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 2

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

Medicare Physicians

Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic

Practitioners

Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists

Therapists

Physical Therapist Occupational Therapist Qualified Speech-Language Therapist

PQRS

Eligible for Incentive Subject to Payment Adjustment

Value Modifier

Included in Definition of “Group” (1) Subject to VM (2)

EHR Incentive Program

Eligible for Medicare Incentive Eligible for Medicaid Incentive Subject to Medicare Payment Adjustment X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 6

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 7

VM Will Be Applied to Physician Payment Only

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Physicians include:

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MDs / DOs

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Doctor of dental surgery or dental medicine

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Doctor or podiatric medicine

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Doctor of optometry

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Chiropractor

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Relation to Other Quality Program Incentives and Payment Adjustments

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2014 Incentives and 2016 Payment Adjustments

PQRS Value Modifier EHR Incentive Program 10-99 EPs 100+ EPs PQRS Reporting (Up or Neutral Adj) MD & DO DDM Oral Sur Pod.

Incentive Pay Adj

0.5% of MPFS (1.0% with MOC)

-2.0% of MPFS PQRS Reporting

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

Non-PQRS Reporting -2.0% of MPFS

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

PQRS Reporting (Down Adj) Non-PQRS Reporting -1.0% or -2.0% of MPFS -2.0% of MPFS Medicare Inc.

$4,000 $12,000 (based on when EP 1 st demo MU) N/A

Medicaid Inc.

$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)

Medicare Pay Adj -2.0% of MPFS Opt.

Chiro.

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2014 Incentives and 2016 Payment Adjustments

PQRS Value EHR Incentive Program Modifier Groups of 10+ EPs Medicare Inc.

Medicaid Inc.

Medicare Pay Adj.

Incentive Pay Adj.

Practitioners Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife

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

Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologits Therapists Physical Therapist

N/A

Occupational Therapist Qualified Speech-Language Therapist

0.5% of MPFS

-2.0% of MPFS

See above N/A N/A N/A 11

Value Modifier Policies for 2015 & 2016

Value Modifier Components

Performance Year Group Size Available Quality Reporting Mechanisms 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. Patient Experience Care Measures

2015 Finalized Policies

2013 100+ GPRO-Web Interface, CMS Qualified Registries, Administrative Claims

2016 Finalized Policies

2014 10+ GPRO-Web Interface (Groups of 25+ EPs), CMS Qualified Registries, EHRs, and 50% of EPs reporting individually Same as 2015 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) N/A PQRS CAHPS: option for groups of 25+ EPs; required for groups of 100+ EPS reporting via Web Interface 12

Value Modifier Policies for 2015 & 2016

Value Modifier Components

Cost Measures Benchmarks Quality Tiering Payment at Risk

2015 Finalized Policies

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 Group Comparison Optional -1.0%

2016 Finalized Policies

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) Specialty Adjusted Group Cost 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). -2.0% 13

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

PQRS Reporting Mechanism

1. GPRO Web interface (Groups of 25+ EPs) 2. GPRO using CMS-qualified registries 3. GPRO using EHR

Type of Measure

Measures focus on preventive care and care for chronic diseases (aligns with the Shared Savings Program) Groups select the quality measures that they will report through a PQRS-qualified registry. Quality measures data extracted from a qualified EHR product for a subset of proposed 2014 Physician Quality Reporting System quality measures.

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“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) 16

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

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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 17

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 19

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. 20

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.

2.

assign beneficiaries who have had a plurality of primary care services (allowed charges) rendered by primary care physicians. 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 21

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 Clinical Care Patient Experience Population/Community Health Patient Safety Care Coordination Efficiency Quality of Care Composite Score

VALUE MODIFIER AMOUNT

Total per capita costs (plus MSPB) Total per capita costs for beneficiaries with specific conditions Cost Composite Score 24

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.

High quality Average quality Low quality Low cost +2.0x* +1.0x* +0.0% Average cost +1.0x* +0.0% -1.0% High cost +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.

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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 Individual EPs and Groups of 2-9 EPs Did EP or group meet 2014 PQRS incentive criteria?

No Yes 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)

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How Does PQRS Participation Affect the Value Modifier?

Groups 10+ EPs Yes Do you plan to report for PQRS in 2014?

No Does the group plan to report PQRS as a group?

Yes No Does group plan to meet 2014 PQRS incentive criteria?

Yes 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 No Does group plan to meet criteria to avoid 2016 PQRS payment adjustment?

Group will avoid the 2016 PQRS payment adjustment No Does group meet 50% threshold?

Yes At least 50% of Individual EPs in group report satisfactorily and meet the criteria to avoid 2016 PQRS payment adjustment . 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% 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

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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 30

How Can I Access My Report and Drill-Downs?

1. Navigate to the Portal

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Go to https://portal.cms.gov

2. Login to the Portal

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

3. Enter the Portal

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

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How Can I Access My Report and Drill-Downs?

4. Complete Role Attestation

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Choose the applicable option to complete your request access (“I plan to use this data in my capacity as a…” 5. Navigate to the Folders Report

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Choose your QRUR or drill-down report from the applicable reports folder 6. Select Your Medical Group Practice

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

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How Can I Access My Report and Drill-Downs?

7. Export the QRUR

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You can view the QRUR online, as well as export and print the report to a Portable Document File (.pdf) 8. Export Drill Down Reports

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

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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 34

What Information Is Included on the Performance Highlights Page?

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)

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For More Information

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Visit the CMS Physician Value Modifier policies and the annual quality and resource use reports: www.cms.gov/physicianfeedbackprogram

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Medicare Learning Network®

• This MLN Connects™ video is part of the Medicare Learning Network® (MLN), a registered trademark of the Centers for Medicare & Medicaid Services (CMS), and is the brand name for official information health care professionals can trust. 37

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

• For more information about the Medicare Learning Network (MLN), please visit http://cms.gov/Outreach-and Education/Medicare-Learning-Network MLN/MLNGenInfo/index.html

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