A Primer on CMS Quality Measurement: PQRS and MACRA

A Primer on CMS Quality Measurement: PQRS and MACRA

By Anne C. Chiang, MD, PhD

Article Highlights

  • The cost and complexity of cancer care in the United States continues to increase.
  • Centers for Medicare and Medicaid Services’ (CMS) strategy to reduce costs has been to focus on value by utilizing guidelines and clinical pathways, and by using quality metrics to measure guideline adherence and patient outcomes.
  • The Physician Quality Reporting System (PQRS) uses incentive payments and payment adjustments to promote quality reporting.
  • The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed to reform Medicare payments, and it will likely accelerate the current trends in health care toward value-based systems that will reform payment and delivery of care.
  • ASCO continues to provide feedback to CMS regarding cancer-specific implementation issues and to develop its signature programs—such as the Quality Oncology Practice Initiative (QOPI®), the QOPI Certification Program, and Patient-Centered Oncology Payment—to meet ongoing needs.

The cost of cancer care in the United States has continued to rise over the past decade as the population ages, with more patients, more expensive drugs, and costly restructuring in cancer care delivery to implement electronic health records (EHRs) and to meet safety and regulatory standards. For example, the U.S. Pharmacopeial Convention chapters 797 and 800 describe enforceable standards that apply to chemotherapy storage, preparation, and administration that may require renovation of equipment or facilities.1 

In 2011, the estimated direct medical costs for cancer care in the United States totaled $88.7 billion, with 50% of that cost for physician or hospital outpatient office visits, 35% for inpatient stays, and 11% for prescription drugs.2 Projections of growth from 2010 to 2020 based on 13.8 million and 18.1 million cancer survivors, respectively, estimated the costs associated with cancer care to be $124.57 billion and $157.77 billion, respectively.3 However, in 2012, 8.5% of the adult U.S. population were diagnosed with cancer, already totaling more than 20 million patients and more than 29 million ambulatory visits to physician offices, hospital outpatient offices, and emergency departments.4

Physician Quality Reporting System

The Centers for Medicare and Medicaid Services’ (CMS) strategy to reduce costs has been to focus on value, for example, improving patient outcomes by increasing efficiency, reducing errors by utilizing guideline and clinical pathways, and using quality metrics to measure guideline adherence and patient outcomes. Providers can report as individual eligible professionals or as a group practice (Group Practice Reporting Option [GPRO]) to CMS through the Physician Quality Reporting System (PQRS). This program uses incentive payments and payment adjustments to promote quality reporting. For PQRS, individual eligible professionals can report data using a qualified clinical data registry (QCDR) or via direct EHR transfer using certified EHR technology or another data submission vendor. Larger groups can use a web interface for GPRO or Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient surveys. PQRS is separate from the American Recovery and Reinvestment Act of 2009, which established incentive payments to promote the adoption and meaningful use of EHRs and interoperable health information technology.5

CMS Timeline for Payment Adjustments for PQRS

As of 2015, eligible professionals were subject to a payment adjustment if they did not report 2013 quality measure data for covered physician professional services for Medicare Part B fee-for-service beneficiaries. In 2016, eligible professionals who have not reported for the 2014 year will receive a 2% negative payment adjustment on their Medicare physician fee schedule services provided in 2016. At minimum, eligible professionals must report on at least one measure for at least 50% of their applicable patients to avoid the 2016 payment adjustment.

To avoid negative payment adjustments, eligible practitioners must report on nine individual measures in three or more National Quality Strategy domains for at least 50% of the eligible professional’s patients. If group reporting is done through a web interface (e.g., GPRO), then 22 measures must be reported. Data can be collected directly by a vendor from the EHR or through a CMS-approved, or “deemed,” QCDR that submits benchmarked data to CMS.

PQRS Transitions Into Part of MACRA

Fig. 1
PQRS reporting represents a basic shift for CMS reimbursement from fee-for-service to pay-for-performance using CMS-approved clinical pathways and quality metrics. Recently, the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) was passed to reform Medicare payments.6 Again, the focus is to incentivize participation in quality programs through a Merit-Based Incentive Payment System (MIPS) or Alternative Payment Model (APM).

The MIPS program includes components of PQRS, the Value-Based Payment Modifier, and the Medicare EHR incentive program (Meaningful Use). APMs include accountable care organizations, patient-centered medical homes, and bundled payment models.

The current expectation by CMS is that 85% of payments will be linked to quality, with 30% occurring through APMs and new delivery systems. CMS’s goal is that by 2018, 50% of quality improvement will occur through APMs (Fig. 1).

An Aggressive MACRA Timeline

Fig. 2
MACRA will likely accelerate the current trends in health care toward value-based systems that will reform payment and delivery of care. In 2019, the individual adjustment programs PQRS, Meaningful Use, and Value-Based Payment Modifier will be incorporated into MIPS. The assessments that eventually make up a physician’s composite MIPS score will be based on four categories: quality, resource use, meaningful use of electronic health records, and clinical practice improvement activities. Although the current programs do not sunset until the end of 2018, CMS will begin measuring quality in 2017 as the performance year serving as the basis for calculation of the MIPS composite score threshold and individual rating in 2019. The specific milestones in the MACRA timeline are shown in Figure 2.

ASCO’s Quality Oncology Practice Initiative

ASCO has convened a task force of its leaders to understand and prepare its membership for MACRA and respond to requests for information regarding implementation issues. Because 2017 is a measurement year, it is critical that there are robust oncology measures in place for eligible professionals to choose from.

Currently, ASCO members can report PQRS measures through participation in ASCO’s Quality Oncology Practice Initiative (QOPI®). CMS has approved QOPI as a QCDR, with more than 185 clinical measures that are highly relevant to contemporary ambulatory practice. Participants abstract and submit data for a set of core measures, PQRS measures, or additional modules (e.g., disease-specific). eQOPI® is a data-submission process for QOPI that is in development that allows for direct pull of primarily structured data from the practice electronic medical record.

 Participating practices receive detailed reports of their performance on quality metrics, which allows them to compare with national benchmark data to identify areas for improvement and develop focused improvement plans. In 2019, eligible professionals who do not have a specified percentage of their revenue from APMs will need to participate in MIPS. Participation in QCDR counts as a Clinical Improvement Activity to improve the MIPS Composite Score.

PQRS and MACRA Measures of a Practice

Fig. 3
Practices not using APM will need to participate in MIPS reporting (Fig. 3). Currently, most group practices use a vendor to report PQRS data to CMS. The full list of PQRS measures is available at cms.gov and includes specialty-specific, primary care, as well as general cross-cutting measures.

Although a smaller oncology practice would select cancer-specific measures to report to CMS, a large multidisciplinary group may select broader measures, such as primary care, that will be reported for all of its members, including subspecialty groups that may not perform as well for the selected measures.

For example, Yale Medical Group falls into the category of a group practice with more than 100 providers, and they report their via Group Reporting. Due to the group size, Yale is responsible for selecting and paying a certified survey vendor to implement the CAHPS survey for PQRS. The CAHPS for PQRS Survey satisfies three of the nine required measures, and the additional six measures—which include influenza vaccination, blood pressure control, and breast and colon cancer screening—are satisfied through a vendor. 

Participating in the QOPI QCDR is a key step to prepare for MACRA implementation and ensures that a hematology/oncology practice is measured on the cancer care that it provides to its patients. ASCO’s strategy is to ensure that QOPI participation will also meet MIPS requirements for reporting on clinical practice activities and meaningful use. ASCO is also working to develop a payment reform proposal called Patient-Centered Oncology Payment (PCOP) to restructure how oncologists are reimbursed for cancer care and allow high-quality, affordable care. PCOP would meet the definition in MACRA of an APM.

Physician Performance Challenges

During the 2016 ASCO Quality Care Symposium, a breakout session during the Quality of Care Committee meeting focused on metrics that can measure quality physician performance. Practices currently use measures of productivity, clinical pathway adherence, clinical documentation, and patient satisfaction to measure their physicians. Physicians increasingly report frustration and burnout regarding pressures of time, EHR documentation, as well as increasing regulatory requirements. In such an evolving landscape, ASCO will continue to support its members by informing them of MACRA mandates, communicating with CMS regarding cancer-specific implementation issues, and developing signature programs such as QOPI, the QOPI Certification Program, and PCOP to meet ongoing needs.  

Acknowledgments: I would like to acknowledge ASCO staff members Sybil Green and Robert S. Miller, MD, for their help in providing assistance in the data and in reviewing the manuscript.