AAMC Contact:

Mary Wheatleymwheatley@aamc.org202-862-6297

December 2012

2015 Physician Fee Schedule Value Modifier

Medicare Physician Pay-for-Performance• Established by Sec 3007 of Affordable Care Act• Adjusts payments up or down

• Based on quality compared to cost Outcome measures are risk-adjusted Costs are risk adjusted and exclude geographic adjustments

• Budget neutral (winners and losers)• Timing

• Starts in 2015 for “some” physicians and physician groups based on CY2013 quality and cost data

• 2017 for all physicians

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What is the Value Modifier (VM)?

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2015 VM Affects Most Large Group Practices

Group with ≥ 100 EPs/TIN in 2013?*

2013 Group Reporting or Admin Claims?

Excluded from 2015 VMIncluded in 2017 VM

-1.0% Penalty in 2015

0.0% Penalty (No Adjustment) in 2015

Upward or Downward adjustment based on Cost and Quality Performance

NO

NO

YES

YES

Optional : Quality Tiering

* VM excludes groups participating in Pioneer or MSSP ACOs.

• Large groups (100 or more eligible professionals) must report quality data as a group to avoid automatic VM cut

• 2013: Possible +0.5% incentive for the Physician Quality Reporting System (PQRS)

• 2015: Avoids additional -1.5% reduction for PQRS • Reporting options vary by the size of the group. For

large groups, the choices are:• GPRO Web Interface• Registry• Administrative claims (available for 2013)• EHR (starting in 2014)(See appendix for more details)

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Group Practice Reporting Option (GPRO)

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Quality Measures• PQRS reported measures

(varies by reporting method)

• 3 claims-based outcome measures

• Acute prevention quality indicators composite

• Chronic prevention quality indicators composite

• All cause readmission

Cost Measures• Total cost per capita

• Per capita costs for 4 condition populations

• COPD• Heart Failure• Coronary Artery Disease• Diabetes

Cost measures risk-adjusted and price-standardized

VM - Quality and Cost Measures

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Performance reported through Quality Resource Use Report (QRUR)

Value Modifier Composite

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Quality and cost measures roll-up into domains. Each domain is weighted equally.

Quality/Cost Low Cost Average Cost High Cost

High Quality 2.0x* 1.0x* 0.0%

Average Quality 1.0x* 0.0% -0.5%

Low Quality 0.0% -0.5% -1.0%

Optional Quality Tiering (2015)

• Maximum reduction is -1.0% for low quality and high cost

• Payments are budget neutral; positive adjustment (“x”) will be after performance period ends (and CMS knows the total pool of available dollars to distribute)

• Additional “1.0x” for high risk patients (average beneficiary score in top 25%)• High risk adjustment only applies if score is:

• High quality/low cost• High quality/average cost• Average quality/low cost

*Cells eligible for high risk bonus

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Timing of the 2015 VM

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2013•Cost and Quality Performance Period•Large groups (excluding ACOs) nominate themselves, submit

quality data or choose administrative claims data •Option to elect quality tiering

2014 •CMS calculates 2013 performance results•Fall 2014 – Quality Resource Utilization Reports (QRUR)

based on 2013 data

2015 •Adjustments for VM and PQRS applied

• Sign up with CMS as a group practice by October 15, 2013• Determine Quality Reporting Strategy for each TIN

• For 2013: submit quality data as group or sign up for administrative claims?

• What is long-term alignment with EHR reporting?• Elect quality tiering (yes/no)?

• Try to understand cost and quality performance• Consider implications of Physician Compare reporting

Additional resources on VM and GPRO:• https://www.aamc.org/initiatives/patientcare/patientcarequality/

311244/physicianpaymentandquality.html• https://www.facultypractice.org/

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What do Practices Need to Do?

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Item GPRO Web Registry EHR Administrative Claims

Effective Date 2013 forward 2013 forward 2014 forward 2013 only (CMS could extend after 2013)

Measure selection Pre-determined (18 measures)

Practice selects from available PQRS measures (at least 3 measures)

Practice selects 9 measures for which their EHR is certified

Pre-determined (14 process measures and 3 outcomes)

Submission Process XML Web Tool Registry submits data on groups behalf

EHR submission Groups register but do not need to submit data

Reporting requirements

Populate data fields for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group's sample

Report each measure for at least 80 percent of the group practice's Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Choose 9 measures from 3 domains

Cannot report zero denominators for EHR group reporting

Claims data is used to evaluate performance on 14 quality measures and 3 outcome measures

Individual PQRS can also be applied

Public Reporting of 2013 Performance Data

2013 performance data and patient experience (CG-CAHPS) publicly reported on Physician Compare

No public reporting N/A No public reporting

Assignment of Patients/Beneficiaries

CMS assigns using2-step primary care attribution

Registry/groups identify the patients based on measure specifications

EHR identifies patients based on measure specifications

CMS determines

Qualifies for EHR Clinical Quality Measures (CQM)

Yes (starting in 2014) if using CEHRT

No Yes (starting in 2014) No

Effect on Incentives and Penalties(Incentives require successful reporting)

- Avoids the 2015 VM penalty

- Qualifies for 2013 and 2014 PQRS incentive

- Avoids the 2015 VM penalty

- Qualifies for 2013 and 2014 PQRS incentive

- Avoids the VM penalty starting in 2016

- Qualifies for 2014 PQRS incentive

- Avoid the 2015 VM penalty

- No PQRS incentives

Appendix: GPRO Reporting Options for Large Groups

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