Fact Sheets

Changes for Calendar Year 2015 Physician Quality Programs and Other Programs in the Medicare Physician Fee Schedule

Changes for Calendar Year 2015 Physician Quality Programs and Other Programs in the Medicare Physician Fee Schedule

On Oct. 31, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (MPFS) on or after Jan. 1, 2015. The rule also finalizes 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 website on Medicare.gov. Changes to other CMS programs and initiatives are also discussed in this fact sheet.

The Medicare PFS final rule is one of several rules for calendar year that reflect a broader Administration-wide strategy to deliver better care at lower cost by finding better ways to deliver care, pay providers, and distribute information. Provisions in these rules are helping to move our health-care system to one that values quality over quantity and focuses on reforms such as measuring for better health outcomes, focusing on disease prevention, helping patients return home after the hospital, helping manage and improve chronic diseases, and fostering a more-efficient and coordinated health care system.

This fact sheet discusses the changes to these quality reporting programs and other programs included in this rule. Separate fact sheets, also issued today, discuss the changes to payment policies for services furnished under the PFS, and the continued phase-in of the Value Modifier.

Physician Quality Reporting System (PQRS)

The Physician Quality Reporting System (PQRS) 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 that, 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 final rule, CMS establishes requirements primarily related to the 2017 PQRS payment adjustment.

Summary of PQRS measures

For 2015, we are adding 20 new individual measures and two measures groups to fill existing measure gaps. We are removing 50 measures from reporting for the PQRS. These changes bring the PQRS individual measure set to 255 total measures. Generally, EPs need only report nine measures covering three National Quality Strategy (NQS) domains.

Reporting PQRS measures as individual EPs and group practices under the Group Practice Reporting Option (GPRO)

For the 2017 PQRS payment adjustment, we establish criteria for satisfactory reporting and satisfactory participation that are generally similar to the criteria we finalized for the 2014 PQRS payment incentive. However, the final criteria for satisfactory reporting for the 2017 PQRS payment adjustment differ from the established criteria for the 2014 incentive in the following ways. Avoiding a payment adjustment in 2017 requires:

• Eligible professionals and group practices reporting via claims or registry who see at least one Medicare patient in a face-to-face encounter to report on at least one measure from a newly cross-cutting measures set in addition to any other measures that the eligible professional is required to report.

• All group practices of 25 or more eligible professionals using the GPRO web interface to report measures on a beneficiary sample of 248 patients.

• All group practices of 100 or more eligible professionals that are registered for the GPRO to report on the Consumer Assessment of Healthcare Provider and Systems survey CAHPS for PQRS regardless of the reporting mechanism the group practice chooses. The group practices will bear the cost of administering CAHPS for PQRS.

Medicare EHR Incentive Program

Changes to hardship exceptions for the Medicare EHR Incentive Program

The PFS 2015 final rule includes an Interim Final Rule with a request for public comment (IFC) related to the EHR Incentive Programs. This IFC provisionally adopts changes to the regulatory language about hardship exceptions from the Medicare payment adjustment in the EHR Incentive Programs.

As part of the American Recovery and Reinvestment Act of 2009 (ARRA), Congress mandated payment adjustments under Medicare for eligible hospitals, critical access hospitals, and eligible professionals that are not meaningful users of certified EHR technology. ARRA allows the Secretary to consider, on a case-by-case basis, hardship exceptions for eligible hospitals, critical access hospitals, and eligible professionals to avoid the payment adjustments.

In October, CMS reopened the submission period for hardship exception applications for eligible professionals and eligible hospitals to avoid the 2015 Medicare payment adjustments for not demonstrating meaningful use of Certified Electronic Health Record Technology (CEHRT). Eligible professionals and eligible hospitals that have never met meaningful use before may apply during this reopened hardship exception application submission period if the provider was unable to fully implement 2014 Edition CEHRT due to delays in 2014 Edition CEHRT availability and could not attest by the early attestation deadline for new participants.

The language in the rule makes the necessary changes to the regulation to support the extension of the hardship application period.

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

While we are still requiring EPs who report clinical quality measures electronically for the Medicare EHR Incentive Program to use the most recent version of electronically specified clinical quality measures (eCQMs), 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.

Medicare Shared Savings Program

The Medicare Shared Savings Program (Shared Savings Program) was established to facilitate coordination and cooperation among Medicare enrolled providers and suppliers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs through participation in an Accountable Care Organization (ACO). The CY 2015 PFS final rule includes updates to parts of the Shared Savings Program regulations.

Additional Quality Improvement Reward

In this rule, CMS finalized 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. Based on the comments received, we finalized that ACOs can receive up to four points to reward improvements in quality performance, beginning in 2015.

Revisions to Quality Measure Benchmarks

In response to comments received by stakeholders, CMS is modifying its benchmarking methodology for “topped out” measures. CMS will 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.

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

The 2015 revisions reflect up-to-date clinical guidelines and practice, reduce duplicative measures, increase focus on claims-based outcome measures, and reduce ACO reporting burden. The changes do not change the total number of measures used in the Shared Savings Program – the total number of measures will continue to be 33. However, CMS increased the number of measures calculated through claims and decreased the number of measures reported by the ACO through the GPRO web interface. Specifically, new measures will 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;
• Documentation of current medications; and
• Stewardship of patient resources.

CMS received feedback on gaps in measures and will continue to consider recommendations as it maintains the Shared Savings Program measures. CMS will also continue aligning the Shared Savings Program with the EHR Incentive Program.

Physician Compare Website

The 2015 PFS final rule continues to build on our phased approach for public reporting on Physician Compare. We are finalizing the proposal to expand public reporting of group-level measures by making all 2015 PQRS GPRO web interface, registry, and EHR measures for group practices of two or more EPs and all measures reported by ACOs available for public reporting on Physician Compare in 2016. We are finalizing that these data must meet the minimum sample size of 20 patients and prove to be statistically valid, reliable, comparable, and accurate.

We are not finalizing the proposal to publicly report 20 PQRS individual measures reported in 2013 and collected through a registry, EHR, or claims in 2015. However, we are finalizing the proposal to expand public reporting of 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, with the exception of those measures that are new to PQRS and thus in their first year. In general, no first year measures will be publicly reported on Physician Compare. All measures submitted, reviewed, and deemed valid and reliable will be reported in the Physician Compare downloadable file; however, not all measures will be included on the Physician Compare profile pages. In addition, we are finalizing including an indicator on Physician Compare for satisfactory reporters under PQRS in 2015 and participants in EHR. We are finalizing the removal of the Cardiovascular Prevention measure group from the PQRS, and thus we modified our final policy with regard to our proposal to support Million Hearts on Physician Compare. Specifically, we are finalizing that EPs will receive a green check mark indicating support for Million Hearts if they satisfactorily reports all four of the following individual measures:

• Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic;
• Preventive Care and Screening: Tobacco Use;
• Controlling High Blood Pressure; and
• Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented.

Understanding the value consumers place on patient experience data, we are finalizing our proposal to publicly report 2015 CAHPS survey data in 2016 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. Finally, we are finalizing our proposal to publicly report individual EP-level QCDR measures with some modifications, including not publishing first year measures. 2015 QCDR data will be publicly reported in 2016 on the Physician Compare website, and we will not require these data to also be publicly reported on the QCDR websites.

The rule will be published in the Federal Register on Nov. 13, 2014. For more information, visit: https://www.federalregister.gov/public-inspection. Please note that this link will change once the rule is published.

For more information on PQRS, visit: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

For more information on the Medicare and Medicaid EHR Incentive Programs, visit: http://www.cms.gov/EHRIncentivePrograms

For more information on Physician Compare, visit: http://www.medicare.gov/physiciancompare

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