An Overview of Value-Based Modifiers

An Overview of Value-Based Modifiers

• Affordable Care Act of 2010 (ACA) • CMS must bring eRx, PQRS and MU into alignment

• CMS to establish a payment modifier for differential Physician payments – Remember Pay for Higher “Value” → Value = Factor (Quality, Efficiency)

An Overview of Value-Based Modifiers

• ACA → Three Health IT Themes 1. Enhance Quality Reporting and Measurement → Needed

for Reimbursement Reform

→ Expand Quality Reporting (PQRS, ACO Performance Measures, etc.)

→ Improve Quality of Care (Evidence-Based Guidelines, CDS)

→ Encourage Quality through Reimbursement Modeling (CMMI)

2. Establish Uniform Operating Rules and Standards

3. Promote Health IT Workforce Development

An Overview of Value-Based Modifiers

Driving the linkage between performance and reimbursement.

An Overview of Value-Based Modifiers

• Builds upon Pilot started 2009 – Resource Use Reporting to MDs → Feedback Reports

• Added claims-based quality measures

• Resource Use will determine Value Modifier

An Overview of Value-Based Modifiers

• CMS Budget neutral → Some will get carrots, others will get sticks

PROGRAM 2012 2013 2014 2015 2016 2017

CMS Value-Based Modifiers

Carrots Carrots / Sticks

None None None +/- TBD

+/- TBD

+/- TBD

An Overview of Value-Based Modifiers

• Two established Federal Quality Measure Programs

• PQRS – Performance on Core Measure Set

• Meaningful Use – EHR Incentive Program Measures

An Overview of Value-Based Modifiers

• CMS Final Rule – Performance Resource Measures (11.28.2011)

o VBM → composite of Quality and Costs o Quality: PQRS and MU used to create 62

preliminary VBM measures for P4P o Costs: Total per capita costs for target populations

→ COPD, Heart Failure, CAD, and Diabetes