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

Overview

On 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. 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. Changes to other CMS programs and initiatives, including the Comprehensive Primary Care Initiative, are also discussed in this fact sheet.

This fact sheet discusses the proposed changes to these quality reporting programs and other programs included in this rule. Separate fact sheets, also issued today, discuss the proposed 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 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.

Summary of proposed PQRS measures

For 2015, we are proposing to add 28 new individual measures and two measures groups to fill existing measure gaps. We are 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, we are 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 i in addition to any other measures that the eligible professional is required to report.

Reporting PQRS measures as individual EPs

For the 2017 PQRS payment adjustment, we are proposing criteria for satisfactory reporting and satisfactory participation by individual eligible professionals that are generally similar to the criteria we 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.

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

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

• We are proposing to change 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.

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

While we are still requiring EPs report on the most recent version of electronically specified clinical quality measures (eCQMs), we are 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.

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 proposed rule includes updates to parts of the Shared Savings Program regulations.

Additional Quality Improvement Reward

In this rule, we propose revising our 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, we seek comments on our proposed approach for rewarding quality improvement and feedback on alternative approaches that may be possible under the Shared Savings Program.

Revisions to Quality Measure Benchmarks

In response to stakeholder feedback regarding “topped out” measures, we propose modifying our 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.

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

For2015, we are 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, we are 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

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

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

We propose to revise our 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.

Physician Compare Website

The 2015 PFS proposed rule continues to build on our phased approach for public reporting on Physician Compare. We propose 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. We propose 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, we propose to publicly report 20 PQRS individual measures reported in 2013 and collected through a registry, EHR, or claims in 2015. In addition, we propose 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, we propose 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, we propose 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, we propose 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.

The proposed rule will be published in the Federal Register on July 3, 2014. CMS will accept comments on the proposed rule until Sept. 2, 2014.

For more information, visit: https://www.federalregister.gov/public-inspection

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/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

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

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