By 2015, group physician practices of 10 or more eligible Medicare providers will be required by the Centers for Medicare and Medicaid Services to participate in the value-based modifier program. Is your practice prepared to participate? This Quirk Healthcare Solutions Insights webinar provides a solid overview of the impending rollout.
Text of Value Based Modifer
Value Based Modier Friday June 13, 2014 Disclaimer: Nothing that we are sharing is intended as legally binding or prescrip7ve advice. This presenta7on is a synthesis of publically available informa7on and best prac7ces.
Overview of the Value Modier Dis5nc5on between Medicare Physicians and Eligible Professionals Rela5on to Other Quality Program Incen5ves and Payment Adjustments 50 Percent Threshold Op5on Quality and Cost Measures Quality-Tiering Decision Tree Topics
Value-Based Payment Modier
Sec5on 3007 of the Aordable Care Act mandated that, by 2015, CMS begin applying a value modier under the Medicare Physician Fee Schedule (MPFS) VM assesses both quality of care furnished and the cost of that care under the MPFS For 2015, CMS will apply the VM to groups of physicians with 100 or more eligible professionals (EPs) For 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 Implementa5on of the VM is based on par5cipa5on in Physician Quality Repor5ng System (PQRS) What is the Value-Based Payment Modier (VM)?
Dis5nc5on between Medicare Physicians and Eligible Professionals
PQRS Value Modier EHRIncenEve Program Eligible for Incen5ve Subject to Payment Adjustment Included in Deni5on of "Group" (1) Subject to VM (2) Eligible for Medicare Incen5ve Eligible for Medicaid Incen5ve Subject to Medicare Payment Adjustment Medicare Physicians Doctor of Medicine x x x x x x x Doctor of Osteopathy x x x x x x x Doctor of Podiatric Medicine x x x x x x Doctor of Optometry x x x x x x Doctor of Oral Surgery x x x x x x x Doctor of Dental Medicine x x x x x x x Doctor of Chiroprac5c x x x x x x PracEEoners Physician Assistant x x x x Nurse Prac55oner x x x x Clinical Nurse Specialitst x x x Cer5ed Registered Nurse Anesthe5st x x x Cer5ed Nurse Midwife x x x x Clinical Social Worker x x x Clinical Psychologist x x x Registered Die5cian x x x Nutri5on Professional x x x Audiologists x x x Therapists Physical Therapist x x x Occupa5onal Therapist x x x Qualied Speech Language Eligible Professionals
The size of a group is determined by how many EPs comprise the group Deni5on of Group: A single Tax Iden5ca5on Number (TIN) with 2 or more individual EPs (as iden5ed by Individual Na5onal Provider Iden5er (NPI)) who have reassigned their billing rights to the TIN An EP is dened as any of the following; A physician A physician assistant, nurse prac55oner, clinical nurse specialist, cer5ed registered nurse anesthe5st, cer5ed nurse-midwife, clinical social worker, clinical psychologist, registered die55an or nutri5on professional A physical or occupa5onal therapist or a qualied speech-language pathologist A qualied audiologist How Is a Group Prac5ce Dened?
Physicians include: MDs / DOs Doctor of dental surgery or dental medicine Doctor of podiatric medicine Doctor of optometry Chiropractor VM Will Be Applied to Physician Payment Only
Rela5on to Other Quality Program Incen5ves and Payment Adjustments
PQRS Value Modier EHRIncenEve Program IncenEve Pay Adjustment 10 - 99 EPs 100+ EPs Medicare Inc. Medicaid Inc. Medicare Pay Adj PQRS- ReporEng Non-PQRS ReporEng PQRS- ReporEng (UP or Neutral Adj) PQRS - ReporEng (Down Adj) Non-PQRS ReporEng MD & DO 0.5% of MPFS -2.0% of MPFS +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 ajested to MU $8,500 or $23,000 (based on when EP rst ajested -2.0% of MPFS DDM Oral Surgery Podiatry N/A Optometry ChiropracEc 2014 Incen5ves and 2016 Payment Adjustments Physicians
PQRS Value Modier EHRIncenEve Programe IncenEve Pay Adjustment Groups of 10+ EPs Medicare Inc. Medicaid Inc Medicare Pay Adjustment PracEEoners Physician Assistant 0.5% MPFS -2.0% MPFS Eps included in the deni5on of "group" to determine group size for applica5on of the value modier in 2016 (10 or more Eps); VM only applied to reimbursement of PHYSICIANS in the group NA Depends on rst ajesta5on NA Nurse PracEEoner Clinical Nurse Specialist NA CerEed Registered Nurse AnestheEst Depends on rst ajesta5on CerEed Nurse Midwife NA Clinical Social Worker Reigistered DieEcian NutriEon Professional Audiologist Therapists Physical Therapy See above See Above See Above NA NA OccupaEonal Therapist 2014 Incen5ves and 2016 Payment Adjustments Non-Physician Providers
Value Modier Components 2015 Finalized Policies 2016 Finalized Policies Performance Year 2013 2014 Group Size 100+ 10+ Available Quality ReporEng Mechanisms GPRO-Web Interface, CMS Qualied Registries, AdministraEve Claims GPRO-Web Interface (Groups of 25+ Eps), CMS Qualied Registries, EHRs, and 50% of Eps reporEng individually Outcome Measures NOTE: The performance on the ouotcome measures and measures reported through the PQRS reporEng mechanisms will be used to calculate a quality composite score for the group for the VM. All Cause Readmission, Composite of Acute PrevenEon Quality Indicators: (bacterial pneumonia, urinary tract infecEon, dehydraEon) Composite of Chronic PrevenEon Quality indicators: (COPD, heart failure and diabetes) Same as 2015 PaEent Experience Care Measures N/A PQRS CAHPS: opEon for groups of 25+ EP; required for groups of 100+ EP reporEng via Web Interface Value Modier Policies for 2015 & 2016
Value Modier Components 2015 Finalized Policies 2016 Finalized Policies Cost Measures 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 beneciaries with four chronic condiEons: COPD, Heart Failure, Coronary Artery Disease and Diabetes Same as 2015 and: Medicare Spending Per Beneciary measure (includes Part A and B costs druing the 3 days berfore and 30 days aher an inpaEent hospitalizaEon) Benchmarks Group Comparison SSpecialty Adjusted Group Cost Quality Tiering opEonal 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 -1.00% -2.00% Value Modier Policies for 2015 & 2015
Groups with 10+ EPs may select one of the following PQRS GPRO quality repor5ng mechanisms and meet the criteria for the 2016 PQRS payment adjustment to avoid the 2.0% VM adjustment Repor5ng Quality Data at the Group Level PQRS ReporEng Mechanism Type of Measure 1. GPRO Web interface (Groups of 25+ EP) Measures focus on prevenEve care and care for chronic diseases 2. GPRO using CMS-qualied registries Groups select the quality mesures that they will report through a PQRS - qualied registry. 3. GPRO using Electronic Health Record Quality measures data extracted from a qualied electronic health record product for a subset of proposed 2014 PQRS quality measures.