Transcript Value Modifier & Physician Group Report Card

QRUR and Value Modifier:
Medicare Physician Report
Card and Pay-for Performance
Program
AAMC Contact:
Mary Wheatley
[email protected]
202-862-6297
August 2013
What are Quality Resource Use
Reports (QRUR) and Value Modifier?
Quality Resource Use
Reports (QRUR)
• Medicare Report Card
(confidential)
• Quality and cost
composite measures
• Ranked “High”,
“Average”, or “Low” for
both cost and quality
• Quality from Physician
Quality Reporting System
(PQRS) data submission
and supplemental claims
information
• Cost data from claims
Value-Based Physician
Modifier (VM)
• Medicare Pay-ForPerformance Program
• Use scores from
QRUR to adjust
payment upward or
downward
• Adjustments start in
2015 for some
practices; 2017 for all
physicians and
physician groups
QRUR Report cards, based on 2012 data, expected mid-September 2013 for
groups with 25 or more professionals
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Calculation
Inputs
Process to Determine QRUR and VM
Groups decide which
PQRS/quality reporting
to choose. Automatic
penalty for not
submitting PQRS data.
CMS Calculates Quality
and Cost Composite
Scores
CMS releases report
with benchmark data to
groups.
Outputs
PQRS
Data
Quality
Composite
Score
Private Feedback
Report
Medicare Part B
payments adjusted
based on scores.
Gray - Data supplied by physician groups
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+
Non-PQRS
Outcome
Measures
(from claims)
Quality &
Resource
Use Reports
(QRUR)
Cost
Measures
(from claims)
Cost
Composite
Score
Pay-forPerformance
Payment
Adjustment
based on scores
(Quality Tiering)
Green – Data supplied by CMS
2015 VM Affects Most Large Group
Practices
Group with ≥ 100
EPs/TIN in 2013?*
YES
NO
Excluded from 2015 VM
Included in 2017 VM
* VM excludes groups participating in Pioneer or
MSSP ACOs.
2013 Group Reporting
or Admin Claims?
NO
-1.0% Penalty in 2015
YES
Optional :
Quality Tiering
0.0% Penalty (No
Adjustment) in 2015
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Upward or Downward
adjustment based on Cost
and Quality Performance
Groups Must Choose PQRS Reporting
Option
• Large groups (100 or more eligible professionals) must
report quality data as a group to avoid automatic VM cut
•
•
2013: Possible +0.5% incentive for the Physician Quality
Reporting System (PQRS)
2015: Avoids additional -1.5% reduction for PQRS
• Reporting options vary by the size of the group. For
large groups, the choices are:
•
GPRO Web Interface
• Registry
• Administrative claims (available for 2013)
• EHR (starting in 2014)
(See appendix for more details)
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VM - Quality and Cost Measures
Quality Measures
• PQRS reported measures
(varies by reporting method)
• 3 claims-based outcome
measures
•
•
•
Acute prevention quality indicators
composite
Chronic prevention quality
indicators composite
All cause readmission
Cost Measures
• Total cost per capita
• Per capita costs for 4 condition
populations
•
•
•
•
COPD
Heart Failure
Coronary Artery Disease
Diabetes
Cost measures risk-adjusted
and price-standardized
Performance reported through Quality Resource Use
Report (QRUR)
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Value Modifier Composite
Quality and cost measures roll-up into domains. Each domain is weighted equally.
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Optional Quality Tiering (2015)
Quality/Cost
Low Cost
Average Cost
High Cost
High Quality
2.0x*
1.0x*
0.0%
Average Quality
1.0x*
0.0%
-0.5%
Low Quality
0.0%
-0.5%
-1.0%
*Cells eligible for high risk bonus
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•
Maximum reduction is -1.0% for low quality and high cost
•
Payments are budget neutral; positive adjustment (“x”) will be after performance
period ends (and CMS knows the total pool of available dollars to distribute)
•
Additional “1.0x” for high risk patients (average beneficiary score in top 25%)
• High risk adjustment only applies if score is:
• High quality/low cost
• High quality/average cost
• Average quality/low cost
Timing of the 2015 VM
2013
2014
• Cost and Quality Performance Period
• Large groups (excluding ACOs) nominate themselves, submit quality
data or choose administrative claims data BY OCTOBER 15
• Option to elect quality tiering
• CMS calculates 2013 performance results
• Fall 2014 – Quality Resource Utilization Reports (QRUR) based on
2013 data
• Adjustments for VM and PQRS applied
2015
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What do Practices Need to Do?
•
Sign up with CMS as a group practice by October 15, 2013
•
Determine Quality Reporting Strategy for each TIN
•
For 2013: submit quality data as group or sign up for administrative
claims?
• What is long-term alignment with EHR reporting?
• Elect quality tiering (yes/no)?
•
Download QRUR reports to understand current Cost and Quality
scores
•
Consider implications of Physician Compare reporting
Additional resources on VM and GPRO:
•
•
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https://www.aamc.org/initiatives/patientcare/patientcarequality/311244/
physicianpaymentandquality.html
https://www.facultypractice.org/
Appendix: GPRO Reporting Options for Large Groups
Item
GPRO Web
Registry
EHR
Administrative Claims
Effective Date
2013 forward
2013 forward
2014 forward
2013 only (CMS could
extend after 2013)
Measure selection
Pre-determined
(18 measures)
Practice selects from
available PQRS
measures (at least 3
measures)
Practice selects 9
measures for which their
EHR is certified
Pre-determined (14
process measures and 3
outcomes)
Submission Process
XML Web Tool
Registry submits data on
groups behalf
EHR submission
Groups register but do
not need to submit data
Reporting
requirements
Populate data fields for
the first 411
consecutively ranked and
assigned beneficiaries in
the order in which they
appear in the group's
sample
Report each measure for
at least 80 percent of the
group practice's
Medicare Part B FFS
patients seen during the
reporting period to which
the measure applies.
Choose 9 measures from
3 domains
Claims data is used to
evaluate performance on
14 quality measures and
3 outcome measures
Public Reporting of
2013 Performance Data
2013 performance data
and patient experience
(CG-CAHPS) publicly
reported on Physician
Compare
No public reporting
N/A
No public reporting
Assignment of
Patients/Beneficiaries
CMS assigns using
2-step primary care
attribution
Registry/groups identify
the patients based on
measure specifications
EHR identifies patients
based on measure
specifications
CMS determines
Qualifies for EHR
Clinical Quality
Measures (CQM)
Yes (starting in 2014) if
using CEHRT
No
Yes (starting in 2014)
No
Effect on Incentives
and Penalties
- Avoids the 2015 VM
penalty
- Qualifies for 2013 and
2014 PQRS incentive
- Avoids the 2015 VM
penalty
- Qualifies for 2013 and
2014 PQRS incentive
- Avoids the VM penalty
starting in 2016
- Qualifies for 2014
PQRS incentive
- Avoid the 2015 VM
penalty
- No PQRS incentives
(Incentives require
successful reporting)
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Cannot report zero
denominators for EHR
group reporting
Individual PQRS can
also be applied