Quality Measures Resource Guide: Quality Reporting is Mandatory in 2016

The United States’ healthcare “fee for service” payment system is rapidly transitioning away from one based on volume to one that is determined by “value” and links costs to improved patient outcomes. The problem with the current system is that patients who stay in service the longest and receive the greatest number of procedures and treatments generate the greatest revenue for providers, regardless of whether patient outcomes are favorable.

The transition to a different payment method began gradually in 2008 with Medicare’s Improvements for Patients and Providers Act, which authorized a 2% bonus of Medicare billing for qualified healthcare providers who successfully reported quality measures. Initially known as the Physician Quality Reporting Initiative, the reporting program is now called the Physician Quality Reporting System (PQRS). PQRS bonus payments have now ended. Clinicians who did not participate in PQRS in 2014 will experience a 2% reduction of their Medicare revenue in 2016. It’s true that, at 2%, only a small percentage of physician revenue is at stake under PQRS. However, under the Affordable Care Act (ACA; Obamacare) the financial penalty for not participating in quality reporting can quickly become significant – and the penalties are growing rapidly.

The reason you have to start paying attention to PQRS now is that, as part of the ACA, the value-based payment modifier (VM) will result in additional payment reductions to both clinicians and hospitals tied to PQRS performance and cost of care. Most clinicians will see the effect of the VM in 2017 based on their PQRS participation in 2015. That means failure to participate in PQRS in 2015 will result in a PQRS penalty of 2% in 2017 and a VM penalty of 2% (for groups of nine or fewer) and 4% (for groups of 10 or more). There are even more penalties, however.

There are penalties for your VM tied to PQRS. You have two options for participating in PQRS as a wound care and/or hyperbaric medicine practitioner. One way is to report the diabetes measure group.¹ The advantage of reporting the measure group is that you only have to report on 20 patients and only the “majority” of them have to be Medicare patients. That means it’s pretty easy to just pick 20 patients living with diabetes (at least 11 of which are Medicare beneficiaries) and input the data for the measures in a registry for reporting. The US Wound Registry is one of the most economical ways to do that.  A few examples of the measures:

Measure No. 1: Diabetes: Hemoglobin A1c  – poor control patients whose most recent HbA1c level (performed during the measurement period) is > 9.0%.

Measure No. 110: Preventive Care and Screening: Influenza Immunization – percentage of patients aged 6 months and older seen for a visit between Oct. 1 and March 31 who received an influenza immunization or who reported previous receipt of an influenza immunization.

Measure No. 117: Diabetes: Eye Exam  – percentage of patients 18-75 years of age living with a diagnosis of diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye-care professional in the measurement period or a negative retinal or dilated eye exam (negative for retinopathy) in the year prior to the measurement period.

Measure No. 119: Diabetes: Medical Attention for Nephropathy  – the percentage of patients 18-75 years of age living with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.

Measure No. 163: Diabetes: Foot Exam  – percentage of patients aged 18-75 years living with diabetes who had a foot exam during the measurement period. 

Measure No. 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention – percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months and who received cessation counseling intervention if identified as a tobacco user.

EHR Incentive Final Rule

The Centers for Medicare & Medicaid Services recently published a final rule that specifies criteria that eligible professionals (EPs) must meet to participate in the Medicare and Medicaid electronic health record (EHR) incentive programs. The new requirements expand Meaningful Use of certified EHR technology to promote health information exchange and improved patient outcomes. The rule also includes changes to the structure of the EHR incentive programs. Major provisions in the EHR incentive program include:

• A revised single set of objectives and measures. This includes a reduction in the overall number of objectives to which a provider must attest.
• Alternate exclusions and specifications for providers previously scheduled to be in stage I of Meaningful Use.
• A shift to calendar-year reporting and a 90-day EHR reporting period for all providers.
• Attesting to objectives and measures using EHR technology certified to the 2014 edition.
• Revisions to attestation and payment adjustment deadlines.

For more information, visit www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/stage3_ep.pdf

Reference

1. 2015 PQRS Measures Groups Specifications Manual. CMS. Accessed online: www.entnet.org/sites/default/files/2015-pqrs-measures-groups-specifications_1.pdf

This resource guide is made possible through the support of Hollister Inc., Libertyville, IL. The statements made within are not connected to any officials or providers affiliated with the company.

Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of US Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.