CMS s framework for Value Modifier

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1 CMS s framework for Value Modifier Relationship between quality of care, cost composites and the Value Modifier Clinical Care Patient Experience Population/ Community Health Patient Safety Care Coordination Efficiency Quality of Care Composite (50%) Value Modifier Score ( 2.0x to +2.0x) Total per Capita Costs Per capita costs per beneficiaries with specific conditions Cost Composite (50%) Exact breakdown of Quality of Care Composite has not been finalized by CMS and will also depend on method we elect to submit data 1

2 Overview of Physician s by Year Year PQRS + MOC Incentive erx Incentive EHR Incentive Physician Compare Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget- Neutral Manner % 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 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 Participation Secretary may include completion of MOC and practice assessment as measure for Value Modifier 2

3 Overview of Physician s by Year (cont.) Year PQRS + MOC Incentive % payment adjustment erx Incentive N/A EHR Incentive Physician Compare Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget- Neutral Manner 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 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 3

4 Overview of Physician s by Year (cont.) Year PQRS erx Incentive EHR Incentive Physician Compare Value Modifier: Differential Payment Modifier Based on Quality Compared to Cost in Budget -Neutral Manner % 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 4

5 2014 PQRS Incentive Individual EPs Proposed Changes to Criteria for Satisfactory Reporting/Participation 2014 Reporting Period Measure Type Reporting Mechanism Proposed Reporting Criteria 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. 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) 5

6 2016 PQRS Payment Adjustment Proposed Changes to Criteria for Avoiding the 2016 PQRS Payment Adjustment 2014 Reporting Period Measure Type Reporting Mechanism Proposed Reporting Criteria 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. 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 Report each measure for at least 50% of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate would not be counted. 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 with a 0% performance rate would not be counted. Measures selected by Qualified Clinical Data Registry Individual EPs Qualified Clinical Data Registry Note: Additional reporting options were finalized in the 2013 PFS Final Rule *Subject to Measure Applicability Validation (MAV) 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. 6

7 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 7

8 2014 PQRS Incentive GPRO Proposed Changes to Criteria for Satisfactory Reporting/ Participation Under the GPRO for the 2014 PQRS Incentive 2014 Reporting Period (Jan 1-Dec 31) (Jan 1-Dec 31) Reporting Mechanism Group Practice Size Proposed Reporting Criteria 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. Certified Survey Vendor and Qualified Registry, direct EHR product, EHR data submission vendor, or GPRO Web Interface Note: Additional reporting options were finalized in the 2013 PFS Final Rule 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). 8

9 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 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 CY calendar year; TIN Tax Identifier Number 9

10 Quality of care will be assessed by; PQRS and claims measures Including readmission data CG CAHPS Will be administered January March 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 10 PQRS physician quality reporting system; CG clinical group; CAHPS Consumer Assessment of Healthcare Providers and Systems

11 Sample CG CAHPS questions 11 Fee for Service Payment/sharedsavingsprogram/Downloads/Final National Implementation Survey nf.pdf

12 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 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) Rating of surgeon (1 item) S CAHPS single item measure NQF National Quality Forum; ASC American College of Surgeons; CAHPS Consumer Assessment of Healthcare Providers and Systems

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