Appendix A: 2015 Reporting Year ACO Quality Measure Benchmarks

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1 Appendix A: 2015 Reporting Year ACO Quality Measure Benchmarks Domain Measure Description Patient/Caregiver Experience ACO #1 Getting Timely Care, Appointments, and Information Pay for Performance Phase In R= Reporting P= Performance 30th 40th 50th 60th 70th 80th 90th PY1 PY2 PY3 R P P Patient/Caregiver Experience ACO #2 How Well Your Doctors Communicate R P P Patient/Caregiver Experience ACO #3 Patients Rating of Doctor R P P Patient/Caregiver Experience ACO #4 Access to Specialists R P P Patient/Caregiver Experience ACO #5 Health Promotion and Education R P P Patient/Caregiver Experience ACO #6 Shared Decision Making R P P Patient/Caregiver Experience ACO #7 Health Status/Functional Status Patient/Caregiver Experience ACO #34 Stewardship of Patient Resources ACO #8 Risk Standardized, All Condition Readmissions R R P ACO #35 Skilled Nursing Facility 30 Day All Cause Readmission Measure (SNFRM)* ACO #36 All Cause Unplanned Admissions for Patients with Diabetes* ACO #37 All Cause Unplanned Admissions for Patients with Heart Failure* ACO #38 All Cause Unplanned Admissions for Patients with Multiple Chronic Conditions* ACO #9 ASC Admissions: COPD or Asthma in Older Adults R P P ACO #10 ASC Admission: Heart Failure R P P ACO #11 Percent of PCPs who Successfully Meet Meaningful Use Requirements ACO #39 Documentation of Current Medications in the Medical Record* R P P ACO #13 Falls: Screening for Fall Risk R P P Page 6 of

2 Pay for Performance Phase In R= Reporting P= Performance 30th 40th 50th 60th 70th 80th 90th Domain Measure Description PY1 PY2 PY3 Preventive Health ACO #14 Influenza Immunization R P P Preventive Health ACO #15 Pneumococcal Vaccination R P P Preventive Health ACO #16 Adult Weight Screening and Follow up R P P Preventive Health ACO #17 Tobacco Use Assessment and Cessation Intervention R P P Preventive Health ACO #18 Depression Screening R P P Preventive Health ACO #19 Colorectal Cancer Screening R R P Preventive Health ACO #20 Mammography Screening R R P Preventive Health ACO #21 Proportion of Adults who had blood pressure screened in past 2 years R R P At Risk Population Depression ACO #40 Depression Remission at Twelve Months* At Risk Population Diabetes At Risk Population Hypertension At Risk Population IVD Diabetes Composite ACO #27 and #41 ACO #27: Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) Hemoglobin A1c Control (HbA1c) (<8 percent) ACO #41: Diabetes Eye Exam* ACO #28 Percent of beneficiaries with hypertension whose BP < 140/90 ACO #30 Percent of beneficiaries with IVD who use Aspirin or other antithrombotic R P P R P P At Risk Population HF ACO #31 Beta Blocker Therapy for LVSD R R P At Risk Population CAD *New measures finalized in the 2015 PFS Final Rule ACO #33 ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD R R P Page 7 of

3 Medicare Shared Savings Program Interaction with the Physician Quality Reporting System (PQRS) Introduction: Medicare enrolled providers and suppliers are subject to a number of CMS quality reporting requirements and initiatives. The Shared Savings Program regulations address alignment with certain quality initiatives, including the Physician Quality Reporting System (PQRS) and Medicare Physician Value Based Payment Modifier (VM), in an effort to reduce provider quality reporting burden. Under the Shared Savings Program eligible professionals billing through ACO participant TINs will be treated as participating in a PQRS group practice and will avoid the PQRS downward payment adjustment if their ACO satisfactorily reports all of the Group Practice Reporting Option (GPRO) Web Interface quality measures. If the ACO satisfactorily reports all of the GPRO Web Interface quality measures for the reporting period, its ACO participant TINs and the eligible professionals billing through those TINs will avoid the PQRS downward payment adjustment. ACO participant TINs and the eligible professionals billing through those TINS are not eligible to participate in PQRS outside of the Shared Savings Program. That is, they may not independently report for purposes of the PQRS apart from the ACO. Please note, that beginning in 2017, CMS is applying the VM to groups and solo practitioners participating in a Shared Savings Program ACO in The 2017 VM adjustments will be based on your ACO s quality and financial performance in calendar year Please visit the VM fact sheet for more information. What is PQRS? PQRS is a quality reporting program that uses payment adjustments to promote quality data reporting by eligible professionals. To avoid the PQRS payment adjustment, which is applied to services billed in 2015 and subsequent years; eligible professionals must satisfactorily report data on quality measures during the applicable reporting period. For more specific information about the PQRS, please visit: Initiatives Patient Assessment Instruments/PQRS/index.html?redirect=/pqri How do changes in Medicare Shared Savings Program ACO participants affect which eligible professionals avoid the PQRS payment adjustment through the Medicare Shared Savings Program? Upon approval to participate in the Shared Savings Program, an ACO must certify its list of ACO participant TINs that have signed ACO participant agreements with the ACO and that have agreed to participate in the Shared Savings Program. ACOs must certify this list at the beginning of each performance year to account for changes in ACO participants during the course of the previous performance year and at such other times as specified by CMS. The list that is certified at the beginning of the performance year determines the ACO participant TINs that must report through the ACO for purposes of the PQRS payment adjustment. The ACO participants included on this certified list may not independently report for purposes of the PQRS apart from the ACO for the performance year and reporting period for which the certified list applies. If the ACO satisfactorily reports all of the GPRO Web Interface quality measures for the reporting period, eligible professionals billing through the TINs of the ACO participants included on the certified list will avoid the PQRS downward adjustment. 1

4 To be included on the certified list of ACO participants, ACO participant TINs must have a signed and valid agreement with the ACO that meets Shared Savings Program requirements, have their program integrity histories screened, be checked for overlapping TINs that are already participating in another ACO or Medicare initiative involving shared savings, and be approved by CMS as described in our guidance found HERE. There are 3 scenarios that may apply to PQRS eligible professionals billing for services through an ACO participant TIN: 1) Eligible professionals in ACO participant TINs that have been added to the ACO but were not included on the certified list of ACO participants submitted at the beginning of the performance year. An ACO participant TIN, and the eligible professionals that bill for services through it, that joined an ACO after a performance year has started will not be eligible to report for purposes of the PQRS payment adjustment through the Shared Savings Program in that year, because the ACO participant TIN will not be part of the certified list of ACO participants submitted and certified by the ACO at the beginning of the performance year. Instead, the ACO participant and it eligible professionals will need to participate in one of the PQRS individual or group reporting options apart from the ACO. 2) Eligible professionals who are joining an ACO participant TIN that is already on the ACO s certified list of ACO participants. Eligible professionals who join an ACO participant TIN (defined as reassigning their billing rights to the ACO participant TIN) that is included on the ACO s certified list of ACO participants submitted at that beginning of a performance year will be eligible to report for purposes of the PQRS payment adjustment, but only for services that are billed through the ACO participant TIN. For example, eligible professionals that join an ACO participant TIN that was included on the ACO s certified list of ACO participants submitted at the start of 2015 will avoid the PQRS payment adjustment for 2017 if the ACO satisfactorily reports all of the GPRO Web Interface measures for the 2015 performance year. 3) Eligible professionals that have assigned their billing to an ACO participant TIN that terminates from an ACO during a performance year in which the TIN appeared on the certified list of ACO participants submitted by the ACO at the start of the performance year. If an ACO participant TIN included on the certified list of ACO participants terminates from an ACO before the end of a performance year, the eligible professionals that bill through that TIN must participate in PQRS through the ACO for that performance year. For example, if a TIN that appeared on an ACO s certified list of ACO participants submitted at the beginning of 2015 chooses to leave the ACO in mid 2015, the TIN and the eligible professionals that bill for services through that TIN will not be eligible to report for purposes of the PQRS payment adjustment apart from the ACO. In this example, the ACO participant TIN and the eligible professionals that bill for services through that TIN will avoid the payment adjustment for 2017 if the ACO satisfactorily reports all of the GPRO Web Interface measures for the 2015 performance year. Consequently, both the ACO and the terminating ACO participant should continue to work together to ensure that the ACO has the necessary information to complete and accurately report quality measure information. These FAQs attempt to address some commonly asked questions about the interaction and timing between the Shared Savings Program and PQRS. FAQs Q1: Are eligible professionals who bill through ACO participant TINs eligible to participate in the PQRS under the Shared Savings Program through an ACO when the ACO reports GPRO quality measures? 2

5 A1: Yes, but only if their ACO participant TIN appears on the list of ACO participants submitted and certified by the ACO to CMS at the beginning of the performance year. The eligible professionals that bill for services provided through an ACO participant TIN will: Be treated as an eligible professional reporting as part of a group practice for purposes of PQRS under the Shared Savings Program. Avoid the PQRS payment adjustment for the applicable program year if the ACO satisfactorily reports all GPRO Web Interface measures for the applicable reporting period (e.g., if the ACO satisfactorily reports all GPRO Web Interface measures for 2015, the ACO participant TIN s eligible professionals will avoid the PQRS payment adjustment for services paid to the ACO participant TIN in 2017). Q2: My TIN joined an ACO as an ACO participant in the middle of the 2015 reporting period. Will the TIN and the eligible professionals that bill through this TIN meet PQRS reporting requirements if the ACO satisfactorily reports all the GPRO Web Interface measures for the reporting period? A2: No. In order for eligible professionals to avoid the PQRS payment adjustment through ACO reporting under the Shared Savings Program, their ACO participant TIN must have appeared on the certified list of ACO participants that the ACO submits and certifies to CMS at the beginning of the performance year that corresponds to the applicable PQRS reporting period. Q3: If my TIN joined an ACO as an ACO participant in the middle of a reporting period, how can I report for purposes of the PQRS payment adjustment? A3: You must participate under PQRS as an individual or as a group practice until the start of the next ACO s performance year. For example, if your TIN joined an ACO on April 15, 2015, you must participate under PQRS for the 2015 reporting period apart from the ACO. If your TIN is on the ACO s certified list of ACO participants submitted and certified for the 2016 performance year, you will be able to participate in PQRS under the Shared Savings Program through the ACO. Please refer to the PQRS website for information on your participation options under PQRS. Q4: Who is eligible to participate in the PQRS under the Shared Savings Program through their ACO? A4: Each eligible professional that bills for services through the TIN of an ACO participant is eligible to participate in the PQRS under the Shared Savings Program as long as the eligible professional is billing under an ACO participant TIN that was included on the certified list of ACO participant TINs that the ACO submitted before the beginning of the reporting period. Q5: I am an eligible professional submitting claims through multiple Medicare enrolled TINs, one of which is participating in an ACO under the Medicare Shared Savings Program. If the ACO satisfactorily reports, will the claims submitted under all of these TINs avoid the payment adjustment? A5: No. Only the claims for services billed through the TIN of an ACO participant that was included on the ACO s certified list of ACO participants will avoid the payment adjustment based on reporting by the ACO. You must separately report PQRS measures under the non ACO participant TIN to avoid the payment adjustment for services billed through the TIN of a non ACO participant. Q6: I bill through the TIN of an ACO participant. May I participate in PQRS under that TIN apart from the ACO to avoid the PQRS payment adjustment? A6: No. Eligible professionals that bill through the TIN of an ACO participant on the ACO s certified list of ACO participants can only meet PQRS reporting requirements when the ACO completely reports the GPRO Web Interface measures under the Medicare Shared Savings Program. You may not report for purposes of PQRS, under the ACO participant TIN, apart from the ACO. 3

6 Q7: How are PQRS payment adjustments determined? A7: Reporting under PQRS for the 2015 reporting period will determine if a negative payment adjustment of 2 percent will be applied to physician fee schedule amounts for services furnished in Q8 How can I ensure ACO participants, including sole proprietors, in my ACO get credit for PQRS participation? A8: ACOs are responsible for certifying their ACO participant list prior to the start of every performance year and at such other times as specified by CMS. Sole proprietors have both an enrollment TIN (or SSN) and a billing TIN (or EIN). Both the enrollment and billing TINs for sole proprietors must be on the ACO s certified list of ACO participants submitted before the beginning of the reporting period; if both TINs are not on the ACO s certified list of ACO participants, the sole proprietor may be subject to the PQRS payment adjustment. Q9: Where can I find additional resources? A9: Additional resources are listed below: Changes to ACO Participants and ACO Providers/Suppliers during the Agreement Period Physician Quality Reporting System (PQRS) List of Eligible Professionals Physician Value Based Payment Modifier 2017 Fact Sheet 4

7 How to Report Once for 2015 Medicare Quality Reporting Programs: Medicare Shared Savings Program Accountable Care Organizations Overview This section serves as a guide to Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs) participants wishing to avoid the 2017 Physician Quality Reporting System (PQRS) payment adjustment, satisfy the clinical quality measure (CQM) component of the Medicare Electronic Health Record (EHR) Incentive Program, and satisfy requirements for the 2017 Value-Based Payment Modifier (VM). Note: The 2017 VM will apply to physicians in TINs that participate in the Shared Savings Program during the calendar year 2015 performance period. Medicare EPs within the ACO group practice (participating via GPRO) are required to attest to the objectives and measures of meaningful use by February 29, 2016 to demonstrate meaningful use in the EHR Incentive Programs. The reporting period for 2015 PQRS is 12 months; The EHR Incentive Program s 90-day reporting period only applies to first-time participants, so all other providers must report a full year of data. Version 1.1 Page 7 of 10 3/5/2015

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