Tag Archives: APA

Moving from Fee for Service to Pay for Quality

With the Affordable Care Act (ACA or PPACA, 2010) and Medicare Access and CHIP Reauthorization Act (MACRA, 2015), the Centers for Medicare & Medicaid services (CMS) have moved further away from fee-for-service payment and toward pay for quality. Under fee-for-service payment, a provider is paid for the volume of services that are completed. Quality, efficacy and cost efficiency are not factors of payment (CMS, 2018).

Pay for quality, at least in theory, is meant to improve the quality and outcome of services while simultaneously decreasing cost. If a smaller number of high quality, pertinent services are provided to a patient, the patient should experience a more positive result (better medical outcome, higher satisfaction, prevention of other medical illnesses, etc.) and the cost would be less. Additionally, if we address prevention, compliance, and engagement we can affect changes at the population level; we can improve the health of the population as a whole and reduce the cost of medical services in the United States.

CMS offers providers two pay for quality tracks, Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (CMS, 2018).

An APM is a payment approach that provides incentives to clinicians who provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population (CMS, 2018). You might have heard of these programs via various names such as Accountable Care Organizations (ACO), shared saving programs, or care models. This type of payment model is most often initiated by a larger hospital or physician system. The system is paid upfront on a monthly basis for care to a given population. Quality measures and other assessments are part of the system. If the clinicians provide high-quality and cost-efficient care, they are eligible for bonuses. If the various measures applied do not meet expected criteria, money has to be returned to CMS.  Therefore, the hospital or physician group that adopts an APM takes on a high level of risk. As a psychologist, you are most likely to be in this type of payment model if you are an employee of a large medical organization. Psychologists can play an important role via decreasing overall cost by attending to the mental health needs of the patients via improving compliance, changing behavioral factors that lead to illness, and in many other ways.

Most psychologists will participate in CMS’s second track called the Merit-Based Incentive Payment System (MIPS). In MIPS, the clinician reports quality measures and other activities that are intended to improve the quality of services provided. It is also hoped that implementation of MIPS will improve clinical outcomes and cost efficiency. Eligible providers began reporting under MIPS in 2017. Psychologists are exempt from reporting MIPS until 2019. Successful participation in MIPS could lead to a payment bonus, but non participation will, likewise, lead to a payment penalty. The potential bonuses and penalties will increase as we approach 2020 and beyond (APA, 2016).

The MIPS system is complex and many aspects of it may not be easy for psychologists to complete, especially those in solo or small practices. CMS established a low volume threshold which many psychologists in smaller practices will fall under.  These psychologists may not have to report MIPS at all. However, keep in mind that any low volume threshold established by CMS is subject to change. The eventual goal of CMS is to have all providers participating in quality reporting.

Because these issues are complex, I will address various MIPS  topics in separate blog posts. The next blog will be about the low volume threshold.

Dori Ann Bischmann, PhD
Clinical Psychologist
APA and WPA Federal Advocacy Coordinator

References:

APA (2016). CMS proposes new Medicare incentive payment system. PracticUpdate Newsletter.
CMS (2018). Quality Payment Program. MACRA-Quality-Payment -Program-, https://www.cms.gov
The patient protection and affordable care act (PPACA), (2010, Mar 23) pub.L.No. 111-148, 124 stat. 119.
The Medicare access and CHIP Reauthorization act (MACRA), (2015)(H.R. 2, Pub. L. 114-10.

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The Structure of Advocacy in the Practice of Psychology

Advocacy is an important function in today’s society.  Those that speak the loudest and/or make the largest donations are able to affect important governmental changes.  Psychologists play an important role in advocacy because we not only advocate for our profession, but we advocate for the mental health needs of our patients and improvements in society at large. We are fortunate to have an advocacy structure set up for us.

APA has the Practice Organization (known as APAPO) which advocates for psychologists and the people we provide services to.  Among the many issues that APAPO might advocate is:  improved mental health care, increased funding for mental health care, improvements to insurance that facilitate access to mental health care, advocating the inclusion of psychologists (and good mental health care) into healthcare initiatives (Affordable care act), parity, changing Medicare law to facilitate psychological services/access and much more.

In order for advocacy to be effective, it is imperative that many psychologists, at the grass-roots level, be involved in sending messages to legislators.  APA has a system  in place that makes it easy for every psychologist to advocate.

Every state, territory and district of the United States has a psychologist designated as the Federal Advocacy Coordinator (FAC).  I am the Wisconsin FAC.  In the FAC role, I represent both APA and WPA and have a variety of responsibilities.  First, through a data base provided by APA, I send out action and information alerts to Wisconsin psychologists.  The alerts are written by APA and then sent out to the FACs for distribution.  You are in the data base if you are a member of APAPO or have previously used the APA (Capwiz) political action portal.

I encourage you to write to your legislators, at the very minimum, when you receive an action alert.  This is the cornerstone of grass-roots advocacy and it really does make a difference.  When a message avalanche hits the hill, legislators and their offices take notice. APA makes it easy by putting a clickable button in the action alert that will take you directly to the advocacy portal.  Enter your zip code to identify your specific federal legislators and then send emails.  APA provides a sample letter for you to use; you can edit the letter any way you wish or send it as written.  Even if you disagree with the APA stance on an issue, I encourage you to make your voice heard and write what you think the legislator should do to address the issue.

A second FAC responsibility is to attend the annual Practice Leadership Conference in March.  The conference provides several days of workshops on cutting edge issues related to the practice of psychology and health care in general. We also receive advocacy training.  On the last day of the conference, we go to Capitol hill in Washington D.C.  We meet with as many Wisconsin legislators as possible while the  other FAC’s meet with their respective legislators.  We essentially blanket the hill advocating the specific agenda delineated by APA.

This year we advocated to include psychologists in the “physician definition” under Medicare law.  We are the only doctoral level providers, licensed to work independently in our states, that are not included under this definition.  Chiropractors, dentists, podiatrists and optometrists are included under the physician definition.  This is important because many Medicare initiatives have been tied to providers that fall under “physician” such as funding to develop electronic health records, use of E & M codes and the ability to be independent in all places of service under all insurances.  Currently, it is required that psychologists have an MD sign off in some places of service for our work with Medicare fee for service beneficiaries. In contrast, MD sign off is not required when the patient has commercial insurance, Medicaid or Medicare advantage plans.  We also advocated to keep mental health services included in Medicaid and other health plans as congress continues to address the affordable care act and Medicaid.

A third responsibility for FAC’s is to meet with, write to or in other ways be active with legislators when they come to their Wisconsin districts.  I go to town hall meetings, listen to Facebook town hall meetings and write to the legislators and their aides.

Finally, the FAC brings this information back to you via education at annual conference, newsletter articles and this blog.  I also communicate with Wisconsin psychologists who have questions about action alerts.

At times, this is a huge responsibility (i.e. when major changes in health care bills are being voted on), but it is rewarding and important work.  I am proud of the role I play in affecting change at the governmental level.   Perseverance and patience are required because change does not occur quickly.  For many years in a row we go to the hill with virtually the same agenda items. Over time, you witness a slow, but important change occurring and then suddenly, or so it seems, the advocated change occurs!

If you have any questions or suggestions, please do not hesitate to contact me.  Thank you for all the help you have given me over the years by contacting your legislators!  Keep it up, we are making progress.

Dori Ann Bischmann, PhD

Federal Advocacy Coordinator

APA and WPA

Capwiz: an online advocacy program developed by Capitol Advantage that allows users to send advocacy messages and alerts to members.  APAPO is a member of Capwiz and utilizes this system to send alerts to psychologists.

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Psychology has a Hero!

Pro Photo of Amy Rosett (2)      

Our hero’s name is Dr. Amy Rosett, a California psychologist who challenged CMS and won!

This is her story:   In 2014, Amy participated in PQRS, reporting measures via claims. While CMS required providers to report 9 measures to receive a bonus, Amy was only able to report 8 measures because there were a limited number of measures pertinent to psychology and her geropsychology practice that can be reported via claims.   Her reporting rate was 100% for each of the 8 measures she reported. She went through the MAV (Measure applicability process: CMS computerized process which attempts to fairly evaluate providers who do not have 9 available measures to report) . The MAV indicated that Amy did not meet 2014 PQRS bonus requirements because she should have used measure # 46 and #317.     Measure #46 (Medication reconciliation post-discharge) requires the provider to review a recent inpatient medication list and correct any discrepancies between the inpatient and outpatient medication list  (To fully reconcile errors, the provider must have the capacity to prescribe, adjust dosages or discontinue a medication).  Measure #317 (screening for high blood pressure) requires providers to measure blood pressure during a session and counsel patients about abnormal blood pressure readings.  While our initial assessment and psychotherapy CPT codes are connected to these measures, most psychologists agree (informal survey, Bischmann 2016) that the quality actions (taking a blood pressure and reconciling medications) required by these measures are not within most psychologist’s scope of practice.

Amy reached out to Diane Pedulla, JD, APAPO (APA provider organization) who specializes in Medicare.  Amy wondered if other psychologists were denied by the MAV review because they hadn’t used  the blood pressure and medication reconciliation measure.  There was little information regarding the experiences psychologists were having with PQRS and the MAV. Mostly, we heard that many psychologists were frustrated with PQRS and had given up on it. Diane helped Amy write an “informal review and submit it to the quality net help desk (qnetsupport@hcqis.org).

Per CMS protocol, the “informal review”  is a formal way to appeal the MAV results.   In her review, Amy aptly pointed out that most psychologists are not trained to measure blood pressure and this is outside our scope of practice.  She also pointed out that the medication reconciliation measure states the measure is to be performed by “physician, prescribing practitioner, registered nurse, or clinical pharmacist.” Psychologists are not included in the list nor do we have the prescribing capacity to correct a medication list.

Unfortunately, Amy’s informal review supported the original MAV results: CMS expected Amy to have performed the blood pressure and medication reconciliation measure.   Amy wasn’t willing to accept this.  With Diane Pedulla’s assistance, a request was made via APA for CMS to review the outcome of Amy’s informal review.  CMS reviewed the outcome and agreed that Amy’s informal review came to the wrong conclusion.  Amy won!

CMS is a large governmental organization. Various departments administer different portions of the PQRS, MAV and provider feedback process.  Amy’s initial denial via the MAV was an unintended consequence.  The issue is that providers such as nurses and others use the CPT codes psychologist’s use.  While it is appropriate for psychiatric nurse practitioners to measure blood pressure and complete a medication reconciliation, it is not typical for psychologists to perform these actions.   Through Amy’s determination, CMS recognized a flaw in the MAV system and they are working on correcting it.

CMS is asking that psychologists send examples (e.g. screen shots, copies etc) of reports they get via MAV so that CMS  can continue to correct any errors and make PQRS work as it was intended.  You might wonder why CMS cannot review information internally to identify errors. Apparently, the people who approve the measures and set up the formula’s for the MAV do not have access to the reports that providers receive.

APA asks that you send examples to pracgovt@apa.org.  You can also send things to me and I will make sure it gets to APA.

 

Written by:  Dori Ann Bischmann, PhD

WPA liaison to Medicare

Advocacy Cabinet

References:

AMA (2015).  Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge-National Quality Strategy Domain:  Communication and Care Coordination.

AMA (2015). Measure #317: Preventive Care and Screening:  Screening for High Blood Pressure and Follow-Up Documented-National Quality Strategy Domain: Community/Population Health.

APAPO (winter 2016).  Participating Successfully in the Medicare PQRS Program:  What to know and do for the 2015 and 2016 reporting years.  Good Practice:  Tools and information for Professional Psychologists, 12-15.

Rosett, A. (2015/2016) personal communications regarding PQRS.  California. http://www.dramyrosett.com.

QualityNet Help Desk (1-866-288-8912, qnetsupport@hcqis.org).

 

 

Pqrs Inquiry

I need your help.   I am trying to gather information regarding psychologist’s experiences with PQRS to share with APA.  I would appreciate any info you can provide about your own experiences and/or what you have heard from peers.

 

Here are some questions to guide you to the types of information I need.

 

  1.  Do you participate in PQRS?   If not, what factors contribute to your decision not to participate?

The following questions are for those who participate in PQRS:

  1. How do you report?   Claims, registry, EHR, GPRO?
  2. For 2014 data, how many measures did you report?
  3. Did you go through the MAV?
  4. Did you pass the MAV?
  5. Did you submit an informal review to CMS?
  6. If you submitted an informal review, what were the results?

7.  Are you aware that there are measures that include 90791 and the psychotherapy codes that require: taking a blood pressure and doing a “medication reconciliation?”

8.  Do you think that it is the scope of practice of most psychologists to measure blood pressure or do medication conciliation? Are these activities that you would feel appropriate doing in your practice?

9. Any other comments you would like to make are very welcome.

 

Thank you in advance for your help.  I will not be including any names in the summary information I provide to APA.  Although I haven’t written on this blog for a long time.  I continue to work on PQRS with others around the nation who work on PQRS issues for and on behalf of psychologists.  We are working to improve the process for psychologists and other providers. As you can imagine, working with CMS is a slow process.

Written by: Dori Ann Bischmann PHD

on behalf of the Advocacy Cabinet, Wisconsin Psychological Association.

 

 

Its a New Year for PQRS: Are You Ready? Updated Addendum.

The dawn of a new year should be your reminder to update your PQRS (Physician Quality Reporting System) measures. Each year, some measures are retired and new measures are introduced.  This year psychologists don’t necessarily have more measures to use, but we do have more reporting options.

APA has partnered with Healthmonix, a registry company, to provide a registry specifically  for psychologists.  The registry is available at http://apapo.pqrs.com.  I used the registry this year and I will share my experiences later in this post.

PQRS Basics for 2015:  There are 6 different ways to report PQRS data.  Most psychologists have two reporting methods available:  Claims-based and registry.  Some psychologists, particularly if employed by large systems, may be able to report via GPRO (a registry based reporting system for group practices) and EHR (directly through electronic heath records).

Claims-based reporting remains the most popular way for providers to report, according to CMS.  Nevertheless, CMS plans to phase out Claims reporting (federal register, 11/13/14) and thus they retired more claims-based measures this year.  There are 6 measures psychologists can report via claims:

#128 body mass index,

#130 documentation and verification of current medications in the medical record,

#131 pain assessment prior to initiation of patient treatment,

#134 screening for clinical depression,

#181 elder maltreatment screen and follow-up plan

#226 preventive care and screening:  tobacco use-screening and cessation intervention.

SEE ADDENDUM below for an additional measure.

CMS is encouraging providers to use registry reporting (or EHR), although no definitive end-date has been established for claims reporting.  Claims-based measures available to psychologists are also available via registry. There are 4 measures only reportable via registry:

#173 unhealthy alcohol use,

#325 adult major depressive disorder (MDD):  coordination of care of patients with specific comorbid conditions,

#383 adherence to antipsychotic medications for individuals with schizophrenia

#391 follow-up after hospitalization for mental illness.

Note that APA also included # 9 major depressive disorder: antidepressant medication during acute phase, but this is an error.  Measure #9 is only available via EHR reporting.  There is also a Measure Group on Dementia available via registry.

Participate in PQRS during 2015 to avoid a 2% payment adjustment (AKA cut, penalty) to your Medicare reimbursement in 2017.  CMS requires that providers report 9 measures covering 3 NQS (national quality strategy domains) on 50% of all FFS (fee for service) Medicare beneficiaries.  PQRS does not apply to Medicare replacement plans.  According to CMS, a provider who see’s at least one FFS Medicare beneficiary, must report at least 1 cross-cutting measure.  A cross-cutting measure is a measure that is reportable via most, if not all, reporting methods.  Several of the claims-based measures are on the cross-cutting measures list.

If a provider does not have 9 available measures (as is the case for psychologists using claims-based reporting), he/she should use as many measures as possible (6 for psychologists reporting via claims).  The reporting will be subject to MAV (measure-applicability validation), which is a system that CMS uses to determine if the provider used all available measures.  If the MAV determines that the provider fulfilled his/her obligation, the provider will get credit for successfully reporting PQRS data and avoid the 2% payment adjustment.

The Measures Group on Dementia is only available via registry.  A “measures group” includes a number of related measures that must be completed on each patient.  CMS requires that measure groups be reported on at least 20 patients, the majority of which need to be FFS Medicare Part B beneficiaries.  When reporting measures groups, you can report data from Medicare replacement plans.

I am pleased that APA set up a registry for psychologists, especially since CMS plans to phase out claims-based reporting.  I found the registry easy to navigate and it provided good feedback about duplicate reports and if I met CMS criteria.  I was able to continue to enter data over time, verify that I met criteria, and then submit to the registry.  Healthmonix staff were helpful in answering specific questions during the process.

A draw back of registry reporting is that it costs $198 per provider per year, at this time.  It is also time-consuming, especially if you wait until the end of the year to submit your data, as I did this year (I was submitting 2014 data via claims for most of the year, but then decided to use the registry).  I had 68 unique FFS Medicare patients encompassing 233 sessions (I entered 100% of my patients, not the 50% that is required by CMS). It took me approximately 11 hours to enter data, but once I was done, I knew that I met CMS criteria and avoided the payment readjustment in 2016 (performance in 2014 impacts payment in 2016).  I chose to enter 100% of my FFS Medicare Patients knowing that I was not 100% compliant on completing measure #130 (verifying medications in the medical record) which requires a review at every session.  Hospitalized patients are easy because the med list is updated daily in the medical record.  Outpatients and home visit patients aren’t as easy.  Patients may not know the names or dosages of medications, but quite frankly, I didn’t feel it was appropriate to discuss medications at every session with every client.

Other benefits of registry reporting include: being prepared when claims reporting is eliminated, provider has complete control over the data reported to CMS, there is no patient identifying data attached to data, increased likelihood of successfully meeting CMS criteria (99%), and participating in the learning curve of quality reporting.

Quality reporting, in one shape or form, is here to stay.  Eventually, all providers will be required to participate whether Medicare providers or not  The data will serve as a way to measure the quality of services relative to similar providers.  Information from quality reporting and other sources will provide a score for each of us.  It is projected that payers and other entities will use the score to make decisions about us, such as what fee to pay us, whether to let us in a provider panel etc.  That’s right, the score we achieve will determine our fee.  Those with higher scores will be paid at higher levels; those with lower scores will be paid less for the same service.  Not participating in quality reporting will lower your score.  CMS and others are looking at ways to measure quality of care with respect to clinical outcomes, financial outcomes, patient satisfaction, population outcomes and many other variables.

Since this is your forum, it is your place to ask questions.  I make every effort to check and double-check what I report to make sure it is accurate, but I am human and there are heaps of documents to sort through.  Please always check with the original sources before implementing specific measures into your practice.  If you see any errors in my posts, please let me know publicly through the blog.  This way we alert others of a potential error and I can correct it quickly.

ADDENDUM.  updated 2/13/15.  Due to the sharp eyes and mind of one of our fellow psychologists Jeremy Katz), it appears that there is another measure that is potentially available to psychologists who report via claims or registry. 

Measure #317:  Preventive care and screening:  screening for high blood pressure and follow-up.   

Sources:

CMS

www.apapo.pqrspro.com

www.apapracticecentral.org

Federal Register/ Vol.79, No. 219/Thursday, November 13, 2014/Rules and Regulations

Healthmonix

Blog author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

Teaser for New Information to Come Soon

There are so many changes in Healthcare that it has been difficult to keep up!   Starting in January, I will to go through the changes in more depth, but for now here is a summary:

1.  Wisconsin is expected to delay the cancellation of Badger care and HRSP (the WI high risk insurance sharing plan) to March so people can avoid coverage gaps while ACA (Affordable Care Act, e.g. Obamacare) website is fixed.

2.  As of January 1, 2014, Medicare payments for mental health services are on full parity with Medical services.  Medicare pays 80% for all services. Thus there is a 20% copay for all services.

3.  Most psychotherapy codes will have a small increase in Medicare reimbursement due to changes in the work value formula.  90832 does not increase and 90791 is expected to decrease by 15% (national average).

4.  SGR cut is delayed for three months to allow congress more time to figure out an alternative.

5.  No news yet on whether recent budget will impact the expected 2% sequestration cut to physician fees.

6.  The healthcare exchange website, Healthcare.gov, is working better and more people have been able to sign up for insurance policies through the website (including me, yippie!), but there are still technical problems to be worked out.

7.  Dean care insurance will be/is expanding its coverage area east into Waukesha County.  Dean does offer insurance plans on the Healthcare exchange for Waukesha Co residents, but in my opinion they don’t yet have enough providers east of Oconomowoc.

8.  Medicare is changing the rules regarding PQRS.  It is expected that completing 9 PQRS measures on 80% of your Medicare patients will be required for 2014 to avoid penalty in 2016.  Some PQRS claims based measures (what psychologists use) may be retired.  New ways to measure services, such as “value” are being proposed for the next couple of years.

9.  It appears that reporting PQRS measures via a registry is valued above reporting via claims based reporting.  APA is discussing the feasibility of developing a registry for psychologists.  It is my read that in the next couple of years psychologists will not be able to participate in PQRS (but will be able to incur penalties) if we are unable to report via Registry.

10.  The “Physician Compare” website is up and running.  This website will provide data on all physicians (including psychologists) and is available to the public (and insurance companies).  The website is put together by Medicare, but it is a requirement of the ACA.  The only interesting data I see on my listing so far is that I participate in PQRS.  Eventually, the ACA’s goal is to include ratings and other information that will allow the public to determine how an individual physician compares to others in his/her discipline.  Imagine what an insurance company might use this information for…..just saying.

11.  Healthcare changes are occurring rapidly.  These are changes you must know or you will potentially suffer penalties, be left out of insurance panels or other undesired things.  Please, please, please be a member of  your respective provider associations.  It is their job to sort through the volumes of government information and bring the must know info to you. It is impossible to keep up with the changes independently and you can’t afford to wait for pertinent info to trickle down through the grapevine. The changes are occurring too rapidly and they are often quite complex.

12.  While most of these changes start within the Medicare program, they will be applied to all programs in one way or another.  With the ACA, what was once restricted to Medicare, will eventually apply to all insurance plans.

13.  Details to come in January when written policies are available for review.

The WPA Advocacy Cabinet

(post author:  Dori Ann Bischmann, PhD)

Dori’s PQRS Picks for 2013

Dori’s criteria for choosing specific PQRS measures:

1. The measures are applicable to my clinical population across settings.
2. The measures can be completed at one session.
3. The measures are used with assessment CPT codes and thus I can complete at initial evaluation.
4. The measures pertain to subjects I already assess.
5. The measures require simple assessment tools, if specified by Medicare, that would be acceptable to my clients.
6. The assessment tools, if specified, are short. I don’t have very much time to complete the face to face portion of my assessments.

And the winners are:

#173 Unhealthy alcohol use
#131 Pain assessment prior to initiation of patient treatment
#226 Screening tobacco use, advise on smoking cessation

Advocacy Cabinet
(Blog author: Dori Bischmann, PhD)

References:

APAPO (Winter 2013) Critical Update: Quality reporting for Medicare providers in 2013. Good Practice: Tools and Information for professional psychologists. 6-9.
CMS (2012) PQRS measures.

Please see former posts on PQRS for recommendations on resources.