Value Modifier

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Information about Value Modifier
Health & Medicine

Published on March 20, 2014

Author: BenQuirk2



Our Insights webinar this week tackles a little-known program that will have a big impact on fee-for-service Medicare providers. The Value-Based Payment Modifier (or Value Modifier for short) is something every Medicare provider should know about as soon as possible. One way or another, providers will wind up on either the incentive or penalty side of this legislation. Take advantage of our webinar for in-depth information on this complex and far-reaching topic.

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  

VM  Calcula8on  

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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