Daniel Green, MD: Hi. I'm Dr Daniel Green. I am the Medical Officer for the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS) in Baltimore. Welcome to this program on avoiding negative payment adjustments in our quality reporting programs.

Joining me today are Molly MacHarris from the Center for Clinical Standards and Quality at CMS. Molly, thanks for joining us.

Molly MacHarris: Thanks for having me.

Dr Green: We are also privileged to have Vidya Sellappan who is in the Office of E-Health Standards at CMS also in Baltimore. Welcome, Vidya.

Vidya Sellappan, MS: Good to be here.

Dr Green: Today’s program is designed to compare the incentive payments and payment adjustments related to the Medicare and Medicaid electronic health records (EHR) incentive programs, which are set for 2015 and 2016. Additionally, we want viewers to be able to describe the incentive payments and negative payment adjustments related to the PQRS quality improvement program as well as the value modifier.

Vidya, can you give us a high-level overview of the Medicare EHR incentive program?

Ms Sellappan: Sure. The Medicare and Medicaid EHR incentive programs provide incentive payments to eligible professionals (EPs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.^[1]

Dr Green: Thanks, Vidya. Molly, can you tell me about some of the other quality reporting programs at CMS?

Ms MacHarris: Sure. There are 2 other programs that we are going to cover today. The first is the Physician Quality Reporting System (PQRS) and the second is the Value-based Payment Modifier. ^[2] PQRS uses a combination of incentive payments and payment adjustments to encourage reporting by eligible professionals, and the Value-based Payment Modifier looks at groups of physicians by quality compared to cost.

Dr Green: Great, thanks. I know we'll talk in more detail about some of the other programs but can you briefly just touch on how the accountable care organizations (ACOs) or shared savings programs relate to PQRS and the value modifier? ^[3]

Ms MacHarris: In addition to the mandatory initiatives described earlier, the PQRS and the Value-based Payment Modifier, providers looking to better coordinate care for patients and use healthcare dollars more wisely may also participate in the Medicare Shared Savings Program. ^[4-6]

Dr Green: Terrific. Thank you. I know that with all the programs that you mention and that Vidya will be discussing, there are quite a few quality reporting programs. As a physician I can appreciate that it's a little complicated and there is a lot of quality reporting. Can you tell me about the efforts at CMS to align these programs and reduce the burden on docs for reporting?

Ms MacHarris: Sure. Great question. At CMS we have actively been trying to reduce reporting burden on eligible professionals. We know that physicians have a lot of things that they have to do during a day and we know there are a lot of quality reporting programs out there. Wherever possible we have tried to align the reporting criteria for various reporting programs, but the ones we are going to specifically be talking about today are of course the EHR incentive program for eligible professionals, the PQRS, the Value-based Payment Modifier, and again the Medicare Shared Savings Program.

Dr Green: As a doctor I can tell you I'm sure happy that you all are trying to streamline this a little bit to make it easier on folks in their busy day. Vidya, I know in the program and in the regulations, different types of providers are responsible for participation in the various programs. Can you comment on that at all?

Ms Sellappan: Dan, there are a lot of eligibility requirements for each of the programs and they vary from program to program. On the screen in front of you there is a table that shows the different types of eligible professionals and the quality programs that they may be eligible for.^[7-9]

Dr Green: I think that will be helpful for our viewers.

Let's talk briefly about 2014.That's the year obviously that we are in and of course eligible professionals are interested to learn what programs may affect them and how those programs will affect them. We have a high-level table that outlines the different quality reporting programs and talks about the upward and downward incentives for folks in 2014. Let us get into some more specifics, though. Vidya, can you talk to me a little bit more about the EHR Incentive Program? Who is eligible and how it works?

Ms Sellappan: Sure, Dan. EPs who are eligible to participate in the Medicare EHR Incentive Program may earn incentive payments for demonstrating meaningful use.^[10] EPs who are eligible for both the Medicare and the Medicaid programs may choose either of the programs that they are eligible for to avoid a payment adjustment. The last year to begin participation in the Medicaid program is 2016. Participation in the Medicare EHR Incentive Program must begin before October 1, 2014 in order to avoid a payment adjustment.

Dr Green: What happens if folks do not start participating by the required time, 2014 or 2016?

Ms Sellappan: Medicare EPs who fail to demonstrate meaningful use by 2014 will be subject to a payment adjustment. In 2015 that payment adjustment is 1% of their Medicare claims. In 2016 and beyond this will increase by 1% each year.

Dr Green: You mentioned that folks who participate also can earn an incentive. Can you briefly go over what the incentive amounts are and how they can go about doing that?

Ms Sellappan: To earn EHR incentive payments for the Medicare EHR Incentive Program, the last year to participate is 2014. If you start participating in 2015 you will avoid payment adjustments but you will not earn incentives.

If you begin the program in 2014 you can earn up to $24,000 over 3 years through the Medicare program, or if you participate in the Medicaid EHR Incentive Program you could earn up to $63,750 over a 6-year period.^[1]

Dr Green: Vidya, you mentioned earlier the Medicaid program and how folks can earn an incentive over 6 years. Can you provide us a few more details about that?

Ms Sellappan: Sure. Providers who choose to participate in the Medicaid EHR Incentive Program can earn incentives as well. The table in front of you shows the potential incentive payments that can be earned over 6 years.^[11] One thing that I do want to note is that Medicaid EPs who are only eligible to participate in the Medicaid EHR Incentive Program will not be subject to Medicare payment adjustments.

Dr Green: If I am an EP, or eligible professional as you just said, in Medicaid, I am exempt, if you will, from the payment adjustment that might otherwise apply to the Medicare EHR program. Is that correct?

Ms Sellappan: Correct. The only individuals who will be subject to a payment adjustment are those who can demonstrate meaningful use on the Medicare side.

Dr Green: Got it. I understand that with the Medicare EHR Incentive Program there are multiple stages. I know that our listeners and viewers have heard about these different stages and I know some of the dates for implementation have changed a little bit. Can you help us understand what the different stages are or how they are different? Because folks are confused about that.

Ms Sellappan: The EHR Incentive Programs divide meaningful use into 3 stages, so a path towards an environment where EHR technology is part of the solution and the practice of medicine. Stage 1 is where all providers begin, and Stage 1 focuses on capturing data in a structured format. Stage 2 focuses on using the data that is captured. Stage 3 focuses on improved outcomes resulting from using the data that is captured.^[12,13]

Dr Green: That’s very helpful. Thanks for explaining that. I know that part of the requirements for meaningful use have to do with electronic clinical quality measures (CQMs). I think folks also got a little bit confused in terms of how they are supposed to report these. Can they attest? Do they actually submit them electronically? What is required in that respect? The other objectives, I think, of meaningful use are a little bit more straightforward and defined in a little bit easier way for folks to understand. Can you tell us a little bit more about the electronic CQMs?

Ms Sellappan: Sure, Dan. A component of the EHR Incentive Program is to report on clinical quality measures. Beginning in 2014 all providers will report on the 2014 version of CQMs. Certified EHR technology must be certified to the 2014 edition certification criteria, including new CQM criteria. The CQM requirements are tied to the year for which you are demonstrating meaningful use. If you are demonstrating meaningful use for 2014 and beyond you will use the 2014 CQMs. If your EHR reporting period is prior to 2014, you will be reporting on a different set of CQMs.^[14,15]

Another thing I want to point out is that attesting to CQMs in the EHR incentive program using the attestation programthat we have does not necessarily meet the same requirements that the PQRS and the Value-based Modifier programs have, so you will need to visit those websites and the requirements for those programs.

Dr Green: That’s a really important point for our viewers to pay attention to, because -- and Molly will talk more about alignment -- there still are places where there are some differences in the programs, so thanks for pointing that out to the viewers. You said they had to report on the 2014 version, if you will, of the measures. Is there a way that eligible professionals can find out if they are using a 2014 certified program?^[16]

Ms Sellappan: Yes, Dan. I would urge providers to work with their EHR vendor to confirm that they have all of the required features that are needed. In addition, the Office of the National Coordinator has a website that provides information on the types of EHRs that are certified to these standards.

Dr Green: Molly, I want to ask you a couple of questions about this. You know we have more and more folks joining ACOs or forming ACOs to participate. Can you tell us how the ACOs or the shared savings programs interact with the information Vidya just gave us?

Ms MacHarris: Sure. EPs who participate in an ACO, specifically within the Medicare Shared Savings Program, can also report once and receive credit for the meaningful use program and PQRS. They would not be following the reporting criteria that were on the previous slides, the 9 measures covering 3 domains. Rather, they would need to complete the web interface and all of the measures and modules within that web interface in its entirety. Another important piece to know is that those EPs would also need to individually register and attest to the remaining core objectives of the meaningful use program that Vidya mentioned earlier.

Dr Green: That's great. I'm sure they will be happy to only have to report once, but as you said they will need to be using meaningful use or certified technology.

Ms MacHarris: Correct.

Dr Green: Very helpful. Again, I'm sure people will be happy to hear that. That was a great summary, if you will, of 2014. Let’s move on to 2015 now and again we will have a high-level slide that our viewers can see about the different programs and the payment adjustments that will take place in 2015 if they are not actively or successfully participating in our programs. Vidya, can you tell us about some of the changes in 2015 for EHR?

Ms Sellappan: Sure. Beginning in 2015, EPs who do not demonstrate meaningful use for their reporting period will be subject to a payment adjustment. EPs who begin participating in the program in 2014 will need to demonstrate meaningful use for a 90-day period that ends no later than September 30th, and attest to meaningful use on October 1, 2014 or prior in order to avoid a payment adjustment to their 2015 Medicare claims.^[10]

Dr Green: That's helpful, and I guess Molly can tell us whether or not that will satisfy PQRS. We will get to PQRS in just a minute. I understand that the meaningful use payments, or the payment adjustment I should say, actually can go down even after 2015. Is that right?

Ms Sellappan: Correct. In 2015 if you are subject to a payment adjustment your payment adjustment will be 1% of your Medicare claims. In 2016 that increases to 2%. Those participants in 2015 who are also hit with an E-prescribing payment adjustment will have a total 2% payment adjustment to their Medicare claims in 2015.^[16]

Dr Green: Wow, so it's really important that folks get on the EHR bandwagon because these payments sound like they grow fairly significantly. Thank you. Molly, let's turn to PQRS for a few minutes. Can you tell me a little bit more about PQRS; what it is, and when it started?

Ms MacHarris: The Physician Quality Reporting System, or PQRS, began back in 2007 as a quality reporting program, and there are 2 main ways that EPs can participate. The first is as an individual. The second is as part of a group practice. We define a group practice as 2 or more NPIs that have reassigned their billing rights to a TIN. I know there are a lot of acronyms in there but we define a TIN as a tax identification number and an NPI as a national provider identifier.^[1]

Dr Green: Thanks for clearing that up because, yes, we do tend to speak in acronyms at CMS. How can folks avoid the 2015 payment adjustment?

Ms MacHarris: Sure. Great question. For the PQRS the reporting opportunities have actually already passed. EPs who are participating as a group practice would have needed to have reported on a 2013 calendar year date of service, and we here at CMS would have needed to receive that information by no later than first quarter 2014.^[17]

Dr Green: I assume that’s true for group practice reporting options (GPROs) as well?

Ms MacHarris: Yes, that is correct. If you are an EP who is part of a group practice and you did not report for PQRS during the 2013 calendar year for purposes of the 2015 payment adjustment, you could have a 1-1/2% payment reduction beginning in 2015. When you add those to the reductions that Vidya talked about earlier for the EHR incentive program, they can really start to add up, so we really want to encourage EPs to start participating in these various programs.

Dr Green: Great point. Now the value modifier you talked about earlier in the program. Can you tell me how the value modifier would affect folks in 2015?

Ms MacHarris: The Value-based Payment Modifier is a new program that was authorized by the Affordable Care Act and it is being rolled out over a couple of different years. In the year 2015 it is being applied to EPs who are part of large group practices; only to groups who have 100 or more NPIs. Again, the NPI is your national provider identifier. Unfortunately, similar to PQRS, the Value-based Payment Modifier reporting period has passed.^[18]

Those group practices would have needed to have registered within a registration system by October 2013, and they would have needed to have reported their PQRS quality metrics under the 2013 year, and CMS would have needed to have received that no later than first quarter 2014.

Dr Green: Wow, so while it is too late for 2013 we obviously do not want folks to endure a penalty or a payment adjustment in 2016, which is based on 2014 reporting.

Ms MacHarris: Yes. As I mentioned earlier and as Vidya mentioned earlier, the adjustments are starting to add up for EPs. The Value-based Payment Modifier has a separate and distinct 1% reduction if you did not satisfactorily report for both the quality metrics. They also have an analysis that looks at quality tiering. The quality tiering analysis compares the EPs within the group, their quality score compared to cost. If they have a low quality and high cost they would receive the 1% negative adjustment.^[3]

Dr Green: The programs obviously are linked. I guess the data from PQRS is used to inform the value modifier folks whether it is high quality or low quality, and then they look at the cost separately?

Ms MacHarris: That's correct. Another important piece to note, which Vidya mentioned earlier, is that the attested results for the CQMs do not apply for the PQRS or the Value-based Payment Modifier. That is an option that is exclusively available for meaningful use participants. If you are an EP who can participate in these multiple programs we really encourage you to start e-reporting your information.

Dr Green: I am glad you brought that up and remembered to tell folks. That's a critical element. Let's talk about 2016 now. As we displayed in an earlier slide, you can see a table of the programs by year and the potential payment adjustments and some of the requirements that are planned for 2016. Molly, I understand in 2014, which again helps to inform some of the 2016 potential payment adjustments, there is a new reporting mechanism in PQRS: the Qualified Clinical Data Registry, or QCDR. Can you tell us a little bit about QCDR?

Ms MacHarris: Sure. The Qualified Clinical Data Registry or QCDR -- we do like to abbreviate things over here at CMS -- is new for the 2014 reporting year. The 2014 reporting year does apply to the 2016 PQRS payment adjustment and to the 2016 Value-based Payment Modifier. The QCDR is a new reporting mechanism. It only applies to individual eligible professionals. These QCDR entities that foster quality improvement can indicate to CMS that they would like to participate in this program and have their eligible professionals report on 9 measures covering 3 domains, one of which must be an outcome measure.^[19]

The reporting criteria would be the 9 measures covering 3 domains at a 50% reporting threshold.

Dr Green: Am I correct in understanding that they can also report on some measures that are not in PQRS?

Ms MacHarris: Yes. The QCDR can have within their measure set all of the measures that are available within PQRS, and we have close to 300 measures that are available within PQRS. The QCDRs may find that there are some measures that they would like to offer to their EPs that we do not have within our measure set, so they can have up to 20 non-PQRS measures that are available to their QCDR participants.

Dr Green: Just one more quick question about QCDRs. As a doctor if I want to use a QCDR and see if there is one available -- for me it would be an OB-Gyn -- how would I go about knowing what is out there?

Ms MacHarris: Sure. That's a really great question. We are actually finalizing our vetting and qualification process for the QCDRs, and a list of the QCDRs -- again, the Qualified Clinical Data Registries -- will be available on the PQRS website. I know we have links for that at the end of the presentation so folks can find that information.

Dr Green: Great, thanks. Just briefly we want to show you some of the proposals for the 2017 program year. This will be the subject of future rulemaking so this is not set in stone but these are some of the payment adjustments for the various programs going forward. The actual details of how to avoid the payment adjustments, again, will be the subject of future rulemaking.

Here, again, for 2018 is a similar table and we would encourage EPs to review this table. Again, the specific requirements will be made available in future rulemaking. Vidya, before we conclude do you have any suggestions or points you want to make for our viewers regarding the meaningful use program?

Ms Sellappan: Sure, Dan. As you can see, multiple programs and initiatives could affect payment rates in coming years. 2014 is an important year to evaluate. The EHR incentive programs have a financial benefit to EPs but the real benefits of these and the quality improvement programs are better care and better value for patients, payers, and practices. Beginning in 2015 EPs will face a negative payment adjustment for nonparticipation in programs such as PQRS or the inability to demonstrate meaningful use in the Medicare EHR incentive programs.

Dr Green: Thank you. Molly, any take-home points you have about the programs you work directly on?

Ms MacHarris: Sure, just a couple in addition to what Vidya mentioned. Again, beginning in 2015, EPs who can participate in these multiple programs, really should for the Medicare EHR Incentive Program, or they should have for PQRS or the Value-based Payment Modifier. Otherwise, they could be subject to multiple payment reductions. The 2016 payment adjustments for PQRS, the Value-based Payment Modifier, the EHR Incentive Program -- 2014 is the reporting period for those so we do strongly encourage folks to go ahead and start reporting. Lastly, at CMS we have tried to align reporting programs wherever possible to reduce burden on our eligible professionals.

There is not a full alignment in every area so we do strongly encourage all EPs to take a look at the respective websites to get the full information.

Dr Green: Great. Thanks, Molly. There are a lot of resources at CMS for folks who want to participate in our quality improvement programs and we would encourage people to look on our website for information about the EHR Incentive Program. There is a specific website for that. We do have also another website for the PQRS program and then on the resource slide you will see web links to the value modifier as well as the shared savings program. We would encourage our viewers, if they do have further questions, to please review this website and they can always call our quality net help desk for live help.

I want to thank you and I want to thank Molly and Vidya for participating today.

Ms Sellappan: Thank you, Dan. Thank you for having us.

Dr Green: The information was very helpful and I know it will be very helpful for our viewers. I would like to thank you, the audience, for joining me in this interesting discussion. Thanks for participating in this activity. Please click on the Earn CME link to take the CME post test and evaluation so that you can earn CME credit. Thank you and have a great day.