Value Based Modifer

Value Based Modifier Friday June 13, 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.

•  Overview of the Value Modifier •  Dis5nc5on between Medicare Physicians and Eligible Professionals

•  Rela5on to Other Quality Program Incen5ves and Payment Adjustments

•  “50 Percent” Threshold Op5on •  Quality and Cost Measures •  Quality-‐Tiering •  Decision Tree

Topics

Value-‐Based Payment Modifier

•  Sec5on 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS)

•  VM assesses both quality of care furnished and the cost of that care under the MPFS

•  For 2015, CMS will apply the VM to groups of physicians with 100 or more eligible professionals (EPs)

•  For 2016, CMS will apply the VM to groups of physicians with 10 or more EPs

•  Phase-‐in to be completed for all physicians by 2017

•  Implementa5on of the VM is based on par5cipa5on in Physician Quality Repor5ng System (PQRS)

What is the Value-‐Based Payment Modifier (VM)?

Dis5nc5on between Medicare Physicians and Eligible Professionals

PQRS Value Modifier EHRIncenEve Program

Eligible for Incen5ve

Subject to Payment

Adjustment

Included in Defini5on of "Group" (1)

Subject to VM (2)

Eligible for Medicare Incen5ve

Eligible for Medicaid Incen5ve

Subject to Medicare Payment Adjustment

Medicare Physicians Doctor of Medicine x x x x x x x Doctor of Osteopathy x x x x x x x Doctor of Podiatric Medicine x x x x x x Doctor of Optometry x x x x x x Doctor of Oral Surgery x x x x x x x Doctor of Dental Medicine x x x x x x x Doctor of Chiroprac5c x x x x x x PracEEoners Physician Assistant x x x x Nurse Prac55oner x x x x Clinical Nurse Specialitst x x x Cer5fied Registered Nurse Anesthe5st x x x Cer5fied Nurse Midwife x x x x Clinical Social Worker x x x Clinical Psychologist x x x Registered Die5cian x x x Nutri5on Professional x x x Audiologists x x x Therapists Physical Therapist x x x Occupa5onal Therapist x x x Qualified Speech Language

Eligible Professionals

•  The size of a group is determined by how many EPs comprise the group

•  Defini5on of Group: A single Tax Iden5fica5on Number (TIN) with 2 or more individual EPs (as iden5fied by Individual Na5onal Provider Iden5fier (NPI)) who have reassigned their billing rights to the TIN

•  An EP is defined as any of the following; •  A physician

•  A physician assistant, nurse prac55oner, clinical nurse specialist, cer5fied registered nurse anesthe5st, cer5fied nurse-‐midwife, clinical social worker, clinical psychologist, registered die55an or nutri5on professional

•  A physical or occupa5onal therapist or a qualified speech-‐language pathologist

•  A qualified audiologist

How Is a Group Prac5ce Defined?

•  Physicians include: •  MDs / DOs

•  Doctor of dental surgery or dental medicine

•  Doctor of podiatric medicine

•  Doctor of optometry

•  Chiropractor

VM Will Be Applied to Physician Payment Only

Rela5on to Other Quality Program Incen5ves and Payment Adjustments

PQRS Value Modifier EHRIncenEve Program

IncenEve Pay

Adjustment

10 -‐ 99 EPs 100+ EPs

Medicare Inc.

Medicaid Inc.

Medicare Pay Adj

PQRS-‐ ReporEng

Non-‐PQRS ReporEng

PQRS-‐ ReporEng (UP or Neutral

Adj) PQRS -‐ ReporEng

(Down Adj) Non-‐PQRS ReporEng

MD & DO

0.5% of MPFS

-‐2.0% of MPFS

+2.0(x), +1.0(x), or neutral

-‐2.0% of MPFS

+2.0(x), +1.0(x), or neutral

-‐1.0% or -‐2.0% of MPFS

-‐2.0% of MPFS

$4,000 -‐ $12,000 (based on when EP

1st ajested to

MU

$8,500 or $23,000 (based on

when EP first ajested

-‐2.0% of MPFS

DDM

Oral Surgery

Podiatry

N/A Optometry

ChiropracEc

2014 Incen5ves and 2016 Payment Adjustments Physicians

PQRS Value Modifier EHRIncenEve Programe

IncenEve Pay

Adjustment Groups of 10+

EPs Medicare

Inc. Medicaid Inc Medicare Pay Adjustment

PracEEoners Physician Assistant

0.5% MPFS -‐2.0% MPFS

Eps included in the defini5on of "group" to determine group size for applica5on of the value modifier in 2016 (10 or more

Eps); VM only applied to reimbursement of PHYSICIANS in the

group

NA

Depends on first ajesta5on

NA

Nurse PracEEoner Clinical Nurse Specialist NA

CerEfied Registered Nurse AnestheEst Depends on first

ajesta5on

CerEfied Nurse Midwife

NA Clinical Social Worker Reigistered DieEcian NutriEon Professional Audiologist

Therapists Physical Therapy

See above See Above See Above NA NA OccupaEonal Therapist

2014 Incen5ves and 2016 Payment Adjustments Non-‐Physician Providers

Value Modifier Components 2015

Finalized Policies 2016

Finalized Policies

Performance Year 2013 2014

Group Size 100+ 10+

Available Quality ReporEng Mechanisms

GPRO-‐Web Interface, CMS Qualified Registries, AdministraEve Claims

GPRO-‐Web Interface (Groups of 25+ Eps), CMS Qualified Registries, EHRs, and 50% of Eps reporEng individually

Outcome Measures NOTE: The performance on the ouotcome measures and measures reported through the PQRS reporEng mechanisms will be used to calculate a quality composite score for the group for the VM.

All Cause Readmission, Composite of Acute PrevenEon Quality Indicators: (bacterial pneumonia, urinary tract infecEon, dehydraEon) Composite of Chronic PrevenEon Quality indicators: (COPD, heart failure and diabetes)

Same as 2015

PaEent Experience Care Measures N/A PQRS CAHPS: opEon for groups of 25+ EP; required for groups of 100+ EP reporEng via Web Interface

Value Modifier Policies for 2015 & 2016

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, does not include Part D costs) Total per capita costs for beneficiaries with four chronic condiEons: COPD, Heart Failure, Coronary Artery Disease and Diabetes

Same as 2015 and: Medicare Spending Per Beneficiary measure (includes Part A and B costs druing the 3 days berfore and 30 days aher an inpaEent hospitalizaEon)

Benchmarks Group Comparison SSpecialty Adjusted Group Cost

Quality Tiering opEonal Mandatory: Groups of 10 -‐ 99 EPs receive only the upward (or neutral) adjustment, no downward adjustment. Groups of 100+ both the upward and downward adjustment apply (or neutral adjustment).

Payment at Risk -‐1.00% -‐2.00%

Value Modifier Policies for 2015 & 2015

•  Groups with 10+ EPs may select one of the following PQRS GPRO quality repor5ng mechanisms and meet the criteria for the 2016 PQRS payment adjustment to avoid the 2.0% VM adjustment

Repor5ng Quality Data at the Group Level

PQRS ReporEng Mechanism Type of Measure

1. GPRO Web interface (Groups of 25+ EP) Measures focus on prevenEve care and care for chronic diseases

2. GPRO using CMS-‐qualified registries Groups select the quality mesures that they will report through a PQRS -‐qualified registry.

3. GPRO using Electronic Health Record Quality measures data extracted from a qualified electronic health record product for a subset of proposed 2014 PQRS quality measures.

“50 Percent” Threshold Op5on

•  If a group does not seek to report quality measures as a group, CMS will calculate a group quality score if at least 50 percent of the eligible professionals within the group report measures individually. –  At least 50% of EPs must successfully avoid the 2016 QRS payment adjustment

–  EPs may report on measures available to individual EPs via the following repor5ng mechanisms: •  Claims

•  CMS Qualified Registries

•  Electronic Health Record •  Clinical Data Registries (new for 2014)

Repor5ng Quality Data at the Individual Level – 50% Threshold Op5on

•  Two-‐step process: •  CMS will query the PECOS system to iden5fy groups of physicians with

10 or more EPs as of October 15, 2014 •  Generates a list of poten5al groups that could be subject to the VM

•  CMS will analyze claims for services furnished during the 2014 performance year through at least February 2015 •  Remove groups from the October PECOS list that did not have 10 or more EPs that billed under the group’s TIN during 2014

•  Groups will NOT be added to the October PECOS list aqer that query

How Does CMS Determine Whether a Group of Physicians Has 10 or More EPs?

Quality and Cost Measures

•  Total per capita costs measures (Parts A & B)

•  Total per capita costs for beneficiaries with 4 chronic condi5ons: •  Chronic Obstruc5ve Pulmonary Disease

•  Heart Failure

•  Coronary Artery Disease

•  Diabetes

•  Medicare Spending Per Beneficiary (MSPB) measure (3 days prior and 30 days aqer an inpa5ent hospitaliza5on) ajributed to the group providing the plurality of Part B services during the hospitaliza5on

•  All cost measures are payment standardized and risk adjusted.

•  Each group’s cost measures adjusted for specialty mix of the EPs in the group

What Cost Measures will be used for Quality-‐Tiering?

•  5 Total Per Capita Cost Measures •  Iden5fy all beneficiaries who have had at least one primary care service

rendered by a physician in the group

•  Followed by a two-‐step assignment process 1.  assign beneficiaries who have had a plurality of primary care services (allowed

charges) rendered by primary care physicians.

2.  For beneficiaries that remain unassigned, assign beneficiaries who have received a plurality of primary care services (allowed charges) rendered by any eligible professional

•  MSPB measure – ajribute the hospitaliza5on to the group of physicians providing the plurality of Part B services during the inpa5ent hospitaliza5on

Cost Measure Ajribu5on

Quality-‐Tiering

•  Each group receives two composite scores (quality and cost)

•  CMS uses the following steps to create each composite: •  Create a standardized score for each measure )performance rate –

benchmark / standard devia5on) •  Equally weight each measures' standardized score within each domain.

•  Equally weight each domain’s score into the composite score.

How Does CMS Use the Quality and Cost Measures to Create a Value Modifier Payment Adjustment?

•  Use domains to combine each quality measure into a quality composite and each cost measure into a cost composite

Quality-‐Tiering Methodology

Chart from CMS website

•  Each group receives two composite scores (quality of care; cost of care), based on the group’s standardized performance (how far away from the na5onal mean).

•  Group cost measures are adjusted for specialty composi5on of the group

•  This approach iden5fies sta5s5cally significant outliers and assigns them to their respec5ve cost and quality 5ers.

Quality-‐Tiering Approach for 2016 (Based on 2014 PQRS Performance)

Low Cost Average Cost High Cost

High quality

Average quality

Low quality

+2.0x*

+1.0x*

+0.0%

+1.0x*

+0.0%

-‐1.0%

+0.0%

-‐1.0%

-‐2.0%

•  VM for 2016 will be applied to Medicare paid amounts to items and services billed under the Physician Fee Schedule at the TIN level

•  Beneficiary cost-‐sharing not affected

•  Applied to the items and services billed by physicians under the TIN, but not to other eligible professionals

•  If a physician changes from one TIN in a performance year to another TIN in a payment adjustment year, VM would be applied to the TIN that either met or did not meet the VM qualifica5on. The upward / downward does not follow the EP but follows the TIN.

Downward VM Payment Adjustment in 2016

Decision Tree

PQRS Par5cipa5on in 2014 for Individuals and Groups of 2 – 9 EPs

Individual EPs and Groups of 2-‐9 EPs



Did EP or group meet 2014 PQRS incen5ve criteria




All EPs earn 0.5% PQRS incen5ve (addi5onal 0.5% available for

successful MOC par5cipa5on for eligible physicians) ALSO avoids the PQRS payment adjustment

Did EP or group meet criteria to avoid 2016 PQRS payment adjustment?







You will avoid the 2016 PQRS payment adjustment








All EPs will be subject to the 2016 PQRS payment adjustment of -‐2.0%








All EPs will be subject to the 2016 PQRS payment adjustment of -‐2.0%

EPs and Groups of 2-‐9 EPs are NOT subject to the VM in 2016

VM / PQRS Par5cipa5on in 2014 for Individuals and Groups of 10+ EPs

Groups of 10+ EPs

Do you plan to report PQRS in 2014?

Groups of 10+ EPs

Do you plan to report PQRS in 2014? NO

ALL EPs in group will be subject to the 2016 PQRS

payment adjustment of -‐2.0% All Physicians in group will be subject to the 2016 Value

Modifier downward adjustment of -‐2.0%

Groups of 10+ EPs


NO




Does the group plan to report to PQRS as a group?

Yes

Yes

All EPs earn 0.5% PQRS incen5ve and avoids 2016 PQRS

payment adjustment

Groups of 10+ EPs


NO





Yes

Yes


payment adjustment

No

Does group plan to meet criteria to avoid 2016 PQRS

payment adjustment

Yes

Group will avoid the 2016 PQRS payment

adjustment

No

Groups of 10+ EPs


NO





Yes

Yes


payment adjustment

No

Does group plan to meet criteria to avoid 2016 PQRS

payment adjustment

Yes

Group will avoid the 2016 PQRS payment

adjustment

No

Physicians in Groups of 10 – 99 EPs: Subject to upward or neutral VM adjustment Physicians in Groups of 100+ EPs: Subject to upward, neutral or downward VM adjustment

•  [email protected]

Q&A

Chart from CMS website

Value Based Modifer

Healthcare

clinical social

successful

modier downward

pqrs payment

primary care

group meet

standardized

meet criteria