Published on March 20, 2014
Value Modiﬁer Wednesday, March 19, 2014 Disclaimer: Nothing that we are sharing is intended as legally binding or prescrip7ve advice. This presenta7on is a synthesis of publically available informa7on and best prac7ces.
Background • Quality of care-‐based, budget neutral diﬀeren8al payment • Aﬀordable Care Act requirement • Cost and quality data included in payment calcula8on • Speciﬁc to Fee-‐For-‐Service Medicare • Emphasis on repor8ng quality data through PQRS
• Physicians in groups of 100+ (2015) or 10+ (2016) eligible professionals – Single Taxpayer Iden8ﬁca8on Number (TIN) – 2 or more individual eligible professionals – Reassigned Medicare billing rights to the TIN • Begin phase-‐in of VM in 2015, phase-‐in complete by 2017 • Performance in CY 2014 eligible for payments in CY 2016 • Compara8ve performance informa8on • Reimbursement model that rewards value • Two primary components: – The Physician Quality and Resource Use Reports – Development and implementa8on of VBM • Supports transforma8on of Medicare through value-‐based purchasing Value Modiﬁer (VM)
Eligible Professionals Medicare physicians! Practitioners! Therapists! Doctor of Medicine Physician Assistant Physical Therapist Doctor of Osteopathy Nurse Practitioner Occupational Therapist Doctor of Podiatric Medicine Clinical Nurse Specialist Qualified Speech-Language Therapist Doctor of Optometry Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant) Doctor of Oral Surgery Certified Nurse Midwife Doctor of Dental Medicine Clinical Social Worker Doctor of Chiropractic Clinical Psychologist Registered Dietician Nutrition Professional Audiologists
Timeline 2012 2013 2015 2016 2017 Conﬁden8al feedback to successful PQRS par8cipants on VM criteria Ini8al performance period begins VM applied to large group prac8ces VM applica8on con8nues VM for all physicians
VM Policies Value Modiﬁer Components 2015 Finalized Policies 2016 Finalized Policies Performance Year 2013 2014 Group Size 100+ 10+ Available Quality Repor8ng Mechanisms GPRO-‐Web Interface, CMS Qualiﬁed Registries, Administra8ve Claims GPRO-‐Web Interface, CMS Qualiﬁed Registries, EHRs, and 50% of EPs repor8ng individually Outcome Measures NOTE: The performance on the outcome measures and measures reported through the PQRS repor8ng mechanisms will be used to calculate a quality composite score for the group for the VM. All Cause Readmission Composite of Acute Preven8on Quality Indicators: (bacterial pneumonia, urinary tract infec8on, dehydra8on) Composite of Chronic Preven8on Quality Indicators: (chronic obstruc8ve pulmonary disease (COPD), heart failure, diabetes) Same as 2015 Pa8ent Experience of Care Measures N/A PQRS CAHPS: Op8on for groups of 25+ EPs
VM Policies Value Modiﬁer Components 2015 Finalized Policies 2016 Finalized Policies Cost Measures Total per capita costs measure (annual payment standardized and risk-‐adjusted Part A and Part B costs) Total per capita costs for beneﬁciaries with four chronic condi8ons: COPD, Heart Failure, Coronary Artery Disease, Diabetes Same as 2015 and Medicare Spending Per Beneﬁciary measure (includes Part A and B costs during the 3 days before and 30 days aeer an inpa8ent hospitaliza8on) Benchmarks Group Comparison Specialty Adjusted Group Cost Quality Tiering Op8onal Mandatory Groups of 10-‐99 EPs receive only the upward adjustment, no downward adjustment. Groups of 100+ both the upward and downward adjustment apply. Payment at Risk -‐1.0% -‐2.0%
VM Criteria • 2% Incen8ve – Par8cipate in the PQRS Group Prac8ce Repor8ng Op8on (GPRO) by October 15 AND sa8sfy repor8ng criteria for that year – Par8cipate in the GPRO by October 15 AND successfully report at least one relevant PQRS measure – Analyzed under the PQRS administra8ve claims-‐ based repor8ng op8on by October 15
Quality Measures for Quality Tiering • Group measures reported through the GPRO PQRS OR 50% threshold op8on • Three outcome measures: – All Cause Readmission – Composite of Acute Preven8on Quality Indicators (bacterial pneumonia, urinary tract infec8on, dehydra8on) – Composite of Chronic Preven8on Quality Indicators (COPD, heart failure, diabetes) • PQRS CAHPS Measures for 2014 (Op8onal) – Pa8ent Experience of Care measures – For groups of 25+ eligible professionals
Cost Measures for Quality Tiering • Total per capita cost • Total per capita cost measures for beneﬁciaries with four chronic condi8ons – Chronic obstruc8ve pulmonary disease – Heart failure – Coronary artery disease – Diabetes • Plurality of primary care services • Cost adjustments • Hierarchical Condi8on Categories (HCC) risk adjustment
Budget Neutrality • Posi8ve adjustments oﬀset by nega8ve adjustments • Tiered system • Groups with high quality and low cost get highest upward adjustment • Addi8onal upward payment adjustment for services provided to high risk beneﬁciaries
Physician Feedback Reports • Provided since 2010 • Physician Feedback reports at TIN level • Physician Feedback reports to groups with 25 or more eligible professionals – Quality and cost measure performance – Composite benchmarks – Group VBM amount – Basis for determina8on – Episode-‐based cost measures
Repor8ng Quality Data at Group Level • For groups with 10+ EPs to avoid the 2.0% VM adjustment PQRS ReporGng Mechanism Type of Measure 1. GPRO Web interface Measures focus on preven8ve care and care for chronic diseases (aligns with the Shared Savings Program) 2. GPRO using CMS-‐ qualiﬁed registries Groups select the quality measures that they will report through a PQRS-‐qualiﬁed registry. 3. GPRO using EHR Quality measures data extracted from a qualiﬁed EHR product for a subset of proposed 2014 Physician Quality Repor8ng System quality measures.
Repor8ng Quality Data at Individual Level • If 10 providers bill from the same TIN, CMS will auto enroll • Group quality score calculated by CMS – At least 50 percent of EPs within the group report measures individually • At least 50% must successfully avoid the 2016 PQRS payment adjustment • EPs may report on measures available to individual EPs: – Claims – CMS Qualiﬁed Registries – EHR – Clinical Data Registries (new for CY 2014)
Concerns • Collec8on and analysis of relevant and meaningful experience • Moun8ng regulatory requirements • Penal8es and cuts • Results published on Physician Compare website
The Future • Expanded inclusion in CY 2016 • Commercial payers
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