Barbara Connors, D.O., M.P.H. Patrick Hamilton Centers for Medicare & Medicaid Services Philadelphia Regional Off

1. Stage 2 Meaningful Use and 2013 PQRS Updates Webinar Barbara Connors, D.O., M.P.H.Patrick Hamilton Centers for Medicare & Medicaid ServicesPhiladelphia Regional Office January 15, 2013

2. Physician Quality Reporting System (PQRS)

3. PQRS – Who is an Eligible Professional? EPs include: • Physicians • MD, DO, Doctor of Podiatric Medicine, Doctor of Optometry, Doctor of Dental Surgery, Doctor of Dental Medicine, Doctor of Chiropractic • Practitioners • PA, NP, Clinical Nurse Specialist, CRNA, Certified Nurse Midwife, Clinical SW, Clinical Psychologist, RD, Nutrition Professional, audiologists • Therapists: • PT, OT, Qualified Speech-Language Therapist

4. PQRS Goals • Align with other Medicare quality reporting programs that have quality reporting requirements • Encourage eligible professionals into reporting for the PQRS payment adjustment by providing alternative means to avoiding the 2015 and 2016 payment adjustments • Emphasize PQRS facilitates the overall improvement in quality of care

5. CMS Quality and Reporting Program Alignment • PQRS and the EHR Incentive Program Extension of the PQRS-Medicare EHR Incentive Pilot to 2013 • Satisfactory reporting criteria for the 2014 PQRS Incentive via the EHR-based reporting mechanism and the criteria for meeting the CQM component of meaningful use under the EHR Incentive Program • Requirement of Certified Electronic Health Record Technology (CEHRT)

6. PQRS Group Practice Reporting Option (GPRO) & Medicare Shared Savings Program • PQRS GPRO measures aligned with measures under MSSP • Under the Medicare Shared Savings Program, ACOs successfully reporting measures under the Medicare Shared Savings Program via the GPRO Web Interface will not be subject to the PQRS payment adjustments as long as the ACO satisfactorily reports at least 1 measure

7. PQRS and the Value-based Payment Modifier • The Value-based Payment Modifier and meeting the criteria for satisfactory reporting for the 2013 PQRS incentive and 2015 PQRS payment adjustment • Group practices consisting of 100+ eligible professionals, beginning in 2013 will be subject to the Value-based Payment Modifier Note: The 2015 and 2016 Value-based payment modifier does not apply to ACOs

8. PQRS Reporting Periods 2015 PQRS payment adjustment: • 6-month and 12-month reporting periods that coincide with the 2013 PQRS incentive reporting periods 2016 PQRS payment adjustment • 6-month and 12-month reporting periods that coincide with the 2014 PQRS incentive reporting periods 2017 and subsequent PQRS payment adjustments • 12-month reporting periods only

9. Incentive and Payment Adjustment Amounts 2013: 0.5% Incentive 2014: 0.5% Incentive 2015: 1.5% Payment Adjustment will be applied in 2015 based on reporting in 2013 2016: 2.0% Payment Adjustment will be applied in 2016 based on reporting in 2014

10. Reporting Mechanisms Registry • Expand use of the registry-based reporting mechanism to group practices participating in the GPRO EHR • Beginning in 2014: • All direct EHR products and EHR data submission vendor’s products must be certified by the Office of the National Coordinator as CEHRT. • Expand use of the EHR-based reporting mechanism to group practices participating in the GPRO in 2014 GPRO Web Interface • Adoption of the Medicare Shared Savings Program method of assignment and sampling

11. Reporting Mechanisms Administrative Claims • A reporting mechanism under which an eligible professional or group practice elects to have CMS analyze claims data to determine which measures an eligible professional or group practice reports • For the 2015 PQRS payment adjustment only • Under this reporting mechanism, eligible professionals or group practices need to complete this election by the October 15, 2013 deadline

12. Benefits of Participating as an Individual Eligible Professional There is no requirement to register to participate as an individual Exception: If an individual eligible professional wishes to elect the administrative claims-based reporting mechanism to avoid the 2015 PQRS payment adjustment, the eligible professional must affirmatively elect to be analyzed under this reporting mechanism • For eligible professionals in solo practices, participating in PQRS as an individual is the only option for you • Eligible professionals within your group practice may freely choose which PQRS measures to report

13. How to Participate as an Individual Choose a reporting period, reporting mechanism, and reporting criterion • Reporting Periods: 6-month, 12-month • Reporting Mechanisms: Claims, Registry, EHR (EHR direct product and EHR data submission vendor), and Administrative Claims (to avoid the 2015 PQRS payment adjustment only) Choose the individual measures or measures groups you wish to report • Note: For help on choosing measures, please see the “How to Get Started” section of the CMS PQRS website and contact the QualityNet Help Desk if you still have questions Start Reporting!

14. PQRS Payment Adjustment For 2015 and subsequent years, a payment adjustment with respect to covered professional services furnished by an eligible professional will be applied if the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reporting period for the year Applicable adjustment amount: • 2015: 1.5% • 2016 and subsequent years: 2.0%

15. How to Avoid the Payment Adjustment in 2015 There are 3 ways an individual eligible professional may meet the criteria for satisfactory reporting for the 2015 PQRS payment adjustment: • Meet the criteria for satisfactory reporting for the 2013 PQRS Incentive • Report 1 valid measure or measures group using the claims, registry, or EHR-based reporting mechanisms • Elect to be analyzed under the administrative claims-based reporting mechanism Note: If participating in PQRS through another CMS program (such as the Medicare Shared Savings Program), please check the program’s requirements for information on how to simultaneously report under PQRS and the respective program.

16. How to Avoid the Payment Adjustment in 2016 There is 1 way an eligible professional may meet the criteria for satisfactory reporting for the 2016 PQRS payment adjustment: • Meet the criteria for satisfactory reporting for the 2014 PQRS Incentive Note: We may establish additional ways to meet the criteria for satisfactory reporting for the 2016 PQRS payment adjustment in future rulemaking.

17. Definition of a PQRS Group Practice • Group Practice = A single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by their individual National Provider (NPI), who have reassigned their Medicare billing rights to the TIN • We have changed the definition of group practice to include groups of 2-24 eligible professionals. • Beginning in 2013, all group practices can participate in the PQRS group practice reporting option (GPRO)

18. GPRO Reporting Benefits of Participating as a Group Practice: Billing and reporting staff may report one set of quality measures data on behalf of all eligible professionals within a group practice, reducing the need to keep track of eligible professionals’ reporting efforts separately

19. How to Participate as GPRO 1. Self-Nominate to Participate in the PQRS Group Practice Reporting Option (GPRO) • Group practices will submit a self-nomination statement via a CMS developed website • Deadline to Self-Nominate: October 15, 2013 2. Choose a Reporting Mechanism and Reporting Criterion Available Reporting Mechanisms in 2013 • GPRO Web Interface, Registry, and Administrative Claims 3. Beginning in 2014, the EHR-based reporting mechanism will also be available for use under the GPRO Start Reporting!

20. GPRO Payment Adjustment For 2015 and subsequent years, a payment adjustment with respect to covered professional services furnished by an eligible professional will be applied if the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reporting period for the year • Applicable adjustment amount: • 2015: 1.5% • 2016 and subsequent years: 2.0%

21. How to Avoid the Payment Adjustment in 2016 There is 1 way a group practice may meet the criteria for satisfactory reporting for the 2016 PQRS payment adjustment: Meet the criteria for satisfactory reporting for the 2014 PQRS Incentive under the GPRO • Note: We may establish additional ways to meet the criteria for satisfactory reporting for the 2016 PQRS payment adjustment in future rulemaking

22. PQRS Measures Total # of Individual PQRS Measures: 2013 there are 259 measures 2014 there are 288 measures Consider Million Hearts measure GPRO Measures: 18 measures, including 2 composites, for a total of 22 measures (same as the measures available for reporting under the Medicare Shared Savings Program) • Note: For help on selecting measures on which to report, please see the “How to Get Started” section of the CMS PQRS website and contact the QualityNet Help Desk if you still have questions

23. e-Prescribing Initiative

24. The eRx Incentive Program: Updates • Most of the requirements for the remainder of the eRx Incentive Program were established in the CY 2012 Medicare PFS final rule. Please note that, although the self-nomination deadline to participate in the PQRS GPRO was extended to October 15, the self-nomination deadline to participate in the eRx GPRO remains January 31. Updates to the eRx Incentive Program: • New Criteria for the eRx group practice reporting option (eRx GPRO) • Since, accordingly with PQRS, we expanded definition of group practice to include groups of 2-24 eligible professionals, we finalized new criteria for becoming a successful electronic prescriber under the eRx GPRO: • Report the electronic prescribing measure for at least 75 instances during the applicable 2013 eRx incentive or 2014 eRx payment adjustment reporting period

25. eRx Incentives for 2012 and 2013 • Most of the requirements for the remainder of the eRx Incentive Program were established in the CY 2012 Medicare PFS final rule. Please note that, although the self-nomination deadline to participate in the PQRS GPRO was extended to October 15, the self-nomination deadline to participate in the eRx GPRO remains January 31. Updates to the eRx Incentive Program: • New Criteria for the eRx group practice reporting option (eRx GPRO) • Since, accordingly with PQRS, we expanded definition of group practice to include groups of 2-24 eligible professionals, we finalized new criteria for becoming a successful electronic prescriber under the eRx GPRO: • Report the electronic prescribing measure for at least 75 instances during the applicable 2013 eRx incentive or 2014 eRx payment adjustment reporting period

26. eRx Payment Adjustments for 2014 (-2.0% of MFPS) • Most of the requirements for the remainder of the eRx Incentive Program were established in the CY 2012 Medicare PFS final rule. Please note that, although the self-nomination deadline to participate in the PQRS GPRO was extended to October 15, the self-nomination deadline to participate in the eRx GPRO remains January 31. Updates to the eRx Incentive Program: • New Criteria for the eRx group practice reporting option (eRx GPRO) • Since, accordingly with PQRS, we expanded definition of group practice to include groups of 2-24 eligible professionals, we finalized new criteria for becoming a successful electronic prescriber under the eRx GPRO: • Report the electronic prescribing measure for at least 75 instances during the applicable 2013 eRx incentive or 2014 eRx payment adjustment reporting period

27. Hardship Exemptions for eRx Payment Adjustments • Most of the requirements for the remainder of the eRx Incentive Program were established in the CY 2012 Medicare PFS final rule. Please note that, although the self-nomination deadline to participate in the PQRS GPRO was extended to October 15, the self-nomination deadline to participate in the eRx GPRO remains January 31. Updates to the eRx Incentive Program: • New Criteria for the eRx group practice reporting option (eRx GPRO) • Since, accordingly with PQRS, we expanded definition of group practice to include groups of 2-24 eligible professionals, we finalized new criteria for becoming a successful electronic prescriber under the eRx GPRO: • Report the electronic prescribing measure for at least 75 instances during the applicable 2013 eRx incentive or 2014 eRx payment adjustment reporting period

28. eRx Informal Review Process • Implementation of an eRx Informal Review process • How to Request an eRx Informal Review for the 2012 or 2013 eRx Incentives: • Informal Review Request Method: email • Deadline: 90 days following the receipt of the applicable full year eRx feedback reports • How to Request an eRx Informal Review for the 2013 or 2014 eRx Payment Adjustments: • Informal Review Request Method: email • Deadline: • For the 2013 eRx payment adjustment: February 28, 2013 • For the 2014 eRx payment adjustment: February 28, 2014

29. HITECH Meaningful Use: Stage 2 & Payment Adjustments

30. HITECH Meaningful Use Stage 2 Final Rule • Changes to Stage 1 of meaningful use • Stage 2 of meaningful use • New clinical quality measures • New clinical quality measure reporting mechanisms • Payment adjustments and hardships • Medicare Advantage program changes • Medicaid program changes

31. Changes to Stage 1: CPOE Current Stage 1 Measure New Stage 1 Option This optional CPOE denominator is available in 2013 and beyond for Stage 1

32. Changes to Stage 1: Vital Signs New Stage 1 Measure Current Stage 1 Measure The vital signs changes are optional in 2013, but required starting in 2014

33. Changes to Stage 1: Testing of HIE Current Stage 1 Measure Stage 1 Measure Removed The removal of this measure is effective starting in 2013

34. Changes to Stage 1: E-Copy & Online Access New Stage1 Objective Current Stage 1 Objective • The measure of the new objective is 50% of patients have accessed their information; there is no requirement that 5% of patients do access their information for Stage 1. • The change in objective takes effect in 2014 to coincide with the 2014 certification and standards criteria

35. Changes to Stage 1: Public Health Objectives Current Stage 1 Objectives New Stage 1 Addition This addition is for clarity purposes and does not change the Stage 1 measure for these objectives.

36. Stages of Meaningful Use Stage 3 Stage 2 Stage 1

37. Meaningful Use: Changes from Stage 1 to Stage 2 Stage 1 Stage 2

38. 2014 Changes • EHRs Meeting ONC 2014 Standards – starting in 2014, all EHR Incentive Programs participants will have to adopt certified EHR technology that meets ONC’s Standards & Certification Criteria 2014 Final Rule • Reporting Period Reduced to Three Months – to allow providers time to adopt 2014 certified EHR technology and prepare for Stage 2, all participants will have a three-month reporting period in 2014.

39. Stage 2 EP Core Objectives EPs must meet all 17 core objectives:

40. Stage 2 EP Core Objectives EPs must meet all 17 core objectives:

41. Stage 2 EP Menu Objectives EPs must select 3 out of the 6:

42. Aligning CQMs Across Programs • CMS’s commitment to alignment includes finalizing the same CQMs used in multiple quality reporting programs for reporting beginning in 2014 • Other programs include Hospital IQR Program, PQRS, CHIPRA, and Medicare SSP and Pioneer ACOs Children’s Health Insurance Program Reauthorization Act Medicare Shared Savings Program and Pioneer ACOs Physician Quality Reporting System Hospital Inpatient Quality Reporting Program

43. Clinical Quality Measures • CQM reporting will remain the same through 2013. • 44 EP CQMs • 3 core or alternate core (if reporting zeroes in the core) plus 3 additional CQMs • Report minimum of 6 CQMs (up to 9 CQMs if any core CQMs were zeroes) • 15 Eligible Hospital and CAH CQMs • Report all 15 CQMs • In 2012 and continued in 2013, there are two reporting methods available for reporting the Stage 1 measures: • Attestation • eReporting pilots • Physician Quality Reporting System EHR Incentive Program Pilot for EPs • eReporting Pilot for eligible hospitals and CAHs • Medicaid providers submit CQMs according to their state-based submission requirements.

44. Electronic Submission of CQMs Beginning in 2014 • Beginning in 2014, all Medicare-eligible providers in their second year and beyond of demonstrating meaningful use must electronically report their CQM data to CMS. • Medicaid providers will report their CQM data to their state, which may include electronic reporting.

45. CQM Selection and HHS Priorities All providers must select CQMs from at least 3 of the 6 HHS National Quality Strategy domains: • Patient and Family Engagement • Patient Safety • Care Coordination • Population and Public Health • Efficient Use of Healthcare Resources • Clinical Processes/Effectiveness

46. Changes to CQMs Reporting • Beginning in 2014 Prior to 2014

47. Payment Adjustments • The HITECH Act stipulates that for Medicare EP, subsection (d) hospitals and CAHs a payment adjustment applies if they are not a meaningful EHR user. • An EP, subsection (d) hospital or CAH becomes a meaningful EHR user when they successfully attest to meaningful use under either the Medicare or Medicaid EHR Incentive Program • Adopt, implement and upgrade ≠ meaningful use • A provider receiving a Medicaid incentive for AIU would still be subject to the Medicare payment adjustment.

48. Payment Adjustments % Adjustment shown below assumes less than 75% of EPs are meaningful users for CY 2018 and subsequent years % Adjustment shown below assumes more than 75% of EPs are meaningful users for CY 2018 and subsequent years

49. EP EHR Reporting Period • Payment adjustments are based on prior years’ reporting periods. The length of the reporting period depends upon the first year of participation. • For an EP who has demonstrated meaningful use in 2011or2012: * Special 3 month EHR reporting period • To Avoid Payment Adjustments: • EPs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years.

50. EP EHR Reporting Period • For an EP who demonstrates meaningful use in 2013for the first time: * Special 3 month EHR reporting period • To Avoid Payment Adjustments: • EPs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years.