Download PowerPoint - The Massachusetts eHealth Institute

Behavioral Health and
CMS Quality Programs
January 26, 2015
Agenda
 Introduction
 Three CMS Programs
– Meaningful Use
– PQRS
– MIPS
 MeHI’s Role
– Interpret & Navigate the Regulations
– Prepare & Strategize
– Services & Solutions
 Questions & Answers
 Facilitated Dialogue
2
Current State of Affairs: Behavioral Health
High Prevalence
High Cost
High Co-Morbidity
“If 10% reduction can be made in excess healthcare costs of patients with comorbid psychiatric
disorders via an effective integrated medical-behavioral healthcare program, $5.4 million of
healthcare savings could be achieved for each group of 100,000 insured members…the cost of
doing nothing may exceed $300 billion per year in the United States.23”
Treatment Challenges
Source: A Place at the Table: Behavioral Health and CMS’ Physician Quality Reporting System. National
Council for Behavioral Health.
3
Importance of Behavioral Health Integration
4
Barriers to Effective Behavioral Health Integration
Licensing
Privacy
Reimbursement
Source: Barriers to Behavioral Health and Physical Health Integration in Massachusetts, June 2015,
Blue Cross Blue Shield Foundation of Massachusetts
Financial
Data Sharing
Systems
Privacy Laws
Provider Access
& Training
Source: MassHealth Approaches to Behavioral Health Integration: Integration through Innovation,
Dr. Julian Harris, Medicaid Director, Health Policy Commission, April 3 2013.
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Expanded Role of Health IT Drives Change
 Payment Reform
 Quality Reporting
 Practice Transformation
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Improve
Care Delivery
Outcomes
Meaningful Use
Al Wroblewski, PCMH CCE
Client Services Relationship Manager
Meaningful Use Eligible Professionals (EPs)
Eligible Professionals
Medicare
•
•
•
•
•
Doctor of medicine or osteopathy (MD or DO)
Doctor of oral surgery or dental medicine
Doctor of podiatric medicine
Doctor of optometry
Chiropractor
Medicaid
•
•
•
•
•
•
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Physicians (MD or DO)
Nurse Practitioners
Certified Nurse-Midwives
Dentists
Physician Assistants who furnish services in a Federally Qualified
Health Center (FQHC) or Rural Health Clinic (RHC) led by a
Physician Assistant
Clinical Nurse Specialists – to be determined
CMS Meaningful Use Rules: 2015-2017
CMS Final Rule – Changes to Participation Timeline
2015
Attest to modified criteria for 2015-2017 (Modified Stage 2)
with accommodations for Stage 1 providers
2016
Attest to 2015-2017 criteria (Modified Stage 2)*
2017
Attest to either 2015-2017 criteria (Modified Stage 2) or
full version of Stage 3 using 2015 Edition CEHRT
2018
Attest to full version of Stage 3 using 2015 Edition CEHRT
*some alternate exclusions remain in 2016 for Stage 1 providers
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CMS Final Rule – Changes to EHR Reporting Periods
 In 2015, all providers attest using an EHR reporting period of any
continuous 90-day period within the calendar year
 In 2016:
– first-time MU participants will attest using any continuous 90-day period
within the calendar year
– returning participants will attest using a full calendar year (January 1,
2016 through December 31, 2016)
 In 2017:
– first-time MU participants and anyone choosing to demonstrate Stage 3
will attest using any continuous 90-day period within the calendar year
– returning Stage 2 participants will attest using the full calendar year
(January 1, 2017 through December 31, 2017)
 In 2018, all providers will attest to Stage 3 using the full calendar year
(January 1, 2018 through December 31, 2018)
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CMS Final Rule – List of Objectives
 Meaningful Use Objectives – Modified Stage 2
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Protect Patient Health Information – Security Risk Analysis
Clinical Decision Support (CDS)
Computerized Provider Order Entry (CPOE)
Electronic Prescribing (eRx)
Health Information Exchange (HIE) – previously known as “Summary of Care”
Patient Specific Education
Medication Reconciliation
Patient Electronic Access (Patient Portal)
Secure Electronic Messaging (Eligible Professionals only)
Public Health and Clinical Data Registry Reporting
a.
b.
c.
d.
Immunization Registry Reporting
Syndromic Surveillance Reporting
Specialized Registry Reporting
Reportable Lab Results Reporting (Eligible Hospitals only)
[Note: No change in General Requirements or Clinical Quality Measure reporting]
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CMS Meaningful Use Rules: Stage 3
Stage 3 Meaningful Use - Objectives
1.
2.
3.
4.
5.
6.
7.
8.
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Protect Electronic Health Information
Electronic Prescribing (eRx)
Clinical Decision Support
Computerized Provider Order Entry (CPOE)
Patient Electronic Access to Health Information
Coordination of Care through Patient Engagement
Health Information Exchange
Public Health Reporting
Stage 3 Meaningful Use – Key Elements
 Coordination of Care through Patient Engagement
– 10% of patients use portal or API
– 25% of patients must receive message from EP
– 5% of patients enter their own data or may come from
other agencies
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Stage 3 Meaningful Use – Key Elements
 Health Information Exchange
– 50% of outgoing referrals/transitions sent electronically
– 40% of incoming referrals/transitions and new patients come
with summaries of care
– 80% of incoming referrals/transitions and new patients have
medications, allergies, and problem lists reconciled
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Stage 3 Meaningful Use – Key Elements
 Public Health Reporting
– Must report 3 measures
– Types of Registries
• Immunization
• Syndromic Surveillance
• Electronic Case Reporting
• Other Public Health Registries
• Clinical Data Registries
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Physician Quality
Reporting System (PQRS)
Elisabeth Renczkowski, Content Specialist
PQRS Overview
How does PQRS work?
 PQRS is a reporting program that uses payment adjustments to
promote reporting of quality information by Eligible Professionals (EPs)
 EPs report data to CMS on quality measures for covered Physician
Fee Schedule (PFS) services furnished to Medicare Part B FFS
beneficiaries
 EPs must report on each unique NPI/TIN combination they use to bill
Medicare
 Two-year gap between performance year and payment year
– Providers who satisfactorily report PQRS for Program Year 2015 will avoid
negative payment adjustments to their Medicare reimbursements in 2017
and so on
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PQRS Eligible Professionals (EPs)
PQRS Eligible Professionals
• Doctor of Medicine
• Certified Nurse Midwife*
• Doctor of Osteopathy
• Clinical Social Worker
• Doctor of Podiatric Medicine • Clinical Psychologist
• Doctor of Optometry
• Registered Dietician
• Doctor of Oral Surgery
• Nutrition Professional
• Doctor of Dental Medicine
• Audiologists
• Doctor of Chiropractic
• Physical Therapist
• Physician Assistant
• Occupational Therapist
• Nurse Practitioner*
• Speech-Language
Therapist
• Clinical Nurse Specialist*
• Certified Registered Nurse
Anesthetist*
* Includes Advanced Practice Registered Nurse (APRN)
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Payment Adjustments
Payment Adjustments
PQRS
No incentive for EPs who
successfully report (last year was
2014)
Value Modifier
Upward, neutral, or downward
payment adjustments for EPs who
successfully report PQRS measures
(performance-based payment
adjustments)
Penalty for failure to report
Penalty for failure to report
(automatic payment adjustments)
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Total Payment Adjustments – Failure to Report
 If an EP fails to report PQRS in 2015, the following payment
penalties will apply to their 2017 reimbursements:
PQRS Penalty
Value Modifier Penalty
applies to all EPs
solo EPs and
groups of 2-9
groups of 10+
-2%
-2%
-4%
 Bottom line: Total penalty for failing to report in 2015
• -4% for solo EPs and groups of 2-9
• -6% for groups of 10 or more
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Value Modifier
Value Modifier
 The Value Modifier (VM) provides differential payment based on the
quality of care compared to the cost of care
 PQRS reporting is the basis for the quality portion of the Value Modifier
performance-based payment adjustments
 Performance on PQRS measures matters!
• This differs from reporting CQMs for the Meaningful Use (MU) programs,
where it is acceptable to report a performance rate of 0
 Performance-based payment adjustments for those who do report
PQRS in 2015:
• upward or neutral adjustment (solo practitioners and groups of 2-9)
• upward, neutral, or downward adjustment (groups of 10 or more)
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Value Modifier
 All EPs are included to determine group size
– Currently, upward and downward VM payment adjustments are only
applied to reimbursement of physicians in the group
2017 Value Modifier
based on 2015 PQRS reporting
Solo EP
2-9 EPs
10+ EPs
Physicians
Upward or
Neutral
Upward or
Neutral
Upward,
Neutral, or
Downward
Practitioners
N/A
N/A
N/A
Therapists
N/A
N/A
N/A
 In 2018, CMS will apply the VM to all EPs, including practitioners
and therapists. CMS will finalize exactly how the VM will apply to
those EPs in future rulemaking
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Reporting Methods
Reporting Methods
Individual Eligible Professionals (EPs) can report via:
•
•
•
•
•
Medicare Part B Claims
Qualified PQRS Registry
Direct EHR product that is certified (CEHRT)
CEHRT via Data Submission Vendor
Qualified Clinical Data Registry
Group Practice Reporting Option (GPRO)

A group is defined as 2 or more EPs who have reassigned their billing rights
to the group TIN

Depending on the group size, groups can report via:
•
•
•
•
•
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Qualified PQRS Registry
Direct EHR product that is certified (CEHRT)
CEHRT via Data Submission Vendor
CMS Web Interface (25+ only)
Clinician & Group Consumer Assessment of Healthcare Providers and
Systems (CG-CAHPS), paired with one of the options above (25+ only)
Reporting Considerations
Reporting Considerations
 Individual Measures - EPs and groups must report on at least 50% of
eligible instances
– Definition of “eligible instance” depends on the specific measure
– Must report on 9 measures across 3 NQS domains
– Must include at least 1 cross-cutting measure
– All measures must have a >0% performance rate (i.e. must be performed
successfully for at least 1 eligible patient)
– If reporting using GPRO, must report Individual Measures
 Measures Groups - EP selects a group of related measures and
reports on all of those measures for 20 eligible patients
– Majority of patient sample (at least 11 patients) must be traditional
Medicare Part B beneficiaries
– All measures must have a >0% performance rate (i.e. be performed
successfully for at least 1 eligible patient)
– Measures Groups are only an option for Individual EPs and only available
through a Qualified PQRS Registry
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Reporting Considerations
Measures-Applicability Validation (MAV)
 If an EP reports less than 9 measures (or reports ≥9 measures
across fewer than 3 domains), the MAV process will be applied
 MAV determines if an EP or group has met the requirements to
avoid the PQRS payment adjustment, despite reporting less than
9 measures (or reporting ≥9 measures, but covering fewer than 3
domains)
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Reporting Considerations – Behavioral Health
Recommended Measures for Behavioral Health:
 Dementia Measures Group
 Individual Measures – Examples:
– #325: Adult Major Depressive Disorder (MDD): Coordination of
Care of Patients with Specific Comorbid Conditions
– #134: Preventive Care and Screening: Screening for Clinical
Depression and Follow-Up Plan
– #173: Preventive Care and Screening: Unhealthy Alcohol Use
– #226: Preventive Care and Screening: Tobacco Use: Screening
and Cessation Intervention
– #383: Adherence to Antipsychotic Medications for Individuals
with Schizophrenia
 MAV strategy
– Report on Measure #173 and #226
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Medicare Access and CHIP
Reauthorization Act (MACRA)
Thomas Bennett, Client Services Relationship Manager
Legislative Background
 Medicare Access and CHIP Reauthorization Act (MACRA)
– signed into law April 16, 2015
– replaces the Sustainable Growth Rate (SGR) with a revised
reimbursement model
– contains several other provisions related to:
• program integrity
• fraud and abuse
• extension of the Children’s Health Insurance Program (CHIP)
 Bottom line: MACRA will change how Medicare pays physicians
and other health care providers
 CMS is currently developing proposals to implement the key
elements of MACRA
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Emerging Payment Methodologies
Merit-Based Incentive Payment System (MIPS)
Alternative Payment Models (APMs)
Physician-Focused Payment Models (PFPMs)
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MACRA Reimbursement Rates
 From 2015-2019, annual increase (fee schedule update) of 0.5%
 Starting in 2019, the base reimbursement rate holds steady
– physicians can supplement their reimbursement by participating in the
Merit-Based Incentive Payment System (MIPS) and/or Alternative
Payment Models, such as Accountable Care Organizations (ACOs)
– MIPS payment adjustments based on composite performance score
increase from +/- 4% in 2019 to +/- 9% in 2022 and beyond
– APM incentive payment (5% lump sum) will be available from 2019-2024
 Starting in 2026, an annual increase (fee schedule update) of
0.25% resumes
– physicians who participate in an Alternative Payment Model (APM) are
eligible for a higher annual increase of 0.75%
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Massachusetts eHealth Institute
Merit-Based Incentive
Payment System (MIPS)
Merit-Based Incentive Payment System (MIPS)
 Merit-Based Incentive Payment System (MIPS) consolidates
3 existing programs
• Physician Quality Reporting System (PQRS)
• Value-based Modifier (VM)
• EHR Incentive Payment Program (Meaningful Use)
 For the 2015 and 2016 performance years (and the
corresponding 2017 and 2018 payment years), PQRS, VM
and MU will continue as separate and distinct programs
 Anticipated that 2017 will be the first MIPS performance year
(2017 performance would dictate 2019 payment
adjustments)
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Merit-Based Incentive Payment System (MIPS)
MIPS Eligible Professionals
First two years
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Physicians
Physician Assistants
Nurse Practitioners
Clinical Nurse Specialists
Nurse Anesthetists
Third year and beyond
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•
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All of the above, plus:
Physical Therapists
Occupational Therapists
Speech-language Pathologists
Audiologists
Nurse Midwives
Clinical Social Workers
Clinical Psychologists
Dietitians
MIPS Composite Performance Score
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Four Steps to Prepare for MIPS
Start the Conversation
Expand Knowledge Beyond MU, PQRS,
and VM
Maintain or Expand Efforts with MU, PQRS,
and VM
Contact MeHI
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Massachusetts eHealth Institute
Your Massachusetts Health IT Resource
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MeHI’s eHealth Services
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Questions
Questions?
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Contact Us
Al Wroblewski & Thomas Bennett
Client Services Relationship Managers
(508) 870-0312 ext. 603 ext. 403
[email protected]
[email protected]
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Elisabeth Renczkowski
Content Specialist
(508) 870-0312 ext. 623
[email protected]