Aligned Quality Reporting: How To

The Centers for Medicare and Medicaid Services (CMS) officials explained how eligible professionals can report on clinical quality measures (CQMs) one time to meet CMS requirements for its physician quality reporting system (PQRS), meaningful use electronic health records (EHR) incentive program, and value-based modifier (VM) program.  They explained all of this on a national provider call on Wednesday.

CMS experts described the methods for eligible professionals (EPs) to do this on their own, through their group practices, or through the accountable care organizations (ACOs) they belong to, if those ACOs participate in the Medicare shared savings program or the Pioneer ACO program.

Although many have long called for the CMS to align quality reporting across these programs, it may not be easy for most physicians to follow the CMS' instructions for reporting one time. That's because they must use a certified EHR, a qualified registry, or a special web interface to do so. From 2011-2013, CMS data show, nearly three quarters of EPs used PQRS' claims-based reporting mechanism. Most of these EPs will have to shift to an entirely different reporting method to take advantage of the new alignment announced by CMS.

EPs can continue to report on CQMs using PQRS claims (although CMS is trying to end this by 2017, which was communciated in the 2014 Medicare Physician Fee Schedule published in the Federal Register), CMS officials confirmed during the provider call. But they will have to report separately to the three programs.

Reporting Once

The "report once" methodology requires EPs to report for 12 months, starting January 1, 2015. By doing so successfully, they can do the following:

  • Avoid the 2017 PQRS penalty of 2% of Medicare payments;

  • Satisfy the CQM component of the meaningful use requirements;

  • Qualify for bonuses under the VM program in 2017 if their quality scores are high enough. If they are in groups of 10 or more and have low scores, they may see their payments adjusted downward.

If the EPs do not satisfactorily report their CQMs to PQRS, the following will occur:

  • They will lose 2% of Medicare payments as a result of the PQRS penalty.

  • They will fail to satisfy the CQM component of the meaningful use program, which will also carry a penalty.

  • They will be subject to the VM automatic negative payment adjustment, which is 2% for soloists and groups of two to nine EPs and 4% for groups of 10 or more EPs, if at least 50% of the EPs do not satisfactorily report to PQRS as individuals.

These positives and negatives are similar in the group reporting and ACO reporting cases except that Pioneer ACO members are not subject to the VM adjustments.

Individual EPs can use either a certified EHR or a qualified clinical data registry to report their data to the CMS. If EPs assign their billing rights to a group practice, that group can use a certified EHR or a group practice reporting option (GPRO) web interface if the practice includes 25 or more EPs. An ACO must use the GPRO web interface on behalf of its EP members.

EPs who report individually must deliver data on at least nine CQMs in three national quality strategy domains, or on as many measures as they have data for. They can choose these from a group of 256 PQRS quality measures; however, not all of these measures are eligible for the required reporting methods.

For EPs who assign their billing rights to a group practice, the reporting requirements are a bit different. With the direct EHR reporting method, they can either report on nine CQMs in three domains or on six CQMs in two domains plus have a consumer assessment of healthcare providers and systems (CAHPS) for PQRS patient satisfaction survey conducted by an approved vendor. If they use the GPRO web interface, they have to report on all the measures included in that interface for a prepopulated Medicare beneficiary sample. If there are more than 100 doctors in the group, they also have to take a CAHPS survey.

ACOs must also report on all of the quality measures included in the GPRO web interface for the beneficiary sample. Individual EPs and groups that do not use that interface, however, can use both Medicare and non-Medicare patients in quality reporting as long as they report on at least one measure that includes a Medicare patient.