Tag Archives: quality measures

The Fee for Service Train is Leaving the Station: Next Stop ‘Value-based Payments’ –Why this Matters Now!

Health care costs reached $3.3 trillion in 2016 (Sahadi, 2018), and as much as 60% of all medical care visits involve some mental and behavioral health component (Rozensky, 2014). To address cost containment, the health care landscape is evolving toward new reimbursement mechanisms to replace fee-for-service payments (Nordal, 2012). Notably, payers and providers have hypothesized that payment with measures of value will eclipse fee-for-service by 2020 (McKesson Health Solutions, 2016).

This has implications for psychologists, such as increased use of electronic health records, evidence-based practices, telehealth, ehealth, integration into medical teams, quality metrics, and payment reforms (e.g., value-based payment models, bundled payments, and shared-savings models).

The US federal government is spearheading payment reforms through regulatory and legislative changes. It is important for psychologists to realize that value-based payment initiatives related to behavioral and mental health will impact their practice, as the federal government is often the driver of change that then trickles down to third-party payers. Medicare providers have experienced value-based payment models for at least 10 years. The payment models have become increasingly complex with larger potential cuts/bonuses.

For those providers required to participate, the newest Medicare program called MIPS varies payment from negative nine (-9) percent to positive nine (+9) percent of the posted rates for a given service. If a provider does not participate in the program, Medicare reimbursement is decreased by 9 percent, but if the provider successfully participates, a bonus of up to 9 percent is possible. The percentage (cut or bonus) is applied to all Medicare reimbursement received in an entire year. Thus, the consequences of not participating can be significant to your bottom line.

To help you prepare for value-based payment, WPA is hosting a workshop that will address the following: 1) overview of federal and regulatory trends driving value-based payment (i.e., CMS, MACRA, MIPS, etc.) 2) overview of the psychological research supporting measurement-based care (also referred to as routine outcome monitoring) 3) application of measurement-based care to one’s practice (including a practical demonstration of how to use the registry that APA is developing as a resource for psychologists) and 4) helpful guidelines from a provider with over 10 years of experience in value-based reporting and value-based payment.

Program Presenters: C. Vaile Wright , PhD is the Director of Research and Special Projects in the Practice Directorate at the American Psychological Association. She is involved in developing professional and clinical practice guidelines and increasing outcomes measurement and quality improvement efforts, including the development of a CMS-approved Outcomes Data Registry. She is widely published in peer-reviewed journals. Dori Bischmann, PhD has been participating in quality reporting since Medicare started the program in 2006. She was among the first psychologists to report via APA’s outcomes Data Registry, called MIPSPRO (formerly PQRSPRO). She is also the APA representative to the Physician’s Consortium of Provider Improvement, a group of medical professionals involved in creating and using quality measures.

Program Name: The Fee for Service Train is Leaving the Station: Next Stop ‘Value-based Payments” –Why this Matters Now!

Program Date: November 2, 2018 Program time: 9:00 to 4:00

Program Place: For more information contact: http://wipsychology.org

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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.

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.

 

 

Measure #317: Preventive care and screeing: Screening for High blood pressure and follow-up

High blood pressure screen #317

2015 reporting options:  Claims and registry

Patient age:  18 and up

Diagnosis Code:  No specific diagnosis is associated with this measure.  Measure not appropriate for patients who already have an active diagnosis of hypertension.

CPT codes:  90791, 90832, 90834, 90837, 96118

Reporting requirements:  1. Report once per reporting period (calendar year). 2. Measure blood pressure during the qualifying session.  You can not obtain the measurement from an outside source (such as the medical record).  My interpretation of this is that you must do the blood pressure reading yourself or you could have an aid/nurse do the reading in your presence.    3. If BP falls in the pre-hypertensive or hypertensive range, document a follow-up plan (see CMS for recommendations on possible follow-up plans). 

Blood pressure parameters:

Prehypertensive:  greater than 120/80 but less than 139/89

Hypertensive:  greater than 140/90 

Please see CMS.GOV, 2015 measures list for additional details about this measure.

Resources:

CMS.GOV (12/23/14).  2015 measures list, Measure #317 Preventive Care and Screening:  Screening fo High Blood Pressure and Follow-up Documented_National Quality Strategy Domain: Community/Population Health   

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

PQRS Measure #128: preventive Care and Screening: Body Mass Index (BMI) screening and Follow-up Plan

BMI measure #128

2015 reporting options:  Claims and registry

Patient age:  18 and up

Diagnosis Code:  No specific diagnosis is associated with this measure.

CPT codes:  90791, 90832, 90834, 90837, 96150, 96151, 96152

Reporting requirements:  1. Report once per reporting period (calender year). 2. Measure height and weight (information can be gathered from outside source such as the physician’s office or via another provider in facility, i.e. dietician) and calculate the BMI.  Self-reported values, from the patient, cannot be used.  The BMI data used should be no older than 6 months.  Use a BMI chart to determine the BMI from height and weight data. Many different BMI charts are available, in the public domain, via the internet.  Normal BMI parameters are as follows: 

Age 65 years and older; BMI greater than 23 and less than 30 kg/m. 

Age 18-64; BMI greater than 18.5 and less than 25 kg/m. 

 3. If the BMI is outside normal parameters, establish a follow-up plan.  The follow-up plan may include a referral to another provider (e.g. dietician, physician), education or specific psychological goals to address weight. 4. Document BMI and follow-up plan in medical record.   

SIDE NOTE: While we are not supposed to use self-reported values, it is my opinion that I will use self-reported values on occasion.  In my facilities, I can gather the information from the dietician’s notes.  In my outpatient office, I can weigh and measure the patient with the available scale.  However, in the office and when I do home visits I may have to rely on the patient’s report, if I am unable to get data from a physician’s office.  It is my opinion that it is better to complete the measure, using the patient’s self reported data, than to skip the measure or put the patient in danger (I work with disabled patients who may or may not be able to safely get on a scale.  I will not take that risk, even in the office where a scale is available.)  Furthermore, height information gathered from outside sources may be based upon the patient’s self report.  I have talked to dietician’s in hospitals where I work.  They typically ask the patient for their height.  They don’t measure the pt directly unless they are ambulatory (usually outpatients) or comatose (wherein the patient can not report a height. The dietician measures the patient from the sternum to the tip of his/her fingers and then doubles that for a measure of the patient’s height).    

Please see CMS.GOV, 2015 measures list for additional details about this measure.

Resources:

CMS.GOV (12/23/14).  2015 measures list, Measure #128 (NQF 0421):  Preventive care and screening:  body mass index (BMI) screening and follow-up plan-National Quality Strategy Domain:  Community/Population Health.   

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

Dori’s PQRS Picks for 2015

In 2015, I will again report via registry.  So my requirements for picking measures include:  measures that are appropriate for psychologists, measures that are appropriate for my client mix and measures that are available via registry.

All of the claims-based measures are available for registry reporting, so those of you who are reporting via claims can utilize the first section of my picks.  This year there are only 6 (there actually appear to be 7*) measures available for claims-based reporting that are appropriate for psychologists (APAPO, 1/25/15).  You must report on as many of these measures as are appropriate to your patient population to meet Medicare’s criteria for successful PQRS reporting.  Obviously, if you do not work with individual’s over age 65, you would not report on measure # 181, elder maltreatment screen and follow-up plan.  But if you have even one client over age 65 (who is a Medicare FFS recipient),  you must report on measure #181.  The remaining 5 measures are appropriate for every psychological practice. 

Recall that Medicare requires that providers report on 9 measures over the 3 NQS domains on 50% of eligible FFS Medicare recipients.  Since 9 measures aren’t available to psychologists via claims, you will need to report on all 6 available (or 5 if no patients over age 65) measures and will be reviewed via the MAV system (see previous post for description of MAV).  

The 7 measures available for claims based and registry reporting include:

#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, (note that the age for this measure is 12 yrs and up) 

#181 elder maltreatment screen and follow-up plan

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

#317 preventive care and screening: screening for high blood pressure and follow-up

Since I will be reporting via registry, I will also be using 3 additional measures to bring my total measures count to 9.   Note that there is an additional measure and measure group that could be used if reporting via registry.  I have chosen not to use those two options because they do not fit my patient population.

The three registry only measures I will be using are:

#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.

For additional details about PQRS and these measures, see previous posts.  I will be outlining some of the new measures in subsequent posts.

*Measure #317: Preventive care and screening:  screening for high blood pressure and follow-up appears to be appropriate for psychologists to report.  APA did not include this measure in it’s list, but it does include our CPT codes

Resources:

http://www.apapracticecentral.org

CMS.gov (12/23/14).  PQRS, 2015 measures list.

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

 

 

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