2016 PQRS and VBMfor Pathology

PERFORMANCE THAT MATTERS

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Table of Contents

Summary 1PQRS 1 Definitions 2 PQRSBasics 2 MAV 2 Claims-basedvs.Registry-based Reporting 3PathologyPQRSmeasuresfor2016 3Value-BasedPaymentModifier(VBM) 4

SUMMARY

PathologyPQRSreportingrequirementsfor2016aresimilartothosein2015.If2016PQRSisnotre-ported,ornotreportedaccurately(acommonproblem),pathologistsingroupsof10ormoreproviderswillseea-6%adjustment toMedicarepayments in2018.Those insmallergroupswillseea-4%adjustment.

ThereareseveralwaystoreportPQRSmeasuresbutaregistryisstronglyrecommendedforpathologists,sinceCMSisphasingoutclaims-basedreportingandEHRreportingusuallyisn’tpractical.Mostimportant,however,aregistryapproachcaneliminatetheriskofthe-4%to-6%penalty.

PQRSresultsalsoshowupon“PhysicianCompare”andproposedchangeswillmapPQRSperformanceintoa5starratingsystemforconsumersbycomparingresultsacrossproviders.

PQRS

ToavoidpenaltiesfornotreportingPQRSandVBM,pathologistsmustmeettheBasic Reporting Requirements: -Individualsorgroupswhoreportindividualmeasuresmustcompleteninemeasuresforat

least50%of theeligibledenominator,andthosemeasuresmust include three National Quality Strategy Domains.

-Oneofthosemeasuresmustbe“cross-cutting,”asdefinedbyMedicare:apopulation-widemeasurerequiredforproviderswhoseeatleastonepatientina“face-to-face”encounter.

However,theserequirementsdonotmatchwellwithmanypathologistssincenocross-cuttingmeasuresapplyandthereisamaximumof8measuresavailabletomostpathologygroups(seebelow).Asaresult,pathologistsaresubjecttothe“MAV”audit,describedbelow.

PQRSissettoexpireafterthisyear(the2016PQRSreportingyearaffects2018Medicarepayments)

AT A GLANCE:

-PQRS/VBMpenaltiesare-4%to-6%

-Registryreportingisstronglyrecommended

-2016measuresforpathologyareunchangedfrom2015

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andbereplacedbytheMerit-BasedIncentivePaymentSystem(MIPS)in2017(whichwillaffect2019payments).MIPSismandatedbyMACRA(theMedicareAccessandCHIPReauthorizationActof2015).MACRA eliminated the annual SGR payment reductions and, among other items, replaces PQRS,MeaningfulUseandtheVBM(ValueBasedModifier)programs.

However,whilethenamePQRSwilleventuallydisappear,thequalityreportingcomponentofMIPSwillbeheavilybasedonPQRS,meaningthatworkdonetocomplywithPQRSwilltransitionintotheMIPS environment. Furthermore, non-reporting penalties increase with MIPS, adding additionalincentivetohavegoodqualityreportinginplace.

DEFINITIONS

Thefollowingabbreviationsareusedinthispaper,consistentwithCMSterminology:EP–EligibleprofessionalGP–GroupPracticeEHR–ElectronicHealthRecordQCDR–QualifiedClinicalDataRegistry

PQRSBASICS

-ThereisnoincentivepaymentforreportingPQRSmeasuresin2016.However,bonuspaymentsmaybeearnedviatheValueBasedModifierProgram(whichstartswithPQRSdata).

-EPswhodonotsuccessfullyparticipatein2016willreceivea-2%PQRSpaymentadjustmentanda-2%or-4%VBMadjustmentontheir2018Medicarepayments.

-While therearehundredsofPQRSmeasures,only8 typicallyapply topathology,asdescribedbelow.

-PQRScanbereportedviaclaims,registry,EHR,QCDRorGPRO(groupsonly).Thefirst4 methods are typically used for individual EPs, even when part of a group. However, claims-based reporting is being phased out by CMS so it is recommended to use one of the other methods.

-Foratleast50%ofMedicarepatients,CMSrequiresreportingon9measures,atleastoneofwhichisaso-called“cross-cuttingmeasure”.Butmanyproviders,includingpathologists,donothave9applicablemeasures,inwhichcasetheMAVapplies(seebelow).

It is very important to note that measures are defined on a measure-by-measure basis, not by specialty.Thatisbecausetwoprovidersinthesamespecialtymaynotperformthesameservices.

MAVForthosewhoreportfewerthanninemeasuresorfewerthanthreedomains,theMeasureApplicabilityValidation(MAV)Auditapplies.MedicarecomparesyourPQRSdatatoitsmeasurespecificationstoidentifyothermeasureswhichcouldhavebeenreported,butwerenot.Whilethemeasurestheyidentifymaynotseemrelevant,iftheymeetMedicare’sdefinition,theydirectlyaffectyourPQRScompliance.

PERFORMANCE THAT MATTERS

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Claims-based vs. Registry-based Reporting

Inthispaper,wefocusprimarilyonclaimsandregistry-basedreportingsincemanypathologygroupsdonothavetheabilitytouseanEHRforEHR-basedreporting(andmanyEHRsdonothavethenecessaryCEHRTcertification to report themeasures).QCDR isabroader topicas that reportingmethodtypicallyrequiresadditionalqualitymeasuresbeyondthoseinPQRS.

With PQRS penalties now significant (-4% to -6% when combined with the VBM penalty), registryreporting is becoming almost essential. This is because claims-based reporting doesn’t provideanyMAVinsight,untilitistoolate.Furthermore,theprocesstoreviewclaims-filedPQRSdataiscumbersome,atbest.In2015,thosewhousedclaims-basedreportingspentcountlesshourstryingtodeterminewhatdataCMSactuallyhad.Andevenwhenbaddatawasappealed,penaltieswerestillapplied.Registryreportingprovidesongoingfeedbackand,importantly,providesfeedbackonhowanEPorgroupwillfareinaMAVAudit.Inaddition,witharegistry,PQRSdatacanbeupdatedorevenreplaced,something that is impossiblewithclaims-basedfiling.Asaresult,usingaregistryeliminatesMAVandPQRSpenaltyrisks.

PATHOLOGYPQRSMEASURESFOR2016

Forpathology, therearenoPQRSmeasurechangesfor2016versus2015.The2016measures,asidentifiedbyCAPareshownhere.Notethatthesearethepossiblemeasures,buteachEPandgroupneedstodeterminewhichapplytotheircircumstances:

-Breast Cancer Resection Pathology Reporting -Measure#99–pTcategory(primarytumor)andpNcategory(regionallymphnodes)

withhistologicgrade -Colorectal Cancer Resection Pathology Reporting -Measure #100 – pT category (primary tumor) and pN category (regional lymph

nodes)withhistologicgrade -Barrett’s Esophagus -Measure#249–EsophagealbiopsieswithadiagnosisofBarrett’sesophagusthat

alsoincludeastatementondysplasia -Radical Prostatectomy Pathology Reporting -Measure#250–ReportsincludethepTcategory,thepNcategory,theGleasonscore

andastatementaboutmarginstatus -Immunohistochemical (IHC) Evaluation of HER2 for Breast Cancer Patien ts -Measure#251–QuantitativeHER2evaluationbyIHCusesthesystemrecommended

bytheASCO/CAPguidelines -Lung cancer reporting (biopsy/cytology specimens) -Measure#395–Pathologyreportsbasedonbiopsyand/orcytologyspecimenswith

adiagnosisofnon-smallcelllungcancerclassifiedintospecifichistologictypeorclassifiedasNSCLC-NOSwithanexplanationincludedinthepathologyreport

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-Lung cancer reporting (resection specimens)-Measure#396-Pathologyreportsbasedonresectionspecimenswithadiagnosis

ofprimarylungcarcinomathatincludethepTcategory,pNcategoryandfornonsmallcelllungcancer,histologictype

-New Melanoma reporting-Measure#397–Pathologyreportsforprimarymalignantcutaneousmelanomathat

includethepTcategoryandastatementonthicknessandulcerationandforpT1,mitoticrate

DetailsforeachmeasureareavailableintheCMSIndividualMeasuresGuide,availableasadownloadatthisCMS page.

VALUE-BASEDPAYMENTMODIFIER(VBM)

LikePQRS,theValue-BasedModifier(VBM)affectsMedicarepaymentswithaone-yeardelay.Hence,performancein2015hasalreadydeterminedPQRSandVBMpaymentadjustmentsfor2017.Andperformanceduringthisyear(2016)willdetermineadjustmentsfor2018payments.

For2015,CMSdescribedtheVBMasfollows:“Inordertobeeligibleforupward,downward,orneutralpaymentadjustmentsundertheValueModifierquality-tieringmethodologyandtoavoidanautomaticnegative twopercent (“-2.0%”) (forphysiciangroupswithbetween2 to9EPsandphysiciansolopractitioners) or negative four percent (“-4.0%”) (for physician groups with 10 or more EPs) ValueModifierpaymentadjustmentinCY2017,EPsingroupsandsolopractitionersMUSTparticipateinthePQRSandsatisfyreportingrequirementsasagrouporasindividualsinCY2015.Quality-tieringismandatoryforgroupsandsolopractitionerssubjecttotheValueModifierinCY2017.Groupswith10ormoreEPsaresubjecttoupward,neutral,ordownwardadjustmentunderquality-tiering,andgroupswithbetween2to9EPsandphysiciansolopractitionersaresubjecttoonlyupwardorneutraladjustmentunderquality-tieringin2017.”

Whilethepreciserulesfor2016arenotclearontheCMSwebsite,itappearsthatgroupsunder10providersarenowsubjecttoa-2%VBMpenalty,andcontinuetobeeligiblefora+2xincentive,basedontheirqualityandcostresults.ButthisassumesthatthegroupreportsitsPQRSmeasures.Anygroupunder10providersthatdoesnotreportPQRSsuccessfullywilldefinitelyseea-4%penalty.

Inaddition,for2016,non-physicianpractitioners(NPPs)areincludedintheVBM:PAs,NPs,etc.Asinpreviousyears,theseprovidersnewtotheprogramarenotsubjecttodownwardadjustments,butthatappliesonlytosoloNPPsorthoseinagroupofonlyNPPs.Solophysiciansandgroupsoftwoormorephysiciansand/orNPPsaresubjecttopaymentadjustments(upordown)basedontheirratioofqualitytocostascomparedtootherprovidersintheMedicareprogram.

Tosummarize,theupwardordownwardpaymentadjustmentfactorsandpercentagesfor2016VBMareasfollows:

-Forsolophysiciansandgroupsuptonineproviders:+2.0xand-2.0%.-Forgroupswith10ormoreproviders:+4.0xand-4.0%.

PERFORMANCE THAT MATTERS

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