The CMS Value-Based Payment Modifier

What Medicare Eligible Professionals Need to Know in 2014

Topics

• Overview of the Value Modifier• Distinction between Medicare Physicians and Eligible

Professionals• Relation to Other Quality Program Incentives and

Payment Adjustments• “50 Percent” Threshold Option• Quality and Cost Measures• Quality-Tiering• Accessing Your QRUR Reports

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Value-Based Payment Modifier

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

• Section 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 Medicare Physician Fee Schedule

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

• For CY 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

• Implementation of the VM is based on participation in Physician Quality Reporting System

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Distinction between Medicare Physicians and Eligible Professionals

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Eligible Professionals

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  PQRS Value Modifier EHR Incentive Program

 Eligible for Incentive

Subject to Payment

Adjustment

Included in Definition of “Group”

(1)

Subject to VM (2)

Eligible for Medicare Incentive

Eligible for Medicaid Incentive

Subject to Medicare Payment Adjustment

Medicare PhysiciansDoctor of Medicine X X X X X X XDoctor of Osteopathy X X X X X X XDoctor of Podiatric Medicine X X X X X   XDoctor of Optometry X X X X  X   XDoctor of Oral Surgery X X X X  X X XDoctor of Dental Medicine X X X X  X X XDoctor of Chiropractic X X X X  X   XPractitioners              Physician Assistant X X X   X  Nurse Practitioner X X X   X  Clinical Nurse Specialist X X X        Certified Registered Nurse Anesthetist X X X        Certified Nurse Midwife X X X     X  Clinical Social Worker X X X        Clinical Psychologist X X X        Registered Dietician X X X        Nutrition Professional X X X        Audiologists X X X        TherapistsPhysical Therapist X X X        Occupational Therapist X X X        Qualified Speech-Language Therapist X X X        

How Is a Group Practice Defined?

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

• Definition of Group: A single Tax Identification Number (TIN) with 2 or more individual EPs(as identified by Individual National Provider Identifier [NPI]) who have reassigned their billing rights to the TIN

• An EP is defined as any of the following: • A physician• A physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist; a certified registered

nurse anesthetist; a certified nurse-midwife; a clinical social worker; a clinical psychologist; or a registered dietitian or nutrition professional

• A physical or occupational therapist or a qualified speech-language pathologist• A qualified audiologist

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VM Will Be Applied to Physician Payment Only

• Physicians include:• MDs / DOs• Doctor of dental surgery or dental medicine• Doctor or podiatric medicine• Doctor of optometry• Chiropractor

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Relation to Other Quality Program Incentives and Payment Adjustments

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2014 Incentives and 2016 Payment Adjustments

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PQRS Value Modifier EHR Incentive Program

Incentive Pay Adj

10-99 EPs 100+ EPs

Medicare Inc.

Medicaid Inc.

Medicare Pay Adj

PQRS-Reporting

Non-PQRS Reporting

PQRS-Reporting (Up or Neutral Adj)

PQRS-Reporting (Down Adj)

Non-PQRS Reporting

MD & DO

0.5% of MPFS (1.0% with

MOC)

-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 demo MU)

$8,500 or $21,250

(based on when EP

did A/I/U)$8,500 or $21,250

(based on when EP

did A/I/U)

-2.0% of

MPFS

DDM

Oral Sur

Pod.N/A

Opt.

Chiro.

2014 Incentives and 2016 Payment Adjustments

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PQRS Value Modifier

EHR Incentive Program

Incentive Pay Adj.Groups of 10+

EPsMedicare

Inc.Medicaid

Inc.Medicare Pay Adj.

PractitionersPhysician Assistant

0.5% of MPFS

-2.0% of MPFS

EPs included in the definition of “group” to determine group size for application of the value modifier in 2016 (10 or more EPs); VM only applied to reimbursement of physicians in the group

N/A

$8,500 or $21,250 (based on when EP did A/I/U)

N/A

Nurse Practitioner

Clinical Nurse Specialist N/A

Certified Registered Nurse Anesthetist

Certified Nurse Midwife $8,500 or $21,250 (based on when EP did A/I/U)

Clinical Social Worker

N/A

Clinical Psychologist

Registered Dietician

Nutrition Professional

Audiologits

TherapistsPhysical Therapist 0.5% of

MPFS -2.0% of

MPFS

See above

N/A N/A N/AOccupational Therapist

Qualified Speech-Language Therapist

Value Modifier Policies for 2015 & 2016

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Value Modifier Components

2015 Finalized Policies

2016 Finalized Policies

Performance Year 2013 2014

Group Size 100+ 10+

Available Quality Reporting Mechanisms

GPRO-Web Interface, CMS Qualified Registries, Administrative Claims

GPRO-Web Interface (Groups of 25+ EPs), CMS Qualified Registries, EHRs, and 50% of EPs reporting individually

Outcome Measures

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

All Cause Readmission Composite of Acute Prevention Quality Indicators: (bacterial pneumonia, urinary tract infection, dehydration) Composite of Chronic Prevention Quality Indicators: (chronic obstructive pulmonary disease (COPD), heart failure, diabetes)

Same as 2015

Patient Experience Care Measures N/A PQRS CAHPS: option for groups of 25+ EPs; required for groups of 100+ EPS reporting via Web Interface

Value Modifier Policies for 2015 & 2016

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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 conditions: 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 after an inpatient hospitalization)

Benchmarks Group Comparison Specialty Adjusted Group Cost

Quality Tiering Optional 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 -1.0% -2.0%

Reporting Quality Data at the Group Level

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

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PQRS Reporting Mechanism Type of Measure

1. GPRO Web interface (Groups of 25+ EPs) Measures focus on preventive 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 Reporting System quality measures.

“50 Percent” Threshold Option

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Reporting Quality Data at the Individual Level - 50% Threshold Option

• 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 PQRS

payment adjustment – EPs may report on measures available to individual EPs via the

following reporting mechanisms: • Claims • CMS Qualified Registries • EHR • Clinical Data Registries (new for CY 2014)

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

• Two-step process:• CMS will query the Provider Enrollment, Chain, and

Ownership System (PECOS) to identify groups of physicians with 10 or more EPs as of October 15, 2014

• Generates a list of potential groups that could be subject to the VM• CMS will analyze claims for services furnished during the CY

2014 performance year through at least February 28, 2015• Remove groups from the October 15 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 15 PECOS list

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Quality and Cost Measures

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What Quality Measures will be Used for Quality Tiering?

• Measures reported through the GPRO PQRS reporting mechanism selected by the group OR individual measures reported by at least 50% of the eligible professionals within the group (50% threshold option)

• Three outcome measures: – All Cause Readmission – Composite of Acute Prevention Quality Indicators (bacterial pneumonia,

urinary tract infection, dehydration) – Composite of Chronic Prevention Quality Indicators (COPD, heart failure,

diabetes) • PQRS CAHPS Measures for 2014 (Optional)

– Patient Experience of Care measures – For groups of 25 or more eligible professionals

• Required for groups of 100+ EPS reporting via Web Interface

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What Cost Measures will be used for Quality-Tiering?

• Total per capita costs measures (Parts A & B) • Total per capita costs for beneficiaries with 4 chronic conditions:

– Chronic Obstructive Pulmonary Disease (COPD) – Heart Failure – Coronary Artery Disease – Diabetes

• Medicare Spending Per Beneficiary (MSPB) measure (3 days prior and 30 days after an inpatient hospitalization) attributed to the group providing the plurality of Part B services during the hospitalization

• All cost measures are payment standardized and risk adjusted. • Each group’s cost measures adjusted for specialty mix of the EPs in the

group.

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Cost Measure Attribution

• 5 Total Per Capita Cost Measures – Identify 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 – attribute the hospitalization to the group of physicians providing the plurality of Part B services during the inpatient hospitalization

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Quality-Tiering

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

• 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 deviation)– Equally weight each measure’s standardized score within

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

score.

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Quality-Tiering Methodology

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

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Clinical Care

Patient Experience

Population/Community Health

Patient Safety

Care Coordination

Efficiency

Total per capita costs (plus MSPB)

Total per capita costs for beneficiaries with specific conditions

Quality of Care Composite Score

Cost CompositeScore

VALUEMODIFIERAMOUNT

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

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

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

• This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers.

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Low cost Average cost High cost

High quality +2.0x* +1.0x* +0.0%

Average quality +1.0x* +0.0% -1.0%

Low quality +0.0% -1.0% -2.0%

Eligible for an additional +1.0x if reporting clinical data for quality measures and average beneficiary risk score in the top 25 percent of all beneficiary risk scores.

Downward VM Payment Adjustment in 2016

• VM for CY 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 physician changes from TIN (A) in performance year (CY 2014) to TIN (B) in payment adjustment year (CY2016), VM would be applied to TIN (B) for physician’s items and services billed under TIN (B) during CY 2016

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PQRS Participation in 2014 for Individuals and Groups of 2-9 EPs

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Individual EPs and Groups of 2-9 EPs

Did EP or group meet 2014 PQRS incentive criteria?

Yes No

All EPs earn 0.5% PQRS incentive (additional 0.5%

available for successful MOC participation for eligible

physicians); ALSO avoids 2016 PQRS payment

adjustment

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

Yes No

You will avoid the 2016 PQRS payment adjustment

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 Value Modifier in 2016 (will be subject in 2017, based on PQRS participation)

How Does PQRS Participation Affect the Value Modifier?

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Groups 10+ EPs

Do you plan to report for PQRS in 2014?Yes No

Does the group plan to report PQRS as a group?

No

Does group meet 50% threshold?

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%

Yes

Does group plan to meet 2014 PQRS incentive criteria?

All EPs earn 0.5% PQRS incentive (additional

0.5% available for successful MOC

participation for eligible physicians); ALSO avoids 2016 PQRS

payment adjustment

Yes

Does group plan to meet criteria to avoid 2016 PQRS

payment adjustment?

No

NoYes

Group will avoid the 2016 PQRS payment

adjustment

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

NoYes

At least 50% of Individual EPs in group report satisfactorily and meet the criteria to avoid

2016 PQRS payment adjustment .

Quality and Resource Use Reports (QRURs)

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Quality and Resource Use Reports (QRURs)

• The QRURs are annual reports that provide groups of physicians with:• Comparative information about the quality of care furnished, and the

cost of that care, to their Medicare fee-for-service (FFS) patients• Beneficiary-specific information to help coordinate and improve the

quality and efficiency of care furnished• Information on how the provider group would fare under the value-

based payment modifier (VBM)

• 2012 QRURs are produced and made available to all groups of physicians with 25 or more eligible professionals (EP)

• Late Summer 2014: QRURs for all Groups and Solo Practitioners

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How Can I Access My Report and Drill-Downs?

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1. Navigate to the Portal

2. Login to the Portal

3. Enter the Portal

• Go to https://portal.cms.gov

• Select Login to CMS Secure Portal• Accept the Terms and Conditions and enter your IACS User ID

and Password to login.

• Click the PV-PQRS tab, and select the QRUR-Reports option.

How Can I Access My Report and Drill-Downs?

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4. Complete Role Attestation

5. Navigate to the Folders

Report

6. Select Your Medical Group

Practice

• Choose the applicable option to complete your request access (“I plan to use this data in my capacity as a…”

• Choose your QRUR or drill-down report from the applicable reports folder

• After the report opens, select a Medical Group Practice and click Run Document

How Can I Access My Report and Drill-Downs?

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7. Export the QRUR

• You can view drill-down reports online, as well as export and print the reports to either a .pdf or an Excel file

8. Export Drill-Down Reports

• You can view the QRUR online, as well as export and print the report to a Portable Document File (.pdf)

How Can I Use the 2012 QRUR?

• Verify the EPs billing under your group’s TIN during 2012

• Determine how your group would fare under the Value Modifier (Performance Highlights)

• Examine the number of beneficiaries attributed to your group and the basis for their attribution

• Understand how your group’s performance on quality and cost measures compares to other groups

• Understand which attributed beneficiaries are driving your group’s cost measures

• Understand which beneficiaries are driving your group’s performance on the three hospital-related care coordination quality measures

• Identify those beneficiaries that are in need of greater care coordination

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What Information Is Included on the Performance Highlights Page?

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1. Your Quality Composite Score

2. Your Cost Composite Score

3. Your Beneficiaries’ Average Risk Score

4. Your Quality Tiering Performance Graph

5. Your Payment Adjustment Based on Quality Tiering

(payment adjustments in example based on 2015 VM implementation)

For More Information

• Visit the CMS Physician Value Modifier policies and the annual quality and resource use reports:

• www.cms.gov/physicianfeedbackprogram

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Disclaimer

The content of this video was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This video was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

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Thank You

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