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
3
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
4
Distinction between Medicare Physicians
and Eligible Professionals
5
Eligible Professionals
PQRS
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
Value Modifier
Eligible for
Incentive
Subject to
Payment
Adjustment
X
X
X
X
X
X
X
Included in
Definition
of “Group”
EHR Incentive Program
(1)
Subject to
VM (2)
Eligible for
Medicare
Incentive
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
Eligible for
Medicaid Subject to Medicare
Incentive Payment Adjustment
X
X
X
X
X
X
X
X
X
X
X
X
X
X
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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
9
2014 Incentives and 2016 Payment Adjustments
PQRS
Value Modifier
10-99 EPs
Incentive
Pay Adj
PQRSReporting
Non-PQRS
Reporting
EHR Incentive Program
100+ EPs
PQRSReporting
(Up or
Neutral
Adj)
PQRSReporting
(Down Adj)
Non-PQRS
Reporting
Medicare
Inc.
Medicaid
Inc.
MD &
DO
$8,500 or
$21,250
(based on
when EP
did A/I/U)
DDM
$8,500 or
$21,250
(based on
when EP
did A/I/U)
Oral
Sur
Pod.
0.5% of
MPFS -2.0%
of
(1.0%
with MPFS
MOC)
+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)
N/A
Medicare
Pay Adj
-2.0%
of
MPFS
Opt.
Chiro.
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2014 Incentives and 2016 Payment Adjustments
PQRS
Incentive
Value
Modifier
Pay Adj.
Groups of 10+
EPs
EHR Incentive Program
Medicare
Inc.
Medicaid
Inc.
Medicare
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
$8,500 or
$21,250
(based on
when EP did
A/I/U)
N/A
N/A
$8,500 or
$21,250
(based on
when EP did
A/I/U)
N/A
Clinical Social Worker
Clinical Psychologist
Registered Dietician
N/A
Nutrition Professional
Audiologits
Therapists
Physical Therapist
Occupational Therapist
Qualified Speech-Language Therapist
0.5% of
MPFS
-2.0% of
MPFS
See above
N/A
N/A
N/A
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Value Modifier Policies for 2015 & 2016
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
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
N/A
PQRS CAHPS: option for groups of
25+ EPs; required for groups of
100+ EPS reporting via Web
Interface
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
12
Value Modifier Policies for 2015 & 2016
Value Modifier
Components
Cost Measures
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
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)
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%
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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
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.
14
“50 Percent” Threshold Option
15
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?
• 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
18
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
22
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.
23
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
Quality of
Care
Composite
Score
Patient Safety
VALUE
MODIFIER
AMOUNT
Care Coordination
Efficiency
Total per capita costs
(plus MSPB)
Total per capita costs for
beneficiaries with specific
conditions
Cost
Composite
Score
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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.
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.
25
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
26
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
You will avoid the 2016
PQRS payment adjustment
No
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 meet
50% threshold?
Does group plan to 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
Yes
At least 50% of Individual EPs
in group report satisfactorily
and meet the criteria to avoid
2016 PQRS payment
adjustment .
Does group plan to meet
criteria to avoid 2016 PQRS
payment adjustment?
Yes
No
No
Group will avoid the
2016 PQRS payment
adjustment
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
28
Quality and Resource Use Reports
(QRURs)
29
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 valuebased 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
•
Go to https://portal.cms.gov
2. Login to the Portal
•
•
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
•
Click the PV-PQRS tab, and select the QRUR-Reports option.
31
How Can I Access My Report and Drill-Downs?
4. Complete
Role Attestation
• 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
•
Choose your QRUR or drill-down
report from the applicable reports
folder
6. Select Your
Medical Group
Practice
•
After the report opens, select a
Medical Group Practice and click
Run Document
32
How Can I Access My Report and Drill-Downs?
•
You can view the QRUR
online, as well as export
and print the report to a
Portable Document File
(.pdf)
•
You can view drill-down
reports online, as well as
export and print the
reports to either a .pdf or
an Excel file
7. Export the
QRUR
8. Export DrillDown Reports
33
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)
35
For More Information
• Visit the CMS Physician Value Modifier policies
and the annual quality and resource use
reports:
• www.cms.gov/physicianfeedbackprogram
36
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.
38
Thank You
• For more information about the Medicare Learning Network
(MLN), please visit http://cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNGenInfo/index.html
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