Self-Reporting of PQRS Measures in 2016: What You Choose to Report Does Matter!

This is the first installment in a series of articles that will explain how CMS will use healthcare providers’ QRURs to determine their Medicare Part B payment rates. 

There is an old joke about a police officer who sees a drunken man searching for something under a streetlight. When the officer asks if he can lend any help, the drunk says he’s lost his keys. After a few minutes of aiding the search, the policeman asks the man if he’s sure that he’s looking in the right spot for the lost keys, to which the drunk replies, “No, actually, I lost my keys in an alley.” The officer then asks, “Why are you searching here?” In response, the drunk exclaims, “Because this is where the light is!”

The Centers for Medicare & Medicaid Services (CMS) is using quality and cost data as a way to “shine the light” on physician practice in an attempt to determine which clinicians provide the highest quality care at the lowest cost. Unfortunately, for wound care clinicians this process shines the light in the wrong place — not anywhere near our patients or our practices. 

As a result, wound care practitioners may experience penalties under this new system despite providing high-quality care. It is possible to move the light a bit in the right direction, however. This article is the first in a series of articles that will explain how CMS will use healthcare providers’ Quality and Resource Use Reports (QRURs) to determine their Medicare Part B payment rates. There is math involved in this article and moving forward, and it is not possible to make this casual reading. However, these complex calculations will determine whether wound care practitioners will be able to safely earn a living for themselves in the next decade.

The MACRA Act

On April 1, 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), which established a new framework for practitioner payment that CMS officials hope will reward those who provide “better” care rather than just “more” care. 

MACRA also creates a new quality system — the Merit-Based Incentive Payment System (MIPS) — that combines parts of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBM), and the Meaningful Use (MU) of Electronic Health Record Incentive Programs into one comprehensive program. Beginning in 2017 and continuing annually, Medicare Part B providers will be assessed a MIPS score from 0-100 based on four performance categories: MU (representing 25 points); VBM quality (determined by performance on PQRS measures, up to 30 points); VBM cost (sometimes called “resource use,” 30 points); and a new category known as “clinical practice improvement” (15 points).  

Depending on the MIPS score, the worst performers will see as much as a 9% decrease in their Medicare Part B payments. The highest performers could see a maximum base-payment increase of as much as 27%. The program is budget neutral, which means the money available for incentives comes from the money assessed as penalties. This is what makes it possible for a few clinicians to earn a much higher percentage of their income as a bonus because, frankly, a larger pool of clinicians will experience penalties. The details are complex and it is easy to get lost in them, but the big picture is that a provider’s MIPS score can cause a rapid and profound change to a clinician’s revenue in either a positive or a negative direction.

It’s important to remember that each eligible professional’s (EP’s) MIPS score (and all the EP’s quality performance data) will be available online via CMS’ Physician Compare (www.medicare.gov/physiciancompare).

Consumers will be able to see providers rated on a scale of 0-100 as well as how they compare nationally to their peers. Patients will be looking at these data and so will the private payers. 

Remember, MIPS scores will be reported publicly, including performance rates of individual quality measures. A wound care clinician’s “skill” will be judged by the quality measures that he/she decides to report.

The Quality Game: MU & PQRS

Although MIPS does not begin until 2017, 85% of the score is derived from performance in the two quality programs that clinicians should already be engaged in: MU and PQRS. 

The VBM score is also critical, but is largely based on PQRS performance, making the choice of which PQRS measures to report that much more important. Those clinicians currently doing well with PQRS and MU are set to survive the transition to MIPS next year. To pass the MU of one’s EHR, clinicians must pass 10 objectives (one of which is to exchange data with a specialty registry). For 2016, the deadline to sign up with a specialty registry was Feb. 29, so those who didn’t meet that deadline are going to fail MU in 2016. These clinicians have already lost 2% of their Medicare Part B payments. However, PQRS is a separate program. Clinicians should already have picked the measures they intend to report as part of PQRS in 2016, but it is not too late to select them. This article series should help with that process.  

There are two ways to pass PQRS: 1) report at least one “measures group” on a 20-patient sample, the majority of which (at least 11 of 20) must be Medicare Part B fee-for-service (FFS) patients; and 2) report on at least nine individual PQRS measures covering three National Quality Strategy (NQS) domains on at least 50% of one’s Medicare Part B FFS patients. One of the nine measures must come from the “cross-cutting” measure list. Let’s explain each of these options in more detail.

Reporting PQRS with a Measure Group:

The following link lists 2016 measures groups: https://content.findacode.com/documents/pqri/2016/2016_PQRS_MeasureGroups_ReleaseNotes_11_17_2015.pdf. 

Clinicians only need to report on any 20 of their patients. Those wound care and hyperbaric medicine practitioners who decide to satisfy PQRS via the measures group option are advised here to report the diabetes measure group, which is comprised of six PQRS measures:

1. Measure No. 1 - Diabetes: Hemoglobin A1c Poor Control
2. Measure No. 110 - Preventive Care and Screening: Influenza Immunization 
3. Measure No. 117 - Diabetes: Eye Exam
4. Measure No. 119 - Diabetes: Medical Attention for Nephropathy
5. Measure No. 126 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy-Neurological Evaluation
6. Measure No. 226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Review the release notes in the aforementioned link to better understand the details of individual measures that comprise this group. Clinicians must have data for all the individual elements; just because a clinician has data does not mean he/she will pass the measure. For example, there must be an actual hemoglobin A1c value for PQRS No. 1, but in order to “pass” PQRS No. 1 the hemoglobin A1c value must be less than 9%. 

How do you actually report the measure group? The US Wound Registry (USWR) is an available registry that allows entering of the diabetes measure group data “by hand” on 20 patients. In other words, clinicians can take their charts, sit at a computer, access the registry (after properly logging in for PQRS services), and begin the process of entering data one patient at a time. Clinicians will need to find information required by the measure (eg, lab values, physical examination findings) within each patient’s chart. The measure group cannot be passed by entering “no data.” 

Obtaining and entering data for patients is a relatively easy way to pass PQRS in 2016 (assuming one meets the information needs required by the measure), but this is not a beneficial long-term plan because PQRS is how care quality is going to be portrayed publicly. Those who pick this option will not have their expertise judged on the basis of healing rates or adherence to guideline-based wound care with interventions such as diabetic foot ulcer offloading or venous ulcer compression. 

Care quality as a wound care practitioner will be judged (for example) by whether or not 20 patients treated within the practice got their influenza immunization or received tobacco cessation counseling. This is probably not the best way to convey expertise in wound care. 

The other reason the diabetes measure group is not an advisable long-term strategy for wound care practitioners is that entering data on 20 patients “by hand” does not help one get through the MU of an EHR. The 10 objectives in the MU program are designed to demonstrate how well clinicians are able to harness their EHRs to perform data analytic tasks for themselves. Entering data “by hand” into a registry does not demonstrate that a clinician can effectively use an EHR. 

Reporting PQRS With 9 Quality Measures

For this option, clinicians must report data on 50% of all patients. This measure cannot be passed by entering data “by hand” because of the need to report on half of the patients in one’s practice and to prove that this percentage has been captured. 

Data will have to come from a certified EHR, meaning the EHR is certified for stage II of MU. Clinicians must select nine PQRS measures from at least three of the six NQS domains, which are:

1. Patient Safety
2. Effective Clinical Care
3. Communication and Care Coordination
4. Person- and Caregiver-centered Experience of Care
5. Community/Population Health
6. Efficiency and Cost Reduction. 

For the remainder of this article series, see the PDF version of this article above.