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July 08, 2014

CMS Proposed Medicare Physician Fee Schedule 2014

Late in the evening of July 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (MPFS) on or after Jan. 1, 2015. In addition to the previously reported changes to Open Payments, the proposed rule also proposes changes to several of the quality reporting initiatives that are associated with PFS payments, including the Physician Quality Reporting System (PQRS), Medicare Electronic Health Record (EHR) Incentive Program, and the Medicare Shared Savings Program, as well as changes to the Physician Compare tool on the Medicare.gov website.

I. Physician Quality Reporting System (PQRS)

The Physician Quality Reporting System (PQRS), set forth in sections 1848(a), (k), and (m) of the Act, is a pay-for-reporting program that uses a combination of incentive payments and downward payment adjustments to promote reporting of quality information by eligible professionals (EPs). The program provides an incentive payment through 2014 to EPs and group practices who, during the applicable reporting period, satisfactorily report data on quality measures for covered professional services furnished to Medicare Part B fee-for-service beneficiaries or satisfactorily participate in a qualified clinical data registry (QCDR). Beginning in 2015, a downward payment adjustment will apply to EPs who do not satisfactorily report data on quality measures for covered professional services or satisfactorily participate in a QCDR. In the CY 2015 PFS proposed rule, CMS is proposing updates to the PQRS primarily related to the 2017 PQRS payment adjustment.

A. Summary of proposed PQRS measures

The proposed requirements will primarily focus on the proposals related to the 2017 PQRS payment adjustment, which will be based on an eligible professional's or a group practice's reporting of quality measures data during the 12-month calendar year reporting period occurring in 2015 (that is, January 1 through December 31, 2015).

For 2015, CMS is proposing to add 28 new individual measures and two measures groups to fill existing measure gaps. CMS is proposing to remove 73 measures from reporting for the PQRS. These proposed changes would bring the PQRS individual measure set to 240 total measures. Generally, eligible professionals need only report nine measures covering three National Quality Strategy domains. In addition, CMS is proposing to require that eligible professionals who see at least one Medicare patient in a face-to-face encounter report measures from a newly proposed cross-cutting measures set in addition to any other measures that the eligible professional is required to report.

B. Reporting PQRS measures as individual EPs

For the 2017 PQRS payment adjustment, CMS is proposing criteria for satisfactory reporting and satisfactory participation by individual eligible professionals that are generally similar to the criteria CMS finalized for the 2014 PQRS incentive. An additional criteria being proposed would be that eligible professionals who see at least one Medicare patient in a face-to-face encounter and choose to report PQRS quality measures via claims and registry would be required to report on at least two measures in the newly proposed PQRS cross-cutting measures set.

For what defines a "face-to-face" encounter, CMS proposes to determine whether an eligible professional had a "face-to-face" encounter by seeing whether the eligible professional billed for services under the PFS that are associated with face-to-face encounters, such as whether an eligible professional billed general office visit codes, outpatient visits, and surgical procedures. CMS will not include telehealth visits as face-to-face encounters.

C. Reporting PQRS measures as a group practice under the Group Practice Reporting Option (GPRO)

In lieu of reporting measures under section 1848(k)(2)(C) of the Act, section 1848(m)(3)(C) of the Act provides the Secretary with the authority to establish and have in place a process under which eligible professionals in a group practice (as defined by the Secretary) shall be treated as satisfactorily submitting data on quality measures.

For the 2017 PQRS payment adjustment, CMS is proposing criteria for satisfactory reporting by group practices that are generally similar to the criteria CMS finalized for the 2014 PQRS incentive. However differ in the following ways:

  • Consistent with the group practice reporting requirements under section 1848(m)(3)(C) of the Act, CMS proposes to modify §414.90(j), thereby changing the number of patients for which group practices report measures under the GPRO web interface from 411 for group practices with 100+ eligible professionals and from 218 for group practices with 25-99 eligible professionals to 248 for all group practices with 25 or more eligible professionals.
  • Group practices that have at least one eligible professional who sees at least one Medicare patient in a face-to-face encounter and choose to report via registry would be required to report on at least two measures in the proposed PQRS cross-cutting measures set. If these group practices report using both a certified survey vendor and a registry, only one measure in the cross-cutting measures set would need to be reported.

D. Reporting of electronically specified clinical quality measures for the Medicare EHR Incentive Program

While CMS is still requiring EPs report on the most recent version of electronically specified clinical quality measures (eCQMs), CMS is proposing that EPs would not be required to ensure that their Certified EHR Technology (CEHRT) products are recertified to the most recent version of the electronic specifications for the CQMs.

In the CY 2013 PFS final rule with comment period, CMS finalized the following criterion for the satisfactory reporting for individual eligible professionals reporting individual measures via a direct EHR that is CEHRT or an EHR data submission vendor that is CEHRT for the 2014 PQRS incentive: Report 9 measures covering at least 3 of the NQS domains. If an eligible professional's CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the eligible professional must report all of the measures for which there is Medicare patient data. An eligible professional must report on at least 1 measure for which there is Medicare patient data (see Table 47 at 78 FR 74479).

To be consistent with the criterion CMS finalized for the 2014 PQRS incentive, as well as to continue to align with the final criterion for meeting the clinical quality measure (CQM) component of achieving meaningful use under the Medicare EHR Incentive Program, CMS is proposing to modify §414.90(j) and propose the following criterion for the satisfactory reporting for individual eligible professionals to report individual measures via a direct EHR that is CEHRT or an EHR data submission vendor that is CEHRT for the 2017 PQRS payment adjustment: The eligible professional would report 9 measures covering at least 3 of the NQS domains. If an eligible professional's CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the eligible professional would be required to report all of the measures for which there is Medicare patient data. An eligible professional would be required to report on at least 1 measure for which there is Medicare patient data.

II. Medicare Shared Savings Program

The CY 2015 PFS proposed rule includes updates to parts of the Medicare Shared Savings program (Shared Savings Program) regulations. Under section 1899 of the Act, CMS has established the Shared Savings Program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs. Eligible groups of providers and suppliers, including physicians, hospitals, and other health care providers, may participate in the Shared Savings Program by forming or participating in an Accountable Care Organization (ACO). The final rule implementing the Shared Savings Program appeared in the November 2, 2011 Federal Register (Medicare Shared Savings Program: Accountable Care Organizations Final Rule (76 FR 67802)).

Section 1899(b)(3)(A) of the Act requires the Secretary to determine appropriate measures to assess the quality of care furnished by ACOs, such as measures of clinical processes and outcomes; patient, and, wherever practicable, caregiver experience of care; and utilization such as rates of hospital admission for ambulatory sensitive conditions. Section 1899(b)(3)(B) of the Act requires ACOs to submit data in a form and manner specified by the Secretary on measures that the Secretary determines necessary for ACOs to report to evaluate the quality of care furnished by ACOs. Section 1899(b)(3)(C) of the Act requires the Secretary to establish quality performance standards to assess the quality of care furnished by ACOs, and to seek to improve the quality of care furnished by ACOs over time by specifying higher standards, new measures, or both for the purposes of assessing the quality of care.

Additionally, section 1899(b)(3)(D) of the Act gives the Secretary authority to incorporate reporting requirements and incentive payments related to the PQRS, EHR Incentive Program and other similar initiatives under section 1848 of the Act. Finally, section 1899(d)(1)(A) of the Act states that an ACO is eligible to receive payment for shared savings, if they are generated, only after meeting the quality performance standards established by the Secretary.

A. Additional Quality Improvement Reward

In this rule, CMS proposes revising the quality scoring strategy to recognize and reward ACOs that make year-to-year improvements in quality performance scores on individual measures by adding a quality improvement measure that adds bonus points to each of the four quality measure domains based on improvement. Additionally, CMS seeks comments on the proposed approach for rewarding quality improvement and feedback on alternative approaches that may be possible under the Shared Savings Program.

B. Revisions to Quality Measure Benchmarks

In response to stakeholder feedback regarding "topped out" measures, CMS proposes modifying the benchmarking methodology to use flat percentages to establish the benchmark for a measure when the national FFS data results in the 90th percentile being greater than or equal to 95 percent.

C. Modifications to the Quality Measures that Make Up the Quality Reporting Standard

For 2015, CMS is proposing revisions to reflect up-to-date clinical guidelines and practice, reduce duplicative measures, increase focus on claims-based outcome measures, and reduce ACO reporting burden. The proposed changes increase the number of measures calculated through claims and decrease the number of measures reported by the ACO through the GPRO Web Interface. The total number of quality measures for quality reporting would increase from 33 to 37 measures under this proposal. Specifically, new measures would be added to focus on avoidable admissions for patients with multiple chronic conditions, heart failure and diabetes; depression remission; all cause readmissions to a skilled nursing facility; and stewardship of patient resources; the existing composite measures for diabetes and coronary artery disease would also be updated.

Additionally, CMS is seeking public comment on future quality measures for consideration that address the following areas:

  • Gaps in measures and additional specific measures
  • Measures for retirement (e.g., "topped out" measures)
  • Caregiver experience of care
  • Alignment with the Value-Based Payment Modified ( VBM)
  • Assess care in the frail elderly population
  • Utilization
  • Health outcomes
  • Public health

CMS is also seeking suggestions on ways that the agency might implement EHR-based reporting of quality measures in the Shared Savings Program for consideration in future rulemaking.

D. Proposed Quality Performance Standard for Measures that Apply to ACOs that Enter a Second or Subsequent Participation Agreement

CMS proposes to revise the regulations to provide that during a second or subsequent participation agreement period, the ACO would continue to be assessed on its performance on each measure that has been designated as pay for performance. That is, an ACO would continue to be assessed on the quality performance standard that would otherwise apply to an ACO if it were in the third performance year of the first agreement period.

CMS will do this by modifying §425.502(a)(1) and (a)(2) to indicate that the performance standard will be set at the level of complete and accurate reporting of all quality measures only for the first performance year of an ACO's first agreement period, and that during subsequent agreement periods, pay for performance will apply for all three performance years. New measures that are added to the quality performance standard would be phased in along the timeline indicated when the measure is added and in operational documents.

III. Physician Compare Website

The 2015 PFS proposed rule continues to build on the phased approach for public reporting on Physician Compare. CMS proposes to expand public reporting of group-level measures by making all 2015 PQRS GRPO web interface, registry, and EHR measures for group practices of 2 or more EPs and ACOs available for public reporting on Physician Compare in 2016. CMS proposes these data must meet the minimum sample size of 20 patients and prove to be statistically valid and reliable.

Mirroring the measures finalized for public reporting in the 2014 PFS final rule, CMS proposes to publicly report 20 PQRS individual measures reported in 2013 and collected through a registry, EHR, or claims in 2015. In addition, CMS proposes expanding measures for individual EPs by making all 2015 PQRS individual measures collected via registry, EHR, or claims available for public reporting on Physician Compare in late 2016, if technically feasible. All measures submitted, reviewed, and deemed valid and reliable would be reported in the Physician Compare downloadable file; however, not all measures would be included on the Physician Compare profile pages. In addition, CMS proposes including an indicator on Physician Compare for satisfactory reporters under PQRS in 2015, participants in EHR, as well as EPs who report the PQRS Cardiovascular Prevention measures group in support of Million Hearts.

Understanding the value consumers place on patient experience data, CMS proposes publicly reporting 2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data for PQRS for group practices of two or more EPs who report this data, as well as CAHPS for ACOs for those that meet the specified sample size requirements and collect data via a CMS-specified CAHPS vendor. This would be publicly reported in 2016. Finally, CMS proposes to make available on Physician Compare the 2015 Qualified Clinical Data Registry (QCDR) measure data collected at the individual measure level or aggregated to a higher level of the QCDR's choosing, if technically feasible.

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