Ready or not — it’s coming. How we are paid as healthcare providers will be based on quality, not volume. The Center for Medicare’s (CMS) goal is to have a reimbursement model that is 90% pay-for-performance based, using quality data by 2018. Fortunately, a number of PROs meet Meaningful Use Stage 2 requirements. Unfortunately, the in’s and out’s and do’s and don’ts of how meaningful use works are about as clear as mud. Let’s start with the basics.
A Prelude: Understanding the Lingo
Here’s a quick primer on the alphabet soup you’ll encounter as you try to make sense of Meaningful Use:
- CEHRT: Certified Electronic Health Record Technology — a computer application or component within an application certified by CMS to meet an aspect of Meaningful Use
- CMS: Centers for Medicare & Medicaid Services — the federal agency within HHS that administers Medicare and Medicaid
- CQM: Clinical Quality Measure — a measure used by CMS to assess quality of care
- EHR: Electronic Health Record — a healthcare record in electronic form
- EP: Eligible Professional — a medical practitioner eligible for a Medicare or Medicaid incentive program
- GPRO: Group Practice Reporting Option — one of several different options for reporting PQRS measures
- HHS: US Department of Health and Human Services — the department of the US government to which CMS belongs
- NQS: National Quality Strategy — HHS’s strategy for improving quality in healthcare
- PQRS: Physician Quality Reporting System — a Medicare Part B quality-reporting program
- PRO: Patient Reported Outcome — a patient-reported quality measure
- QDC: Quality Data Code — a procedure code submitted on Medicare and Medicaid claims to indicate participation in a Medicare or Medicaid incentive program
Patient Reported Outcomes and Meaningful Use
Patient-reported outcome (PRO) data now plays a key role when it comes to Meaningful Use. When the incentive first started back in 2011, the data-reporting requirements were related to operational efficiency (aka cost). CMS realized that the stage 1 quality measurement approach was becoming “overbuilt” and was relying on too many clinical process measures that were, at best, weakly correlated to patient outcomes. So when the stage 2 requirements were released, the reporting requirements were much more oriented toward patient outcomes than cost (and furthermore, the goal of the upcoming stage 3 of Meaningful Use is described specifically as “to improve healthcare outcomes”).
The really cool thing about CMS’s growing focus on patient outcomes is that having the cost data from stage 1 of Meaningful Use and the outcome data from stages 2 and 3 is exactly what’s needed to quantity value in healthcare. The really challenging thing, however, is that cost data is much easier to collect than patient-reported outcome data. The majority of Stage 1 Meaningful Use requirements simply can be pulled from what’s already in your electronic health record (EHR) system. But while there may be a place to store the results of patient-reported outcomes in your EHR, you still need a process in place to actually collect them. Now that CMS has made a clear statement that the evolution of Meaningful Use will be centered on patient outcome data, it is imperative that eligible providers (EPs) develop a sustainable system for collecting PRO data.
There are a number of specific clinical quality measures (CQMs) that use PRO data as part of Meaningful Use requirements. We will talk more about those in detail later! But for now, let’s make sure we understand Meaningful Use:
What is Meaningful Use?
Included in the $787 billion American Recovery and Reinvestment Act (ARRA) of 2009 was the HITECH Act, with the intention of digitizing US healthcare records, which would simplify the exchange of health information, which in turn would improve healthcare and increase operational efficiency (aka reduce costs). To facilitate this digitization, the act mandates that eligible healthcare professionals switch from paper to electronic health records. The act came with a $19.2 billion dollar budget to promote the conversion by offering a financial incentivize EPs to make the switch. The act refers to this program as the “meaningful use” of EHRs.
So starting in 2011, to qualify for this “meaningful use” incentive, practitioners had to implement certified electronic health record technology (CEHRT). Those who have not will receive reduced reimbursements, starting in 2015. The reporting requirements for Meaningful Use continue to evolve. Here are the stages that CMS has outlined so far:
- Stage 1 Meaningful Use (2011-2014): Promote basic EHR adoption
- Stage 2 Meaningful Use (2015-2017): Emphasize care coordination and exchange of patient records
- Stage 3 Meaningful Use (2018+): Improve healthcare outcomes
The Perks and Penalties of Meaningful Use
The perks: In 2014 CMS offered an incentive bonus of 0.5% of total Medicare payments to those eligible professionals who met certain requirements for successful reporting. And it was fun while it lasted… that was the last year Medicare offered such an incentive. There is no reporting incentive for 2015.
The penalties: In 2013 CMS introduced a financial penalty for those eligible professionals who do not successfully complete the requirements for satisfactory reporting. In 2015 — and for all subsequent years unless otherwise directed by CMS — that penalty is 2% of your total Medicare payments. For example, if you don’t successfully complete the requirements for satisfactory reporting in 2015, you’ll be subject to a 2% payment adjustment in 2017. And it’s likely that the penalty amount will go up in each new reporting stage. So let’s take a look at Stage 2 Meaningful Use requirements that we are currently up against.
Stage 2 Meaningful Use — It’s here
To meet Stage 2 Meaningful Use requirements, starting in 2015 EPs must report on all of the 17 “core” objectives for Meaningful Use, and any 3 of the 6 “menu” objectives. In addition, EPs must report a minimum of 9 clinical quality measures (CQMs), which track various aspects of patient care. To keep things exciting, the 9 CQMs must cover at least 3 of 6 National Quality Strategy (NQS) domains.
Alignment With PQRS Measures
As a separate program, but with requirements aligned to those of Meaningful Use, CMS developed the Physician Quality Reporting System (PQRS), which requires that all eligible Medicare providers meet specific criteria for the satisfactory reporting of certain outcome measures. Although PQRS is not technically mandatory, eligible professionals who do not meet the reporting requirements are subject to financial penalties which in 2015 — and for all subsequent years unless otherwise directed by CMS — and that penalty is 2% of total Medicare payments. So to avoid the penalty, EPs must report on at least 9 measures for a designated percentage of eligible Medicare patients.
The challenge is finding 9 CQMs for PQRS and Meaningful Use that make sense for your practice. Many of the measures are extremely specific, and if you are a specialist, you have to dig and dig to find 9 that work. For example, if you are an orthopedic surgeon who specializes in adult reconstructive surgery, the colorectal cancer screening CQM may prove challenging… slash impossible… slash impractical.
How Meaningful Use Reporting Works
There are 3 different models for reporting both PQRS and Meaningful Use CQMs to CMS: registry-based (automatic individual submission), the Group Practice Reporting Option (GPRO — automatic group submission), and claims-based (manual individual submission). Here is the skinny:
When you report via a registry, the registry handles most of the quality-measure reporting for you. They simply mine the data, compile it, and submit it to CMS on your behalf. Basically, once you select your PQRS measures, you simply document them, and they manage the rest. You’ll never forget to complete PQRS on an eligible patient because the registry remembers for you.
Group Practice Reporting Option (GPRO)
GPRO is a registry-based PQRS reporting option geared toward multi-provider practices (clinics with two or more providers) that wish to participate as a group. It allows providers who share one tax ID to report measures and reach the required reporting percentage together. This method is not available to those submitting PQRS data via claims. Additionally, practices wishing to participate in GPRO must sign up (self-nominate) for GPRO directly through CMS.
With claims-based reporting, you must manually enter your PQRS data on your claim forms before submitting them to Medicare. Most registries have a claims-based reporting option that helps you to select the appropriate codes when filling out your Medicare claims, but it’s still your responsibility to make sure those codes are properly submitted. For claims-based reporting, you will record your PQRS quality data codes (QDCs) on the claim form just like any other code; however, these QDCs will have a $0.00 (or nominal) charge.
Schedule A Call With a PRO Expert!
Need more help with your PRO related questions? CODE can help! Schedule a call with a CODE expert today to get you on your way to better harnessing your patient reported outcomes.