2016 PQRS and VBM for Pathology2016 PQRS and VBM for Pathology PERFORMANCE THAT MATTERS AdvantEdge...
Transcript of 2016 PQRS and VBM for Pathology2016 PQRS and VBM for Pathology PERFORMANCE THAT MATTERS AdvantEdge...
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.
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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%.
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