Not currently available for group practice reporting (unless each surgeon reports separately as an

individual• Not available to report individual measures outside of a measure group (which in 2014 will require

reporting a measure across 50% of patients who are eligible to be reported on for a given measure)

Physician Compare(Public Reporting)

PQRS(Pay-for-Reporting)

RegistriesQCDRs(Qualified

Clinical Data Registries)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)

QCDRs(Qualified

Clinical Data Registries)

QCDR Quick Facts

• Concept mandated by Congress (at ACS and others’ requests) in the “Fiscal Cliff Bill” to be implemented by January 1, 2015

• Theory was to provide a PQRS bypass for physicians participating in clinical registries that provide more value and quality improvement opportunities than the measures currently approved in PQRS.

• ACS responded to early 2013 CMS request for comments and again in official proposed rule

• CMS qualification criteria finalized in CY 2014 Physician Fee Schedule Final Rule (released by CMS on November 27, 2013)

QCDRs(Qualified

Clinical Data Registries)

QCDR Criteria

• Only available for individual physician participation (no group practice reporting) and must be physician specific

• Measure Sources: CG-CAHPS, NQF-endorsed measures, measures used by boards or specialty societies, and measures used in a quality collaborative

• Report on at least 9 measures (across 3 National Quality Strategy domains)

• Report on at least 50% of patients eligible for each measure selected

• Report on at least 1 outcome measure (example: unplanned readmission)

• At least quarterly feedback reports

Physician Compare(Public Reporting)

PQRS(Pay-for-Reporting)

CLAIMS EHRs RegistriesQCDRs(Qualified

Clinical Data Registries)

Value-Based Payment Modifier

(Value-Based Purchasing/Pay-for-Performance)