Behavioral Health and CMS Quality Programs January 26, 2015 Agenda - PowerPoint PPT Presentation

Behavioral Health and CMS Quality Programs January 26, 2015

Agenda  Introduction  Three CMS Programs – Meaningful Use – PQRS – MIPS  MeHI’s Role – Interpret & Navigate the Regulations – Prepare & Strategize – Services & Solutions  Questions & Answers  Facilitated Dialogue 2

Current State of Affairs: Behavioral Health High Prevalence High Cost High Co-Morbidity “If 10% reduction can be made in excess healthcare costs of patients with comorbid psychiatric disorders via an effective integrated medical-behavioral healthcare program, $5.4 million of healthcare savings could be achieved for each group of 100,000 insured members…the cost of doing nothing may exceed $300 billion per year in the United States. 23 ” Treatment Challenges Source: A Place at the Table: Behavioral Health and CMS’ Physician Quality Reporting System. National Council for Behavioral Health. 3

Importance of Behavioral Health Integration 4

Barriers to Effective Behavioral Health Integration Licensing Privacy Reimbursement Source: Barriers to Behavioral Health and Physical Health Integration in Massachusetts , June 2015, Blue Cross Blue Shield Foundation of Massachusetts Financial Systems Provider Access Data Sharing Privacy Laws & Training Source: MassHealth Approaches to Behavioral Health Integration: Integration through Innovation , Dr. Julian Harris, Medicaid Director, Health Policy Commission, April 3 2013. 5

Expanded Role of Health IT Drives Change  Payment Reform Improve Care Delivery  Quality Reporting Outcomes  Practice Transformation 6

Meaningful Use Al Wroblewski, PCMH CCE Client Services Relationship Manager

Meaningful Use Eligible Professionals (EPs) Eligible Professionals Medicare • Doctor of medicine or osteopathy (MD or DO) • Doctor of oral surgery or dental medicine • Doctor of podiatric medicine • Doctor of optometry • Chiropractor Medicaid • Physicians (MD or DO) • Nurse Practitioners • Certified Nurse-Midwives • Dentists • Physician Assistants who furnish services in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) led by a Physician Assistant • Clinical Nurse Specialists – to be determined 8

CMS Meaningful Use Rules: 2015-2017

CMS Final Rule – Changes to Participation Timeline Attest to modified criteria for 2015-2017 (Modified Stage 2) 2015 with accommodations for Stage 1 providers 2016 Attest to 2015-2017 criteria (Modified Stage 2)* Attest to either 2015-2017 criteria (Modified Stage 2) or 2017 full version of Stage 3 using 2015 Edition CEHRT 2018 Attest to full version of Stage 3 using 2015 Edition CEHRT *some alternate exclusions remain in 2016 for Stage 1 providers 10

CMS Final Rule – Changes to EHR Reporting Periods  In 2015, all providers attest using an EHR reporting period of any continuous 90-day period within the calendar year  In 2016: – first-time MU participants will attest using any continuous 90-day period within the calendar year – returning participants will attest using a full calendar year (January 1, 2016 through December 31, 2016)  In 2017: – first-time MU participants and anyone choosing to demonstrate Stage 3 will attest using any continuous 90-day period within the calendar year – returning Stage 2 participants will attest using the full calendar year (January 1, 2017 through December 31, 2017)  In 2018, all providers will attest to Stage 3 using the full calendar year (January 1, 2018 through December 31, 2018) 11

CMS Final Rule – List of Objectives  Meaningful Use Objectives – Modified Stage 2 Protect Patient Health Information – Security Risk Analysis 1. 2. Clinical Decision Support (CDS) 3. Computerized Provider Order Entry (CPOE) 4. Electronic Prescribing (eRx) Health Information Exchange (HIE) – previously known as “Summary of Care” 5. 6. Patient Specific Education 7. Medication Reconciliation 8. Patient Electronic Access (Patient Portal) 9. Secure Electronic Messaging (Eligible Professionals only) 10. Public Health and Clinical Data Registry Reporting a. Immunization Registry Reporting b. Syndromic Surveillance Reporting c. Specialized Registry Reporting d. Reportable Lab Results Reporting (Eligible Hospitals only) [Note: No change in General Requirements or Clinical Quality Measure reporting] 12

CMS Meaningful Use Rules: Stage 3

Stage 3 Meaningful Use - Objectives 1. Protect Electronic Health Information 2. Electronic Prescribing (eRx) 3. Clinical Decision Support 4. Computerized Provider Order Entry (CPOE) 5. Patient Electronic Access to Health Information 6. Coordination of Care through Patient Engagement 7. Health Information Exchange 8. Public Health Reporting 14

Stage 3 Meaningful Use – Key Elements  Coordination of Care through Patient Engagement – 10% of patients use portal or API – 25% of patients must receive message from EP – 5% of patients enter their own data or may come from other agencies 15

Stage 3 Meaningful Use – Key Elements  Health Information Exchange – 50% of outgoing referrals/transitions sent electronically – 40% of incoming referrals/transitions and new patients come with summaries of care – 80% of incoming referrals/transitions and new patients have medications, allergies, and problem lists reconciled 16

Stage 3 Meaningful Use – Key Elements  Public Health Reporting – Must report 3 measures – Types of Registries • Immunization • Syndromic Surveillance • Electronic Case Reporting • Other Public Health Registries • Clinical Data Registries 17

Physician Quality Reporting System (PQRS) Elisabeth Renczkowski, Content Specialist

PQRS Overview How does PQRS work?  PQRS is a reporting program that uses payment adjustments to promote reporting of quality information by Eligible Professionals (EPs)  EPs report data to CMS on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B FFS beneficiaries  EPs must report on each unique NPI/TIN combination they use to bill Medicare  Two-year gap between performance year and payment year – Providers who satisfactorily report PQRS for Program Year 2015 will avoid negative payment adjustments to their Medicare reimbursements in 2017 and so on 19

PQRS Eligible Professionals (EPs) PQRS Eligible Professionals • • Doctor of Medicine Certified Nurse Midwife* • • Doctor of Osteopathy Clinical Social Worker • • Doctor of Podiatric Medicine Clinical Psychologist • • Doctor of Optometry Registered Dietician • • Doctor of Oral Surgery Nutrition Professional • • Doctor of Dental Medicine Audiologists • • Doctor of Chiropractic Physical Therapist • • Physician Assistant Occupational Therapist • • Nurse Practitioner* Speech-Language Therapist • Clinical Nurse Specialist* • Certified Registered Nurse Anesthetist* * Includes Advanced Practice Registered Nurse (APRN) 20

Payment Adjustments

Payment Adjustments PQRS Value Modifier No incentive for EPs who Upward, neutral, or downward successfully report (last year was payment adjustments for EPs who 2014) successfully report PQRS measures (performance-based payment adjustments) Penalty for failure to report Penalty for failure to report (automatic payment adjustments) 22

Total Payment Adjustments – Failure to Report  If an EP fails to report PQRS in 2015, the following payment penalties will apply to their 2017 reimbursements: PQRS Penalty Value Modifier Penalty applies to all EPs solo EPs and groups of 10+ groups of 2-9 -2% -2% -4%  Bottom line: Total penalty for failing to report in 2015 • -4% for solo EPs and groups of 2-9 • -6% for groups of 10 or more 23

Value Modifier

Value Modifier  The Value Modifier (VM) provides differential payment based on the quality of care compared to the cost of care  PQRS reporting is the basis for the quality portion of the Value Modifier performance-based payment adjustments  Performance on PQRS measures matters! • This differs from reporting CQMs for the Meaningful Use (MU) programs, where it is acceptable to report a performance rate of 0  Performance-based payment adjustments for those who do report PQRS in 2015: • upward or neutral adjustment (solo practitioners and groups of 2-9) • upward, neutral, or downward adjustment (groups of 10 or more) 25

Value Modifier  All EPs are included to determine group size – Currently, upward and downward VM payment adjustments are only applied to reimbursement of physicians in the group 2017 Value Modifier based on 2015 PQRS reporting Solo EP 2-9 EPs 10+ EPs Upward or Upward or Upward, Physicians Neutral Neutral Neutral, or Downward Practitioners N/A N/A N/A Therapists N/A N/A N/A  In 2018, CMS will apply the VM to all EPs, including practitioners and therapists. CMS will finalize exactly how the VM will apply to those EPs in future rulemaking 26

Reporting Methods