As many providers know by now, H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 was recently passed by Congress. In addition to permanently repealing the sustainable growth rate (SGR), one of the major provisions of the Act includes the start of a new payment methodology starting in 2019. Under the proposed methodology providers will be subject to payment adjustment through the Merit-Based Incentive Payment System (MIPS). MIPS combines three existing "incentive" quality programs: the Physician Quality Reporting System (PQRS), Value-Based Modifier and Electronic Health Records (EHR) Incentive/Meaningful Use program. Additionally participation in Alternative Payment Models (APM) would be an option starting in 2026. In the meantime, it is important that providers concentrate on the fulfillment of current quality programs to ensure the avoidance of penalties. .
Currently, PQRS is a CMS reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs) or groups. Beginning in 2015, the PQRS program began to apply a negative payment adjustment to EPs or groups who do not satisfactorily report data on quality measures for covered professional services.
There are five methods for submitting PQRS data to CMS:
1. Claims-based reporting (on Medicare Part B claims)
2. Group practice reporting option (GPRO)
3. Registry-based reporting
4. Qualified clinical data registry (QCDR) reporting
5. Electronic health record (EHR) reporting using certified EHR technology (CEHRT) or a data submission vendor
While none of these methods are new for 2015 some of them may be more familiar to EP's and groups participating in the PQRS program. CMS has implemented significant revisions to the numbers and types of measures that must be reported to avoid the PQRS penalty. Reporting via claims may become increasingly questionable as a viable option in future years as CMS now requires eligible professionals (EPs) who report via the claims-based and qualified registry reporting options to report on at least one of 19 available cross-cutting measures in 2015. There are 13 of the cross cutting measures available to report via claims or through a qualified registry. Additionally, CMS has signaled their intent to eliminate claims based reporting in the future; although, the passage of the new law makes it uncertain of the fate of that reporting method.
ASA QCDR: Another PQRS Solution for Anesthesia Reporting?
The QCDR option only became available in 2014 and many entities received approval to function as a QCDR; those approved for 2015 will be published by CMS by mid-2015. The American Society of Anesthesiologists (ASA), through its affiliate, Anesthesia Quality Institute (AQI), has developed a meaningful way for physician anesthesiologists to successfully participate in the PQRS with its QCDR designation. As the QCDR option is so new, the following outlines several of the requirements and issues to address as groups consider this option moving forward.
The National Anesthesia Clinical Outcomes Registry (NACOR), maintained by AQI, is the only anesthesia-specific QCDR designated by the Centers for Medicare & Medicaid Services for PQRS reporting. In addition to this unique anesthesia-specific focus is the added benefit that using the AQI QCDR means the EP is not limited to current measures within PQRS. There are a variety of non-PQRS measures to choose from in order to meet the 9 measure and 3 domain requirement. It has been noted that meeting PQRS requirements by participating in a QCDR, that may offer more relevant measures, can help anesthesiology groups achieve meaningful quality improvement. There is also the potential to meet the Maintenance of Certification Part IV Practice Quality Improvement requirements simultaneously.
One of the touted benefits for anesthesiologists for reporting through this method is that overall, the ASA QCDR can be seen as a "one stop shop" for all requirements, with responsibility for data collection and scoring. Public reporting is also conducted by the society.
An advantage of using NACOR as a QCDR is that it includes 19 measures selected for their applicability to anesthesia practice. CMS launched the QCDR program partly in response to the concerns of specialties such as anesthesiology that do not have more than a handful of quality measures on the PQRS list. In their first year of operation, 2014, QCDRs were able to add up to 20 non-PQRS measures to the existing PQRS measures, and under the Final Rule the new maximum would be 30. The AQI initially added 11 measures developed with the involvement of ASA's Committee on Performance and Outcome Measures to the eight PQRS measures identified as reportable by anesthesiologists. For 2015, the available AQI QCDR measure count has expanded to 9 PQRS measures and 27 non-PQRS measures to choose from
CMS has finalized the removal of PQRS #30 (Timing of Prophylactic Antibiotic – Administering Physician) as an official PQRS measure as well as the Back Pain Measures Group from the traditional registry reporting option (PQRS #148-151). Under the 2015 MPFS Final Rule, in order to avoid the penalty, EPs using the ASA QCDR option for their PQRS reporting would report at least nine measures covering at least three NQS domains for at least 50 percent of their applicable patients. Of note, there are some differences in this method of reporting versus claims-based or qualified registry.as outlined below:
- For the 9 measures the EP must report on at least 2 outcome measures although there is no "cross-cutting" measure requirement,
- The EP must report on 50% of All applicable patients versus just their Medicare part B patients,
- The measure applicability validation (MAV) process does not apply to a QCDR therefore each EP must report on nine or more measures in order to successfully participate.
- Additonally there is no group reporting through a QCDR, only individual EP's can participate in QCDR PQRS reporting.
The Role of Third Party RCM Providers
There are several outsourced third-party billing and revenue cycle management providers that partner with the Anesthesia Quality Institute (AQI), and these organizations can greatly assist anesthesiology groups with PQRS reporting via the QCDR and other methods as well. For example, Zotec Partners, (ZP) is listed as an AQI preferred vendor (which is described by that entity as vendors that recognize the need for ongoing contribution of case-specific data to NACOR in a timely and efficient manner, and have developed an extract for data transmission to AQI). These vendors can facilitate QCDR reporting efforts if the EP chooses that option. Zotec Partners can also assist anesthesia groups in the identification of the measures providers can and should report, as well as determine how the measures can be tracked as part of their normal work flow if the QCDR or other reporting methods are chosen.
In relation to QCDR reporting, data is also critical to the process, so a group's billing provider should also capture and input data on the group's behalf, and securely store it. Electronically transferring the data to AQI directly will ensure appropriate reporting, especially for PQRS requirements via the ASA QCDR.
It should be noted that AQI participation is free to ASA members and any EPs working with them in the care team model. There is a fee for non-ASA members. Anesthesiologists may already be sending data to NACOR for example, but can still take advantage of the QCDR option by implementing a process for collecting clinical outcomes intra-operatively and in the PACU. Groups can sign up to become members with ASA and pay a small fee, but for groups not yet participating in NACOR, a preliminarily arrangement with the AQI is the next best step.
Participation in NACOR and use of the AQI QCDR to participate in PQRS is one of the many reporting options available to EP's currently. Each individual EP and group will need to carefully consider the current quality reporting environment against the changes that will occur in 2019 in order to successfully avert penalties in the coming years and use their quality metrics in order to improve the cost and quality provided to patients.
Andrew Bolles is a Director of Business Development with Zotec Partners.
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