2017 PQRS Payment Adjustment
In 2015, if an individual EP or group practice does not satisfactorily report or satisfactorily participate while submitting data on PQRS quality measures, a 2% negative payment adjustment will apply in 2017.
The adjustment (98% of the fee schedule amount that would otherwise apply to such services) applies to covered professional services furnished by an individual EP or group practice during 2017.
http://www.cms.gov/Medicare/Quality...ents/PQRS/Payment-Adjustment-Information.html
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I would provide the provider a document outlining the payment adjustment that will occur if the PQRS checklist or other templates in the EHR/ are not used. I would state it is estimated that this will add 5-10 minutes to complete per patient encounter and by taking this extra time, the services provided in 2017 will not be adjusted. I would also provide information about the Merit-Based Incentive Payment System (MIPS) and point out that Medicare is shifting to pay-for-performance versus dominant fee-for service structure. The future holds spending more time per encounter documenting quality measures performed and adjustment for not focusing on these quality activities will result in 4% up to 9% farther into the program. So the checklist might not be appealing and not specifically signify importance at face value but this type of focus requires what the payer is requesting be done.
You could also point out that PQRS adjustments will be ending in 2017 as seen below and again educating the physician about the future MIPS program and discussing how the quality reporting can be accomplished in the most efficient fashion. But committing time to it will be required. It is a battle that is not won with the first explanation of giving more work for the physician. But I believing providing documents that further explain the programs let them understand what is required and why the extra time has to be spent.
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Consolidating Current Law Programs into a unified MIPS Payments to professionals will be adjusted based on performance in the unified MIPS starting in 2018. The MIPS streamlines and improves on the three distinct current law incentive programs: The Physician Quality Reporting System (PQRS) that incentivizes professionals to report on quality of care measures; The Value-Based Modifier (VBM) that adjusts payment based on quality and resource use in a budget-neutral manner; and Meaningful use of EHRs (EHR MU) that entails meeting certain requirements in the use of certified EHR systems.
Sunsetting Current Law Incentive Program Payment Implications The payment implications associated with the current law incentive program penalties are sunset at the end of 2017, including the 2 percent penalty for failure to report PQRS quality measures and the 3 percent (increasing to 5 percent in 2019) penalty for failure to meet EHR MU requirements. The money from penalties that would have been assessed would now remain in the physician fee schedule, significantly increasing total payments compared to the current law baseline.
Professionals to Whom MIPS Applies The MIPS will apply to: doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists beginning in 2018. Other professionals paid under the physician fee schedule may be included in the MIPS beginning in 2020, provided there are viable performance metrics available. Professionals who treat few Medicare patients, as well as professionals who receive a significant portion of their revenues from eligible APM(s) will be excluded from the MIPS.
MIPS Assessment Categories The MIPS will assess the performance of eligible professionals in four categories: quality; resource use; EHR Meaningful Use; and clinical practice improvement activities.
1. Quality. Measures used for this performance category will be published annually in the final measures list developed under the methodology specified below. In addition to measures used in the existing quality performance programs (PQRS, VBM, EHR MU), the Secretary would solicit recommended measures and fund professional organizations and others to develop additional measures. Measures used by qualified clinical data registries may also be used to assess performance under this category.
2. Resource Use. The resource use category will include measures used in the current VBM program. The methodology that CMS is currently developing to identify resources associated with specific care episodes would be enhanced through public input and an additional process that directly engages professionals. The additional process allows professionals to report their specific role in treating the beneficiary (e.g., primary care or specialist) and the type of treatment (e.g., chronic condition, acute episode). This additional process addresses concerns that algorithms and patient attribution rules fail to accurately link the cost of services to a professional. Resource use measurement would also reflect additional research and recommendations on how to improve risk adjustment methodologies to ensure that professionals are not penalized for serving sicker or more costly patients.
3. Meaningful Use. Current EHR Meaningful Use requirements, demonstrated by use of a certified system, will continue to apply in order to receive credit in this category. To
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prevent duplicative reporting, professionals who report quality measures through certified EHR systems for the MIPS quality category are deemed to meet the meaningful use clinical quality measure component.
4. Clinical Practice Improvement Activities. Professionals will be assessed on their effort to engage in clinical practice improvement activities. Incorporation of this new component gives credit to professionals working to improve their practices and facilitates future participation in APMs. The menu of recognized activities will be established in collaboration with professionals. Activities must be applicable to all specialties and attainable for small practices and professionals in rural and underserved areas.
Annual List of Quality Measures Used in MIPS Every year, the Secretary, through notice and comment rulemaking, will publish a list of quality measures to be used in the forthcoming MIPS performance period. Updates and modifications to the list of quality measures will also occur through this process. Eligible professionals will select which measures on the final list to report and be assessed on.
Eligible professional organizations and other relevant stakeholders will identify and submit quality measures to be considered for selection and to identify and submit updates to the measures already on the list. Measures may be submitted regardless of whether such measures were previously published in a proposed rule or endorsed by a consensus-based entity that holds a contract with the Centers for Medicare and Medicaid Services (CMS). Any measure selected for inclusion in such list that is not endorsed by a consensus-based entity must be evidencebased.
To the extent practicable, quality measures selected for inclusion on the final list will address all five of the following quality domains: clinical care, safety, care coordination, patient and caregiver experience, and population health and prevention. Before including a new measure in the final list, the Secretary will submit the measure for publication in an applicable specialtyappropriate peer-reviewed journal, including the method for developing and selecting the measure.
Qualified clinical data registry measures, many of which are maintained by physician specialty organizations, and existing quality measures will not be subject to these additional requirements and will be automatically included in the first program year?s final list of quality measures. These measures will remain in the MIPS program unless they are removed under the rulemaking process.
Composite Performance Score Professionals will receive a composite performance score of 0-100 based on their performance in each of the four performance categories listed above. Professionals will only be assessed on the categories, measures, and activities that apply to them. Scoring weights for performance categories, measures, and activities may be adjusted as necessary, to account for a professional?s ability to successfully report on such category measure or activity and to ensure that individuals are measured on an equitable basis.
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To incentivize improved performance, professionals will also receive credit for improvement from one year to the next in the determination of their quality and resource use performance category score and may receive credit for improvement in clinical practice improvement activities.
MIPS Payment Adjustment Each eligible professional?s composite score will be compared to a performance threshold. The performance threshold will be the mean or median of the composite performance scores for all MIPS eligible professionals during a period prior to the performance period. Professionals will know what composite score they must achieve to obtain incentive payments and avoid penalties at the beginning of each performance period.
Payment adjustments will follow a linear distribution. Eligible professionals whose composite performance scores fall above the threshold will receive positive payment adjustments and eligible professionals whose composite performance scores fall below the threshold will receive negative payment adjustments.
Negative adjustments ? Negative payment adjustments will be capped at four percent in 2018, five percent in 2019, seven percent in 2020, and nine percent in 2021. Eligible professionals whose composite performance score falls between 0 and ? of the threshold will receive the maximum possible negative payment adjustment for the year. Professionals with composite performance scores closer to the threshold will receive proportionally smaller negative payment adjustments. These negative payment adjustments for eligible professionals whose composite performance scores fall below the threshold will fund positive payment adjustments to professionals with composite performance scores above the threshold.
Zero adjustments ? Eligible professionals whose composite performance score is at the threshold will not receive a MIPS payment adjustment.
Positive adjustments ? Eligible professionals whose composite performance scores are above the threshold will receive positive payment adjustments. Eligible professionals with higher performance scores will receive proportionally larger incentive payments up to a maximum of three times the annual cap for negative payment adjustments.
o Additional Incentive Payment ? An additional performance threshold for exceptional performance will be set at the 25th percentile of the range between the initial performance threshold and 100 (e.g., if the performance threshold is a score of 60, the additional performance threshold would be a score of 70) or the 25th percentile of actual composite performance scores for MIPS eligible professionals with composite scores at or above the initial performance threshold (i.e., 75 percent of professionals who receive a positive payment adjustment would receive an additional payment adjustment). Eligible professionals with composite scores above the additional performance threshold will receive an
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additional incentive payment. Aggregate additional incentive payments will be capped at $500 million per year for each of 2018 through 2023. Additional incentive payments will be allocated according to a linear distribution, with better performers receiving larger incentive payments. These payments will enable some professionals to receive incentive payments even if all professionals score above the initial threshold.
A professional?s payment adjustment in one year will have no impact on their payment adjustment in a future year.
The Government Accountability Office (GAO) is required to evaluate the MIPS and issue reports in 2018 and 2021, including an assessment of the professional types, practice sizes, practice geography, and patient mix that are receiving MIPS payment increases and reductions.
Expanded Participation Options and Tools to Enable Success Professionals will have the flexibility to participate in MIPS in a way that best fits their practice environment. These options include: use of EHRs, use of qualified clinical data registries maintained by physician specialty organizations, and the option to be assessed as a group, as a ?virtual? group, or with an affiliated hospital or facility.
Technical assistance will be available to help practices with 15 or fewer professionals improve MIPS performance or transition to APMs. Priority will be given to practices with low MIPS scores and those in rural and underserved areas. Funding will be $40 million annually from 2014 to 2018, with $10 million reserved for practices in areas designated as health professional shortage areas or medically underserved areas.
Professionals will receive confidential feedback on performance in the quality and resource use categories at least quarterly, likely through a web-based portal. Professionals may also receive confidential feedback on performance through qualified clinical data registries.
Encouraging Participation in APMs Professionals who receive a significant share of their revenues through an APM(s) that involves risk of financial losses and a quality measurement component will receive a five percent bonus each year from 2018-2023. A patient-centered medical home APM will be exempted from the downside financial risk requirement if proven to work in the Medicare population. Two tracks will be available for professionals to qualify for the bonus. The first option will be based on receiving a significant percent of Medicare revenue through an APM; the second will be based on receiving a significant percent of APM revenue combined from Medicare and other payers. The second option makes it possible for professionals to qualify for the bonus even if Medicare APM options are unavailable in their area. If no Medicaid APM is available in a state, a professional?s Medicaid revenue will not be counted against the proportion of revenue in an APM. In states where Medicaid APMs are available, Medicaid medical homes will also be exempted from downside financial risk if they are proven to work in the Medicaid population.
Professionals who meet these criteria will be excluded from the MIPS assessment and most EHR
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meaningful use requirements.
The bonus payment for APM participation encourages professionals to consider participation and testing of new APMs, recognizes that practice changes are needed to facilitate such participation, and promotes the alignment of incentives across payers.
To make the bonus opportunity available to the greatest number of professionals, the Secretary is specifically encouraged to test APMs relevant to specialty professionals, professionals in small practices, and those that align with private and state-based payer initiatives. Further, a Technical Advisory Committee will be established to consider physician-focused APM proposals. CMS would be required to provide a detailed response to TAC-recommended APMs. The section also requires HHS to identify potential fraud vulnerabilities in APMs.