CMS s framework for Value Modifier

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CMS’s framework for Value Modifier

1 Clinical Care

Quality of Care Composite

(50%)

Cost Composite

(50%)

Value Modifier

Score (‐2.0x to

+2.0x)

Patient Experience

Population/

Community Health Patient Safety

Care Coordination Efficiency

Total per Capita Costs

Per capita costs per beneficiaries with specific conditions

Relationship between quality of care, cost composites and the Value Modifier

Exact breakdown of Quality of Care Composite has not been finalized by CMS and will also depend on method we elect to submit data

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Overview of Physician Programs by Program Year

Program Year

PQRS + MOC Incentive

eRx Incentive Program

EHR Incentive Program

Physician Compare Value Modifier:

Differential Payment Modifier Based on Quality Compared to Cost in Budget- Neutral Manner 2014 + 0.5% incentive

payment + 0.5% MOC program incentive Last year of PQRS incentive payment Final year for MOC program incentive

- 2.0%

payment adjustment Last year of eRx payment adjustment

Last year to begin to qualify Medicare EHR incentive. New participants limited to

$24,000 maximum over 3 years or

Medicaid EHR incentive maximum $63,750 over 6 years

Medicare EPs in their first year of

demonstrating MU in 2014 must meet the MU functional measure &

CQM reporting requirements by 10/1/2014 in order to avoid a negative payment adjustment in 2015

Post composite scores for DM and CAD for PQRS GPRO

and ACOs participating in the Shared Savings Program

Post PY 2012 and 2013 PQRS GPRO and ACO GPRO measure data Publicly report CG- CAHPS measures collected in PY 2013 for groups of 100+ EPs and ACO GPROs Post PY 2013 PQRS, GPRO, eRX, EHR, MOC and Million Hearts Incentive Program Participation

Secretary may include completion of MOC and practice assessment as measure for Value Modifier

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Overview of Physician Programs by Program Year

^(cont.)

Overview of Physician Programs by Program Year

^(cont.)

PQRS + MOC Incentive

eRx Incentive Program

EHR Incentive Program Physician Compare Value Modifier:

Differential Payment Modifier Based on Quality Compared to Cost in Budget- Neutral Manner

2015 - 1.5%

payment adjustment

N/A 2015 Medicare payment

adjustment begins for those not Meaningful Users of EHRs - 1 %, or - 2% if for 2014 subject to eRx payment adjustment

No Medicare EHR incentives for those not Meaningful Users in prior years

May begin Medicaid EHR incentive maximum $63,750 over 6 years

Medicare EPs in their first year of demonstrating MU in 2015 must meet the MU functional measure & CQM reporting requirements by 10/1/2015 in order to avoid a negative payment adjustment in 2016

Submit report to Congress on Physician Compare web site

Publicly report PY 2014 PQRS and claims derived quality measures for individual physicians Publicly report PY 2014 PQRS GPRO & ACO GPRO measures Post PY 2014 PQRS, GPRO, eRX, EHR, MOC and Million Hearts Incentive Program Participation

Publicly report CG-CAHPS measures collected in PY 2014 for groups of 100+

EPs and ACOs participating in GPRO

Subject to maximum - 1.0% downward adjustment/+1.0+

upward adjustment Applies to groups of 100+ physicians

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Overview of Physician Programs by Program Year

^(cont.)

Overview of Physician Programs by Program Year

^(cont.)

PQRS eRx

Incentive Program

EHR Incentive Program Physician Compare

Value Modifier:

Differential Payment Modifier Based on Quality Compared to Cost in Budget -Neutral Manner

2016 - 2.0%

payment adjustment

N/A Medicare EHR subject to - 2%

Last year to begin Medicaid EHR incentive maximum

$63,750 over 6 years

Medicare EPs in their first year of demonstrating MU in 2016 must meet the MU functional measure & CQM reporting requirements by 10/1/2016 in order to avoid a negative payment adjustment in 2017

Publicly report Specialty Society Measures

TBD in future rulemaking

Subject to maximum -2.0%

downward adjustment/+2.0+

upward adjustment Applies to groups of 10+

physicians

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Proposed Changes to Criteria for Satisfactory Reporting/Participation

2014 Reporting

Period Measure Type Reporting

Mechanism Proposed Reporting Criteria 12-month

(Jan 1 - Dec 31)

Individual Measures * Claims Report at least 9 measures covering at least 3 of the National Quality Strategy domains; OR

If less than 9 measures apply to the EP, then the EP must report 1-8 measures for which there is Medicare patient data; AND

Report each measure for at least 50% of the Medicare Part B FFS patients seen during the reporting period to which the measure applies.

12-month (Jan 1 - Dec 31)

Individual Measures Qualified Registry

Report at least 9 measures, covering at least 3 of the National Quality Strategy domains, AND

Report each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Measures selected by Qualified Clinical Data Registry

Qualified Clinical Data Registry

Report at least 9 measures available for reporting under a qualified clinical data registry covering at least 3 of the National Quality Strategy domains, AND

Report each measure for at least 50% of the EP’s patients. Of the measures reported via a clinical data registry, the EP must report on at least 1 outcome measure.

Note: Additional reporting options were finalized in the 2013 PFS Final Rule

*Subject to Measure Applicability Validation (MAV)

2014 PQRS Incentive – Individual EPs

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Proposed Changes to Criteria for Avoiding the 2016 PQRS Payment Adjustment

2014 Reporting Period

Measure Type Reporting

Mechanism Proposed Reporting Criteria 12-month

(Jan 1 - Dec 31)

Individual Measures * Claims Report at least 9 measures covering at least 3 of the National Quality Strategy domains; OR if less than 9 measures apply to the EP, then the EP must report 1-8 measures for which there is Medicare patient data; AND

Measures with a 0% performance rate would not be counted.

Individual Measures * Claims Report at least 3 measures; OR if less than 3 measures apply to the eligible professional, report 1-2 measures; AND

Individual Measures Qualified Registry Report at least 9 measures, covering at least 3 of the National Quality Strategy domains, AND

Report each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Measures selected by Qualified Clinical Data Registry

Qualified Clinical Data Registry

Report at least 9 measures available for reporting under a qualified clinical data registry covering at least 3 of the National Quality Strategy domains; AND Report each measure for at least 50% of the EP’s patients. Of the measures reported via a clinical data registry, the EP must report on at least 1 outcome measure.

*Subject to Measure Applicability Validation (MAV)

2016 PQRS Payment Adjustment – Individual EPs

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Physician Compare Physician Compare

• Outlines a phased plan for publicly reporting physician performance on quality measures

• In 2014, CMS will publicly report measures reported by large groups and ACOs

– Physicians will have a 30-day preview period of measure results

• In 2014, CMS will publicly report CG-CAHPS measures

• As early as 2015, CMS will publicly report measures for individual physicians

• CMS will work with specialty societies to identify vetted measures for public reporting

• Website redesign is now live

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Proposed Changes to Criteria for Satisfactory Reporting/ Participation Under the GPRO for the 2014 PQRS Incentive

2014 Reporting Period

Reporting Mechanism

Group

Practice Size Proposed Reporting Criteria 12-month

(Jan 1-Dec 31)

Qualified Registry 2+ EPs Report at least 9 measures covering at least 3 of the National Quality Strategy domains; AND

Report each measure for at least 50% of the group practice’s applicable patients seen during the reporting period to which the measure applies.

Measures with a 0% performance rate will not be counted.

12-month (Jan 1-Dec 31)

Certified Survey Vendor and Qualified Registry, direct EHR product, EHR data submission vendor, or GPRO Web Interface

25+ EPs Report all CG CAHPS survey measures via certified survey Vendor; AND

Report at least 6 measures covering at least 2 of

the National Quality Strategy domains using the qualified registry, direct EHR product, EHR data submission vendor, OR all PQRS GPRO measures included in the GPRO Web Interface (Note: The Web Interface is only available to groups of 100 or more).

2014 PQRS Incentive – GPRO

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For Large Groups: Quality and Cost

performance are used to determine payment adjustment starting 2014(!)

• CY2014 performance will impact payments in CY2016

– Only includes groups with ≥100 providers or ACOs – All providers will participate in CY2015

• Multiple is applied to all Medicare part B items and services billed by the TIN in 2016

CY – calendar year; TIN – Tax Identifier Number

Quality/Cost Low Cost Average Cost High Cost

High Quality +2.0x * +1.0x * ‐0‐

Medium Quality +1.0x * ‐0‐ ‐1.0x

Low Quality ‐0‐ ‐1.0x ‐2.0x

* ‐ eligible for an additional +1.0x if reporting clinical data for quality measures and average beneficiary risk score in the top 25% of all beneficiary risk scores 9

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Quality of care will be assessed by;

 PQRS and claims measures

 Including readmission data

 CG‐CAHPS

 Will be administered January – March 2014

 83 questions

‐ Most of the questions are about the interactions with a “focal” provider

‐ Focal provider – the provider who provides the most primary care services based on number of visits in the claims

‐ Other questions ask about clerical staff, specialists and the health care team

PQRS – physician quality reporting system; CG – clinical group; CAHPS – Consumer Assessment of Healthcare Providers and Systems10

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Sample CG‐CAHPS questions

11 http://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/sharedsavingsprogram/Downloads/Final‐National‐Implementation‐Survey‐nf.pdf

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S‐ CAHPS

Surgical Consumer Assessment

• CG‐CAHPS is primary care and medical specialty focused

• ACS has been the measure steward of this NQF‐endorsed Surgical Care Survey

NQF– National Quality Forum; ASC – American College of Surgeons; CAHPS – Consumer Assessment of Healthcare Providers and Systems

NQF‐ENDORSED S‐CAHPS SURVEY MEASURES S‐CAHPS composite measures

Information to help you prepare for surgery (2 items)

How well surgeon communicates with patients before surgery (4 items) Surgeon’s attentiveness on day of surgery (2 items)

Information to help you recover from surgery (4 items)

How well surgeon communicates with patients after surgery (4 items) Helpful, courteous, and respectful staff at surgeon’s office (2 items)

S‐CAHPS single item measure

Rating of surgeon (1 item)