2016 PQRS Reporting Strategy, Part 2

March 3rd, 2016 by Rod Baird

Last week, our blog post provided an annual overview of CMS approved Individual PQRS Measures for use by medical groups practicing in Nursing Facilities, Homecare, Assisted Living, and related places of service (click here to view last week’s post). This week, our blog post focuses on the PQRS reporting strategy for practices. We are only going to describe the strategies that are appropriate for basic and intermediate level reporting here; there are advanced strategies that the average medical group will be unwilling/unable to execute.

The #1 question we are fielding from LTPAC Medical Groups relates to selection of 2016’s PQRS Reporting Strategy.  CMS released the updated 2016 PQRS Measures around Thanksgiving, and are posting expanded documentation as I write.

There continues to be a confusing array of reporting options, this blog post attempts to sort them out.  These include Group (GPRO) and Individual provider reporting elections.  Within those two broad paths, there are two or more branches in each path.  We are only going to describe the strategies that are appropriate for basic and intermediate level reporting here; there are advanced strategies that the average medical group will be unwilling/unable to execute.

The following analysis is written from an admittedly cynical point of view – we find few Medical Professionals who believe the current CMS Quality Measurement Strategies are bona fide, particularly for LTPAC Patients.  Consequently, the analysis’ objectives are to satisfy the required reporting obligations to avoid penalties while minimizing the added time burden.

Under VBP it is nearly impossible for a Primary Physician led group to score ‘high quality’ – so getting a passing grade with the lowest reporting burden is the wisest business strategy (we do acknowledge that there are multiple clinical settings where striving for high quality is the right thing to do, but PQRS for LTPAC Medicine is not one of them).

Why should we care about PQRS?  It’s simple, CMS will penalize you for noncompliance.  Payment Penalties for medical groups failing to report in 2016 appear in payment year 2018 as a Medicare Part B fee-schedule reduction.  They are:

  • Larger (10+) physician led groups – total penalties @ <6%>. That’s <2%> for PQRS and another <4%> from VBP (value based purchasing).
  • Smaller (2-9) physician led groups – total penalties @ <4%>. That’s <2%> for PQRS and another <2%> from VBP.
  • Solo physicians and all NP/PA only groups – total penalties @ <4%>. That’s <2%> for PQRS and another <2%> from VBP.

 OK – a <6%> penalty gets my attention!  How should we report; as a Group or Individually?  Whichever way you report, the objective is to satisfy the threshold requirements for avoiding the VBP penalty.  That means reporting successfully as a Group, or have over 50% of the group’s members successfully report individually.

GROUP PRACTICE REPORTING OPTION – Warning – entering CMS double speak zone! GPRO requires use of Individual Measures, not a Measures Group.  In the past we steered physicians away from GPRO for LTPAC medicine.  However, the 2016 Fee Schedule changed GPRO enrollment options.

  • In 2015 and earlier years, your enrollment was irreversible after a point in time (July of that year). It would be unusual in July to know if you would satisfy reporting requirements 6 months in the future.
  • The final 2016 regulations created the option to ‘unelect’ GPRO up to the 2017 PQRS filing date. We await publication of the policy guidance on the CMS GPRO Webpage to see how this new regulation translates into a procedure.

GPRO has strategic benefits – it allows reporting at the Group TIN level (Taxpayer ID number), as opposed to the Clinician NPI level. Some groups with lots of turn-over or moonlighting staff had historic problems reaching the 50% individual threshold for successful PQRS reporting.  A provider with just 1 patient weighs in equally with a full time census in the hundreds.

You Group will be successful at GPRO if the TIN reports on 9 individual measures for 50% of the total Medicare Part B FFS Population. This could mean more work for some clinicians, but if there are lots of part-time or PRN staff who don’t/won’t/can’t do a PQRS Measures Group, then GPRO may be a viable strategy.

  • Remember – Group Reporting (GPRO) cannot be done successfully using PQRS Measures Groups – this semantic trap caused major failures in the past when it was impossible to ‘back-out’ of the GPRO election.

If you select GPRO, you have two choices:

  1. Successfully reporting 9 or more individual measures via a Quality Registry for >50% of your eligible Part B patient population, or
  2. Web based GPRO (for groups of 25+ providers) – this is, perhaps, both the easiest and highest risk reporting option available.  Your Group registers during the enrollment period and see patients without regard to PQRS.  In January of 2017, CMS selects a random sample of your patient panel (in 2015 the size is 248 patients) – that patient list is based on data from claims your group submitted.  The demographics, CPT® codes, and diagnoses of that sample of patients is compared to the denominator populations for 18 GPRO web interface measures (Note – this link downloads a ‘zip’ compressed file to your computer).
    • How many instances of quality reporting will you have to do?  Theoretically you could do as many as 18 measures x 248 patients = 4,464 reports. In reality, this will be a much smaller number; some measures don’t apply to LTPAC CPT® codes, and only 2-4 diagnoses per claim are typically submitted.  We have anecdotal reports from LTPAC groups of only having to supply replies to 10 total measures spanning 7 patients.   Unfortunately, there were no records retained so it is impossible to validate this.
    • Once your reporting requirements are enumerated, someone in your group searches your medical records for the corresponding quality behaviors. You have to report ‘performance met’ for at least one patient in each of the applicable quality measures to meet minimum requirements.
    • We don’t recommend planning on Web based GPRO, the results aren’t predictable – a big risk in light of the penalties. However, if it is legitimate to enroll in GPRO, then view your panel of patients & measures in January 2017, and disenroll if not happy with the option – then it may be strategy worth considering for groups that have failed at PQRS in the past.

REPORTING PQRS AS INDIVIDUALS WITHIN A GROUP PRACTICE.  This option is straight forward, placing a proportional burden on each member of the group, and allows easy tracking of progress.  Remember, to avoid VBP Penalties, over 50% of total group members (on an annual basis) must successfully report.

Each individual within the group has two basic options to report:

  • Report on at least 1 PQRS Measures Group for 20 or more patients. A majority of the patients must be Medicare Part B.
  • Report on 9 or more individual measures. Measures must cover 3 or more domains of care, 1 measure must be ‘cross-cutting’.

MEASURES GROUP REPORTING REMAINS OUR RECOMMENDED BASIC PQRS STRATEGY. This reporting method is much easier to manage than individual measures – which require a full year of attention.  We encourage medical groups to identify a ‘PQRS manager’ who takes responsibility for selecting the measures group, educating the medical staff, and organizing the reporting strategy. The measures group selected depends on which work-flow best applies within the group, and the array of specialties within the group. There are 8 Measures Groups for 2016 associated with 99304-99310, they are:

CKD HF CAD Sleep Apnea
Dementia Parkinson’s Sinusitis Acute Otitis Externa

Our Clinical and Regulatory Team reviewed each of the 8 Measures groups for utility in the Nursing Facility.  The four groups that we believe are most applicable are in bold.

  • The Parkinson’s Disease Measures Group has the lowest apparent labor burden. A clinician can complete the assessment at bedside; the recommended treatment strategies are LTPAC population appropriate. Based on an analysis of coding for hundreds of LTPAC Clinicians, Parkinson’s is a high frequency diagnosis; the typical practitioner will treat more than the required 20 patients during a calendar year.
  • The Dementia Measures Group may be the most generically appropriate for LTPAC medicine because of the high frequency of Cognitive Impairment in the LTC Setting. In prior years we’ve recommended it as the preferred Measures Group.  There were important changes in the 2016 Group specifications that require revisions in work flow.
    • Good news – only one encounter is now required to satisfy the reporting requirements.
    • Less good news – The Depression Screening Measure Changed – it now requires the completion of a depression screen on the date of the encounter and documentation of a follow-up plan on the date of the positive screen. This adds complications to the work flow.  The LTC appropriate Screening tool is the PHQ-9 (used for the MDS assessment).  There are numerous free websites available to execute the assessment and record the score in your note.  All other questions can be answered without leaving your PQRS recording tool (e.g. EHR or PQRS Form).
  • Heart Failure and CAD Measures Groups: There were minor changes in these two groups which will not affect the workflow. Both are acceptable Measures Groups for LTC settings but have technical drawbacks that make them less desirable outside an office based practice.

To help readers new to PQRS selection strategies, here is some background.  Our EHR (gEHRiMed™) offered the Diabetes Measure Group for 2013-2015. There were 400+ providers who elected to use a Measures Group; no LTPAC clinician elected to use the Diabetes Measures group in 2015 secondary to its rigid approach to a disease management paradigm – judged to be inappropriate for the LTC population.

  • It is key to actually read the definitions of ‘performance met’ contained in each individual measure. Some are flexible, but others, as with Diabetes, are strict.  Picking measures that align with your practice’s goals for a patient population is the logical strategy.

INDIVIDUAL MEASURES – Historically, it was easy to use individual measures – you simply followed 3 measures that were reported on your Part B claims.   Today, you must track 9 measures across 3 domains of care; one measure must be ‘cross-cutting’.  BTW – you better make sure that every provider reports on each of the 9 measures for at least 50% of their Medicare Part B patients!

The complexity of following this set of rules numbs my mind.  Even with full control of an EHR, and the ability to mix PQRS measures with eCQMs, the work load on an individual provider is unacceptable.

  • An additional trap – most of the new individual measures published this year, and many old measures, are only reportable via Registry. So practices whose reporting strategy was based on Claims reporting will find their submitted data being overlooked.

Individual measures do have a place – in highly sophisticated practices trying to manage their quality profiles for MSSP programs, Health Systems, or in preparation for MIPS.  In some situations, Quality Scores are very important.  In my last blog (late February) we publish a complete atlas of LTPAC eligible Individual PQRS measures for use in those situations.  I do want to highlight two new measures that may be useful because they are in a Quality Domain which is poorly represented in the balance of PQRS measures for LTPAC places of service:

  • #342 Pain Brought Under Control Within 48 Hours which applies to palliative care patients in POS 13, 14, and 33 (not #31 or 32). Domain – Person and Caregiver-Centered Experience and Outcomes.
  • #386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences which applies to POS 13, 14,31, 32, and 33. Domain – Person and Caregiver-Centered Experience and Outcomes.

One additional LTPAC appropriate measure to consider:

  • #332: Adult Sinusitis: Appropriate Choice of Antibiotic. Applies to LTPAC POS 13, 14,31,32,33. Domain: Efficiency and Cost Reduction

Sinusitis is the only measure, useful in LTPAC settings that populates the Efficiency and Cost Reduction Domain.

We hope this quick tour of 2016 PQRS reporting offers some LTPAC specific context for your medical group.

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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