PQRS Catch-22 for Specialists: How Medicare’s Division of Measures Can Put You at Risk for Penalties

written by Dave Halpert | February 3, 2015

If you are a specialist, maintaining your Medicare revenues just became more challenging. As of 2015, CMS now requires nine measures instead of three for PQRS reporting. They provided a partial reprieve by reducing the completion rate from 80 percent to only 50 percent. However, successful PQRS reporting is all or nothing—failure to report all nine measures within three domains will result in a penalty for both PQRS and the Value-Based Payment Modifier (VBPM) of 6 percent total in 2017.

With more than 200 measures to choose from, you may wonder what’s the problem; surely you can find nine that are applicable. Unfortunately, it’s not that simple. It’s the domain requirement that makes achieving nine measures more challenging. Specifically, the three NQS domains may prevent you from reporting on a very focused set of measures (and patients), as they have in the past.

What are NQS Domains?

NQS stands for National Quality Strategy, created by the Agency for Healthcare Research and Quality (AHRQ) on behalf of the Department of Health and Human Services. Six priorities were identified in the National Quality Strategy to improve patient care, which form the basis of the six NQS domains. They are:

  1. Communication and Care Coordination (28 Registry measures): Focused on a more integrated care delivery system to treat patients (e.g. measures of whether a specialist communicated findings to the patient’s primary care provider);
  2. Community/Population Health (10 Registry measures): Encourage practices to improve overall population health (e.g. screening patients for tobacco use, and working with patients who use tobacco to quit);
  3. Effective Clinical Care (90 Registry measures): Relate to the prevention and treatment of the leading causes of mortality in the population (e.g. prescription of antiplatelet therapy for patients with coronary artery disease);
  4. Efficiency and Cost Reduction (14 Registry measures): Track practices to make care more affordable to all stakeholders (e.g. inappropriate use of imaging for patients with specific conditions);
  5. Patient Safety (23 Registry measures): Designed to minimize harm that may otherwise come from care delivered (e.g. selection of appropriate antibiotics prior to a surgical procedure); and
  6. Person and Caregiver-Centered Experience and Outcomes (10 Registry measures): Facilitate additional engagement by patients and their families (e.g. whether a plan of care is in place to control pain for patients with cancer and undergoing chemotherapy).

Medicare has attributed all PQRS measures to these categories, and therein lies the problem: Domains are not assigned equally. While the Effective Clinical Care Domain has almost 100 measures from which to choose, Community/Population Health as well as Person and Caregiver-Centered Experience and Outcomes include only a handful.

Not All Specialists Qualify for All Domains

The domain requirement is both a financial and logistical concern, particularly for specialists. Many specialists do not qualify for measures in all six domains, so, when one of the remaining domains only contains non-applicable measures, you can be locked into the remaining three domains.

And it gets even more complicated. Not only are you stuck with the remaining measures, but you must also prove that you are performing as well or better as others reporting the same measures. That’s because if your practice includes more than nine providers, you’ll risk being penalized under the VBPM if you fall within the lower quality-cost tiers compared to other groups.

The VBPM rewards those who are able to perform better than one standard deviation from the mean and penalizes those whose performance is worse. So, even though you may be able to perform above and beyond on dozens of measures, the domain requirement makes it more difficult to have success in both PQRS and the VBPM.

Medicare does recognize that some providers will be unable to fulfill reporting requirements. Before penalties are assessed, Medicare will audit providers, based on claims submitted. This Measure Applicability Validation (MAV) Process determines whether there were any measures that could have been reported, but weren’t. However, don’t assume that you’ll be vindicated through the MAV process—every single claim will be analyzed against every single measure, whether it seems clinically relevant or not.

Review Measures Now to Ensure Correct PQRS Reporting Mix

So, what can you do? Here are two key steps:

  1. Review the measures now, in the beginning of the year, to make sure that you have the requisite number of domains represented in your measure pool. Some may not be obvious, and it may require an adjustment in your practice’s workflow in order to collect that information with the required consistency, including your ability to perform them. Reporting the “not done, reason not specified” option may be an acceptable response, but use it sparingly—these responses will hurt your performance and put your Medicare revenues at risk under the VBPM.
  2. Consider the Qualified Clinical Data Registry (QCDR) option if you do not have the ability to succeed using the existing measures. In 2015, QCDRs have the ability to report up to 30 measures for PQRS that are not part of the standard PQRS measures. As part of the QCDR process, these measures are categorized in the six domains. CMS requires that QCDRs publish their non-PQRS measures, so you can evaluate which QCDRs may be best suited to your practice.

To create a measure reporting pool that will both fulfill PQRS requirements and protect you from VBPM penalties, make sure that your measures are spread over at least three National Quality Strategy Domains. You may have a library of measures where you can show that your performance exceeds national averages. Just remember—unless you are adhering to the National Quality Strategy dimension of 2015 reporting requirements, you are at risk of losing 6 percent of all Medicare Part B reimbursements in 2017.

Founded in 2002, ICLOPS has pioneered data registry solutions for improving population health. Our industry experts provide comprehensive PQRS Reporting with VBPM Consultation solutions that help you both report and improve your performance. ICLOPS is a CMS Qualified Clinical Data Registry.

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