Quality Queries and Quandaries:
Confusion surrounds quality reporting for anesthesia providers. The use of acronyms by the government, such as PQRS, MAV, VM, QRUR, QCDR, MACRA and MIPS, only adds to the problem. The “alphabet soup” of government quality programs is bewildering and complex, and even experienced policy wonks struggle to understand them. Many anesthesia providers throw their hands in the air in exasperation and exclaim, “This is stupid! I’m not doing this.” With 6% of Medicare reimbursement at stake, the decision not to participate can be a costly one. MACRA accentuates this problem, tying 9% of reimbursement to a performance score that includes quality reporting.
At the invitation of Anesthesiology News, this will be the first of a series of columns attempting to answer many of the questions regarding quality reporting. How did we get here? Who must participate? Should I participate as a group or an individual? Can I report via claims in 2016? How do I report via a registry? What is a QCDR and how do I participate?
It Started With Quality Reporting
The first question that needs to be answered is,
“How did we get here?”
The United States spends more on health care than any other country. Are the results better? Well, not exactly. The United States lags behind other countries in objective measures of health, such as infant mortality and life expectancy. In an attempt to address quality the government implemented the Physician Quality Reporting Initiative, the predecessor of the Physician Quality Reporting System (PQRS), in 2006. The PQRS program has changed over the years, and now includes a “carrot and stick” approach, of which good performers are rewarded and poor ones penalized.
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 also focuses on quality reporting. MACRA will be discussed in a future column, but suffice it to say that MACRA is like PQRS on steroids. The Centers for Medicare & Medicaid Services (CMS) has made it very clear that it is moving toward paying for value (health care outcomes per dollar spent) rather than the current fee-for-service program. In fact, CMS has a goal to link 90% of all Medicare payments to value by 2018.
One way to measure outcomes is through quality reporting, and PQRS will continue to be important for anesthesiologists. It is critical that anesthesiologists understand changes to the program and continue to participate, or as Yogi Berra said, “You might wind up somewhere else”—and “somewhere else” could be suffering 9% penalties in your Medicare reimbursement.
In order to understand PQRS, one should answer some basic questions. First, who must participate? The list of eligible providers can be found on CMS.gov, and includes anesthesiologists, certified registered nurse anesthetists (CRNAs), anesthesiologist assistants and nurse practitioners. Essentially, all anesthesia and pain providers who bill for professional services must participate. The penalty for not participating in 2016 is a negative 2% adjustment to payments in 2018. However, PQRS reporting also helps determine the quality component of the value-based modifier (VM). A discussion of the VM is beyond the scope of this article, but failure to report PQRS also will result in a negative 4% VM adjustment to reimbursement in 2018. Previously, CRNA reimbursement was not affected by the VM; that changes this year. There is one exception: CRNAs who practice as solo practitioners or in a group of nonphysicians will be held harmless under the quality tiering portion of the VM.
The next question that one must answer is:
“How do I report?”
Options for reporting include claims (paper), a registry, a qualified clinical data registry (QCDR) and electronic health records. Anesthesia providers commonly use the first three methods. To submit via claims, one simply adds codes to the claim sent to Medicare. As recently as 2015, the overwhelming majority of anesthesia providers reported via claims. Is claims-based reporting an option in 2016? Please read on to find the answer! Providers also can participate in PQRS through a registry or QCDR. A registry is a vendor with whom the eligible professional or group contracts for PQRS reporting purposes. When reporting via a registry, one reports approved PQRS measures into a reporting foundation that has been preapproved and developed by the contracted registry. The registry then submits the data to CMS during the first quarter of the following year (e.g., data for 2016 are submitted in the first quarter of 2017). The cost for a registry is typically $300 per provider per year. Registries and QCDRs will be discussed more fully in the next column.
“Do I report as an individual or group?”
Most providers participate in PQRS as an individual. With this option, your success or failure only affects your individual reimbursement from Medicare. Alternatively, members of a group can participate together using the Group Practice Reporting Option (GPRO). Under the GPRO, providers succeed or fail as a group. The advantage of the GPRO is that high-performing providers can “carry the water” for poor-performing providers. In other words, if you have three providers who report successfully on all of their patients but one provider who only reports on 25% of his patients, the group could still be deemed successful. The deadline to register for the GPRO is June 30, 2016. New in 2016: Groups who register for the GPRO can participate in a QCDR. Please note that the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry does not allow GPRO participation at this time.
“How many measures do I need to report? What if we don’t have enough measures to report?”
Eligible professionals must report nine PQRS measures across three National Quality Strategy (NQS) domains, plus a cross-cutting measure if applicable, on 50% of Medicare fee-for-service patients. (Please note that QCDR reporting requirements are different and will be discussed in a future column.) Each PQRS measure is assigned to one of six NQS domains, which represent the aspect of patient care that the measure most exemplifies. Domains include categories such as patient safety, effective clinical care and efficiency/cost reduction. A cross-cutting measure is a PQRS measure that has broad applicability across multiple specialties. The requirement to report a cross-cutting measure is triggered by a “face-to-face encounter.”
A list of triggering face-to-face encounters can be found on CMS.gov. For the average anesthesia provider, the relevant triggering codes would be evaluation and management codes, including subsequent hospital care and critical care codes. Two common cross-cutting measures reported by anesthesia providers are #47, “Advance Care Plan”; and #130, “Documentation of Current Medications in the Medical Record.” For anesthesia providers, there are less than nine PQRS measures available to report. If a provider reports less than nine measures, the Measure-Applicability Validation (MAV) is activated. The MAV process determines whether a provider is considered a successful PQRS participant when he or she reports less than nine measures. In order to avoid the penalty and 2018 negative adjustment, you must report on all applicable anesthesia measures and at least one cross-cutting measure, if indicated.
Reporting Via Claims
“So where does this leave us for 2016? Can an anesthesia provider successfully report via claims?”
This is the $64,000 question (and maybe more!). The answer is maybe. (Please note that this discussion is different for pain providers and will be addressed in a future column.) Last year, anesthesia providers could report three measures via claims: #44, “Preoperative Beta-Blocker in Patients with Isolated CABG Surgery”; #76, “Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections”; and #193, “Perioperative Temperature Management.” Measure #44 was changed to registry reporting only, and Measure #193 was “retired.” (Anesthesia providers were doing such a good job of active warming that the government retired it!)
This leaves one measure to report via claims in 2016: #76. To successfully undergo the MAV process, you must have at least 15 eligible encounters. So if an anesthesia provider places central lines 15 times during the year, reports Measure #76 and a cross-cutting measure, will he or she be a successful PQRS reporter? The CMS QualityNet Help Desk responded to this question: “Yes. Please see note about cross-cutting measure. Note about cross-cutting measure: An additional requirement is to report a cross-cutting measure, if applicable.” The help desk agreed that reporting Measure #76 and a cross-cutting measure via claims would satisfy the PQRS reporting requirement and avoid the penalty.
What if an anesthesia provider does not place central lines and cannot report Measure #76?
This question also was sent to the help desk, and the response was: “Please note that if you are not able to report Measure #76 via claims, you are required to hire a registry for reporting the other applicable measures or a Qualified Clinical Data Registry (QCDR).” Should you report via claims? As Clint Eastwood says in “Dirty Harry,”
“You’ve gotta to ask yourself one question: ‘Do I feel lucky?’ Well, do ya, punk?”
Please look for future columns on registry reporting, QCDRs, PQRS for pain physicians, and a discussion of MACRA, Merit-Based Incentive Payment System and Alternative Payment Models.