The benefits of PQRS participation and what the College is doing on your behalf

The Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS) program is the first national program to link the reporting of quality data to physician payment. PQRS began in 2007, providing incentive payments only to eligible professionals (EPs) who voluntarily and successfully participated in the program. Although EPs include nonsurgeon health care professionals, such as other physician specialists, podiatrists, and nurses, for purposes of this Bulletin article, EPs are generically referred to as “surgeons.” In 2013, all surgeons began receiving either an incentive payment for participation or a penalty for lack of or unsuccessful participation. This policy will change again in 2015 when surgeons and other providers will no longer receive incentive payments for successful participation. However, surgeons who fail to comply with the program will receive penalties indefinitely.

Table 1 highlights the PQRS incentive and penalty amounts for 2014 and beyond. Penalties are applied to a surgeon’s total Medicare Part B fee-for-service (FFS) amount, two years after the “performance period” ends. This article provides examples of the scenarios surgeons could face for participation or nonparticipation in 2014, as well as an overview on the PQRS program. It also describes what the American College of Surgeons (ACS) is doing to assist members with participation.

Table 1. PQRS payment incentives and penalties

Calendar year Incentive Penalty*

2014

0.5%

2015

1.5% (based on 2013 performance)

2016 and beyond

2.0% (based on 2014 performance)

*Penalties are applied based on an EP’s performance two years prior to the calendar year.

What the ACS is doing

In June, the ACS conducted a brief survey to determine the membership’s understanding of the PQRS program. The results of the survey, featured in Table 2, show that nearly half of the 189 respondents had not participated in PQRS and more than one-quarter were unaware of the incentives and penalties. The College has been doing its part to help surgeons by providing informational material and participation opportunities for surgeons so they can avoid the risks of nonparticipation and enjoy the benefits of the program. What is new for this year is that the ACS has received CMS approval for surgeons to submit data collected from two ACS registries in order to meet the 2014 PQRS reporting requirements—the Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). (See sidebar at the end of this article for details.)

Table 2. Fellow responses to ACS survey on PQRS awareness

Survey questions

Yes

No

Total

Participated in PQRS in 2013 or previous years?

107

82

189

56.6%

43.4%

Do you plan to participate in 2014?

120

69

189

63.5%

36.5%

Are you aware that if you participate in PQRS for 2014, you could receive a 0.5% incentive payment?

149

40

189

78.8%

21.2%

Did you know that if you don’t participate in PQRS for 2014, you will receive a 2% penalty for your Medicare payment?

135

54

189

71.4%

28.6%

Would you be interested in knowing more about the ACS SSR that has been qualified by CMS for PQRS reporting for 2014?

136

53

189

72.0%

28.0%

Financial importance of participating in PQRS

Unlike other CMS programs, PQRS does not have opt-out “exemptions.” EPs must participate to avoid penalties. Under the PQRS program, an EP is defined as any health care professional who is getting paid under or based on the Medicare physician fee schedule.1

2014 PQRS individual reporting options

Surgeons and group practices may participate in the PQRS program in a variety of ways. Surgeons may report individually and choose one of the methods from the following reporting options that are described in greater detail in Table 32:

  • Claims-based reporting option for individual EPs
  • Registry-based reporting option
  • Electronic health records-based reporting option
  • Qualified clinical data registry (QCDR) reporting option

Table 3. Summary of requirements for the 2014 PQRS incentive for surgeons
Individual reporting criteria for satisfactory reporting of individual quality measures via claims, qualified registries, and EHRs and satisfactory participation criterion in qualified clinical data registries

Reporting period

Measure type

Reporting mechanism

Satisfactory reporting criteria/satisfactory participation criterion

12-month (January 1–December 31) Individual measures Claims Report at least 9 measures covering at least 3 National Quality Strategy (NQS) domains; if less than 9 measures covering at least 3 NQS domains apply to the EP, report 1 to 8 measures covering 1 to 3 NQS domains, and report each measure for at least 50 percent of the Medicare Part B fee-for-service patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.* For an EP who reports fewer than 9 measures covering 3 NQS domains via the claims-based reporting mechanism, the EP will be subject to the claims Measures Applicability Validation (MAV) process, which would allow [CMS] to determine whether an EP should have reported quality data codes for additional measures and/or covering additional NQS domains.
12-month
(January 1–December 31)
Individual measures Qualified registry Report at least 9 measures covering at least 3 of the NQS domains; if less than 9 measures covering at least 3 NQS domains apply to the EP, report 1 to 8 measures covering 1 to 3 NQS domains for which there is Medicare patient data, and report each measure for at least 50 percent of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.* For an EP who reports fewer than 9 measures covering 3 NQS domains via the registry-based reporting mechanism, the EP will be subject to the registry MAV process, which would allow [CMS] to determine whether an EP should have reported on additional measures and/or measures covering additional NQS domains.
†12-month (January 1–December 31) Individual measures Direct EHR product and data submission vendor Report 9 measures covering at least 3 of the NQS domains. If an EP’s certified EHR technology does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report the measures for which there is Medicare patient data. An EP must report on at least 1 measure for which Medicare patient data are available.
12-month
(January 1–December 31)
Measures groups Qualified registry Report at least 1 measures group, and report each measures group for at least 20 patients, a majority of whom must be Medicare Part B FFS patients.
6-month
(July 1–December 31)
Measures groups Qualified registry Report at least 1 measures group, and report each measures group for at least 20 patients, a majority of whom must be Medicare Part B FFS patients.
12-month(January 1–December 31) Measures selected by qualified clinical data registry Qualified clinical data registry Report at least 9 measures covering at least 3 NQS domains and report each measure for at least 50 percent of the EP’s applicable patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.* Of the measures reported via a qualified clinical data registry, the EP must report on at least one outcome measure.

*Subject to the Measures Applicability Validation process for claims-based or registry-based reporting.
Finalized in the CY 2013 PFS final rule (see Table 91 at 77 FR 69194).

Each option requires adherence to some complex rules and time lines. The ACS has assembled a list and discussion of each of these options. Successful compliance with any of the appropriate reporting options will allow EPs to earn an incentive payment of 0.5 percent.

Note that group practices have the option to participate in PQRS through the Group Practice Reporting Option (GPRO). These options differ from the individual EP options listed in Table 3. The only circumstance in which a group practice may choose from the GPRO reporting options is if the group practice has sent a request to CMS to participate via the GPRO option by September 30, 2014, and has received CMS approval.3

Likely scenarios

Surgeon may face one of three scenarios in the coming years based on their participation in the 2014 PQRS program, as follows.

Scenario one: Smart Surgeon A

Surgeon A is participating in the PQRS program for calendar year (CY) 2014 using the ACS SSR, allowing Surgeon A to complete and meet all of the requirements necessary to successfully comply with the 2014 PQRS program. This surgeon has a Medicare allowable payment amount of $100,000 in 2014. As a result of successful participation in PQRS 2014, Surgeon A will receive a bonus payment of 0.5 percent, or $500, and, more importantly, will avoid a 2 percent penalty, or $2,000, in 2016. In addition, Surgeon A will be identified as a successful PQRS participant on the CMS Physician Compare website.4

Scenario two: Poor Surgeon B

Surgeon B does not participate in the PQRS program in CY 2014 because of time constraints. Like Surgeon A, Surgeon B has a Medicare allowable amount of $100,000 in 2014. However, due to nonparticipation, Surgeon B will not receive an incentive payment. Instead, Surgeon B will receive a penalty of 2 percent of the total Medicare charges, or $2,000, in 2016. Note that the penalty is applied to Surgeon B two years after the current CY, otherwise known as the performance period. Furthermore, Surgeon B will not be listed as a PQRS participant on the CMS Physician Compare website.

Scenario three: It gets worse for Surgeon B

What could be worse? The penalty can double by adding in the effect of the CMS value-based payment modifier for physicians. The value-based payment modifier provides for differential payment to a physician or group of physicians under the Medicare physician fee schedule and based on the quality of care furnished compared to cost during a performance period.5

If Surgeon B belongs to a group practice of 10 or more physicians in 2014 and that group does not participate in one of the PQRS GPRO options, or if 50 percent of that group does not participate in PQRS via one of the individual reporting options, Surgeon B will receive an additional 2 percent penalty under the value-based payment modifier in 2016. Thus, Surgeon B will face a combined PQRS and value-based payment modifier penalty totaling $4,000 based on a Medicare allowable amount of $100,000 in 2014. On the other hand, successful PQRS reporters, like Surgeon A, will be eligible for value-based payment modifier bonuses.

As outlined in the previous scenarios, successful participation in PQRS is essential for avoiding substantial payment penalties. The PQRS payment penalty will occur indefinitely in future years. In addition to the PQRS and value-based payment modifier programs, other CMS quality programs, such as the Electronic Health Record (EHR) Incentive Program, have penalties that take effect around the same time. (Additional information on the EHR Incentive Program is available.)

Resources for surgeons

Additional background information and PQRS resources are available at www.facs.org/advocacy/regulatory/pqrs, as well as www.cms.gov/PQRS.

Furthermore, ACS staff members are available to answer questions and assist members participating in the 2014 PQRS program, and to facilitate enrollment in the SSR and the MBSAQIP. For PQRS-related questions, surgeons can contact the following ACS staff:

  • General PQRS program questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202-337-2701 or sgokak@facs.org
  • Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care (DROPC), 312-202-5000 or ssr@facs.org
  • Information on the MBSAQIP: Rasa Kraprikas, ACS DROPC, 312-202-5000 or rkrapikas@facs.org
  • CMS is also available to answer PQRS-related questions at 1-866-288-8912 or qnetsupport@hcqis.org

ACS programs to assist in PQRS reporting

The ACS recognizes that it may be difficult for most surgeons to comply with PQRS reporting by using the claims- or EHR-based method. The registry-based reporting option, available through the ACS SSR, and the QCDR, available through ACS MBSAQIP, may be better options for some surgeons to pursue.

SSR

The SSR, formerly known as the ACS Case Log, allows surgeons to track their cases and outcomes in a convenient, easy-to-use, and confidential manner. The SSR can also be used to comply with regulatory requirements, such as submitting 2014 PQRS data. The SSR allows individual EPs to report on the four measures within the Perioperative Care Measures Group or the five measures (if applicable) and/or surgical outcome measures within the General Surgery Measures Group. Surgeons can choose to report on 20 majority Medicare patients for either one of these groups and will have until January 31, 2015, to submit CY 2014 patient information in the SSR. The SSR will submit the PQRS data to CMS.

The SSR is available at no cost to ACS surgeon members and will be available to non-member surgeons later this year for a nominal fee. Surgeons who have used the Case Log in the past can log on to the SSR with the same username and password and begin entering cases at www.facs.org/ssr. For current users, the SSR can produce a report that indicates the surgeon’s eligible PQRS cases, based on measures group Current Procedural Terminology codes. These cases may be easily edited with PQRS-specific data through the report. If surgeons have not used the Case Log in the past, they can register at www.facs.org/members/pbls.html. Surgeons will need to consent to and sign up for PQRS reporting through the SSR if they want the registry to submit data on their behalf.

MBSAQIP

The MBSAQIP has been approved by CMS as a QCDR for PQRS 2014. MBSAQIP participants will have the opportunity to voluntarily elect that their MBSAQIP QCDR quality measures results be submitted to CMS for PQRS participation. Metabolic and bariatric surgeons will receive reports of their QCDR measures results so they can track, and have the opportunity to improve, their results. The MBSAQIP will submit approved 2014 QCDR measures during the first quarter of 2015 on behalf of MBSAQIP participants who elect to have their data submitted. One benefit of using the MBSAQIP is that data are already being collected as part of participation in the MBSAQIP, whereas other options to satisfy PQRS may have additional data burden. Specifications of the approved MBSAQIP QCDR quality measures are available at www.mbsaqip.info/wp-content/uploads/2014/03/MBSAQIP-QCDR-specifications.pdf.


References

  1. Centers for Medicare & Medicaid Services. Physician quality reporting system list of eligible professionals. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf. Accessed June 12, 2014.
  2. Centers for Medicare & Medicaid Services. Revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to Part B for CY 2014. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014-Physician-Fee-Schedule-Final-Rule_CMS-1600-FC.pdf. Accessed June 10, 2014.
  3. Centers for Medicare & Medicaid Services. Group reporting options. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html. Accessed June 12, 2014.
  4. Gokak S. What surgeons should know about…The physician compare website. Bull Am Coll Surg. 2013;98(2):52-53. Available at: http://bulletin.facs.org/2013/02/the-physician-compare-website/. Accessed June 12, 2014.
  5. Centers for Medicare & Medicaid Services. Summary of 2015 physician value-based payment modifier policies. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf. Accessed June 23, 2014.

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