Thomas Walke, PhD

Marjorie Kanof, MD

Health Policy Alternatives, Inc.

How Medicare Data Impacts Your

Practice

November 6, 2015

Questions for Today

• What information is out there that can be useful to examining Medicare payment issues related to the podiatry specialty?

• What information is available on podiatrists that provide services to Medicare beneficiaries?

• What are some of the initial data needs with respect to alternative payment models?

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Public Use Data Files on Medicare Physician

Payment, Utilization, and Quality

• Data from the Physician Fee Schedule (PFS) Proposed and Final Rules

• Data from the PFS Contractor Files

• Medicare Physician Data File: Medicare Provider Utilization and Payment Data: Physicians and Other Supplier Public Use File

• Physician Compare Data

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DATA FROM THE PROPOSED

AND FINAL PFS RULES

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PFS Proposed and Final Rule: Key Data Files

• Addendum B Relative Value Units

• CY 2014 Utilization Data – Specialty, HCPCs, Modifier, Facility, Allowed Charges,

Services (discounted, undiscounted)

• Practice Expense (PE) Input Files – Direct PE input data

– Indirect Practice Cost Indices

– Physician Time

• Other assorted files – Codes subject to various PFS adjustments (e.g., Multiple

Procedure Payment Reduction)

– HCPCS Defined as Misvalued for Target

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PFS Proposed and Final Rule Data: Addendum B

Relative Value Units and Related Information

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PFS Proposed and Final Rule Data:

Medicare Utilization File

• 2014 latest

• Requires analysis

using Excel or

Statistical Software

Allows one to examine

for a specialty:

• the utilization by code

• how usage of code

compares with other

specialties

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PFS Proposed and Final Rule Data:

Practice Expense Input Files

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Example for 11721 (Debride nail 6 or more)

DATA FROM THE PFS

CONTRACTOR FILES

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PFS Contractor Files: Summary

• Medicare rate calculation files that CMS provides to contractors for use in processing claims

• Relative Value File (updated quarterly)

– RVUs for more than 10,000 physician services

– Fee schedule status indicator

– Payment adjustment indicators

• Geographic Practice Cost Indices file

– Details GPCIs for 89 total PFS localities used to adjust payments based on geographic area.

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PFS Contractor File: National RVU File

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Application of PFS Data: Medicare

Snapshot of Podiatry Specialty, 2016

HCPCS Description

2014

Volume of

Services

(millions)

Estimated 2016

Total Medicare

Allowed

Charges, All

Settings

(millions)

% of

Estimated

Total

Medicare

Allowed

Charges

% Change in 2016

Estimated Medicare

Pay Compared with

2015

11721

Debride nail 6 or

more

7.3 $329.3 17% 2.1%

99213

Office/outpatient

visit est

4.3 $316.6 16% 1.0%

99203

Office/outpatient

visit new

1.1 $123.4 6% 0.5%

11056

Trim skin lesions 2

to 4

1.9 $112.9 6% 1.1%

99212

Office/outpatient

visit est

2.2 $95.1 5% 0.5%

11750 Removal of nail bed

0.2 $27.7 1% -30.8%

All other codes

14.4 $980.3 49% 0.8%

Total

31.5 $1,985.34 100.0% 0.4%

Source: HPA analysis of 2016 Medicare Physician Fee Schedule Proposed Rule 12

DATA FROM THE PFS MEDICARE

PHYSICIAN DATA FILE

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• Referred to “officially” as the Medicare Provider Utilization and Payment Data: Physicians and Other Supplier Public Use File

• First released on April 9, 2014 contains never-before-seen data on Medicare Part B fee-for-service payments to physician and other health care providers in 2012

• What does it include? – Provider information for more than 950,000 providers who

participate in Medicare (e.g., names, credentials, gender, provider type.. )

– Service information by Healthcare Common Procedure Coding System (HCPCS) (e.g., number of services provided, number of Medicare beneficiaries served, and service setting)

– Payment information on $90 billion paid out to Medicare beneficiaries in 2013 (e.g., includes average Medicare payment after deductible and coinsurance)

Medicare Physician Data File: Background

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Source: http://graphics.wsj.com/medicare-billing/#/name=&special=Podiatry&city=&state=, accessed October 15, 2015.

• Data available in raw

form on the CMS

website

• Other sites, such as

the Wall Street

Journal have search

engines that make it

easier to lookup

particular providers

and drill down for

more detail.

Medicare Physician Data File: Podiatry

Example

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Medicare Physician Data File: Podiatry

Example (Con’t)

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Medicare Physician Data File:Podiatry Example

(Con’t)

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Medicare Physician Data File: Potential Uses

and Concerns

Potential Uses of Physician Data File

• Greater program

transparency

• Source of information for

consumers and providers

• Use of data by state,

commercial payers and

federal audit agencies,

investigative journalists.

Potential Concerns about Use of Data

• Data can be misleading!

Multiple providers are

allowed to bill using the same

NPI (e.g., group practices)

• Does not include data on

services performed on 10 or

fewer beneficiaries

• Extremely large dataset and

difficult to manipulate without

statistical software

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QUALITY DATA FROM

PHYSICIAN COMPARE

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Physician Compare: Podiatry

Example

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Physician Compare: Limited Quality Information

Posted (for now)

Individual EPs have a green check on their profile page:

• Satisfactorily report under PQRS

• Successfully participate in Electronic Prescribing (eRx) Incentive program;

• Participate in EHR Incentive program; or

• Report as part of the 2013 PQRS Cardiovascular Prevention measures group in support of Million Hearts®.

Group Practices have a green check on their profile page:

• Satisfactorily report under the Group Practice Reporting Option (GPRO); or

• Successfully participate in the eRx Incentive program.

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Physician Compare: Benchmarking and Star

Ratings

• CMS finalized its 2016 proposal to adopt the Achievable Benchmark of Care (ABCTM) methodology

• CMS plans to use the benchmark to “systematically assign stars for the Physician Compare 5-star rating”

• CMS provides additional details in the final rule about how the methodology would work.

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DATA NEEDS FOR ADVANCED

PAYMENT MODELS

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Advanced Payment Models: Data

Needs • More granular data – patient-based data

• Broader Perspective (what settings are affected) – All Part A and B Services

– Hospital

– Physician

– LTC

– DME

– Part B Drugs

• Provider Control

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Part A and Part B Payment for Surgical Procedure

(30 days pre/90 days post-admission)

65%

18%

18%

3%

5% 12%

1%

Admission

Re-admission

Other Physicians

Surgeon

Hospital OPD

Post-Acute Care

DME

Concluding Observations

• Abundance of payment and utilization data available for Medicare policy analysis

• Limited quality data available and posted

• Be aware of information being reported on you from the Physician Data file or on Physician Compare

• Continue to examine the feasibility of advanced payment models/bundling

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While I can explain the meaning of life, I don’t dare try to

explain how the Medicare system works.

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Time for your questions?