michael schweitz, md president coalition of state rheumatology organizations the quality and value...
TRANSCRIPT
Michael Schweitz, MDPresident
Coalition of State Rheumatology Organizations
THE QUALITY AND VALUE MOVEMENT:
ACOS AND VALUE BASED PAYMENT SYSTEMS
Accountable Care Organizations (ACOs)Value-Based Payment Modifier (VBM)/Physician
Feedback ProgramPhysician Quality Reporting System (PQRS)Medicare and Medicaid EHR Incentive ProgramPhysician CompareEmerging Payment and Care Delivery Models
AGENDA
ACCOUNTABLE CARE ORGANIZATIONS
Section 3022 of the Aff ordable Care Act requires HHS to establish the Medicare Shared Savings Program (MSSP) (i.e., Accountable Care Organizations (ACOs))
ACOs ACOs are groups of physicians, hospitals, and other health care
providers who come together voluntarily to give coordinated high quality care to the Medicare patients they serve
Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors
When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program
More than 280 Medicare ACOs in operation to date Approx. 220 “Traditional” Medicare ACOs; More than 60 other ACO
models Innovation Center ACOs: Pioneer and Advanced Payment Model
ACCOUNTABLE CARE ORGANIZATIONS
October 2011 – CMS issues final rules on Medicare ACOs
Highlights Eligible Organizations
Physicians/professionals in group practice arrangements Networks of individual practices of physicians/professionals Joint ventures/partnerships of hospitals, physicians,
professionals Hospitals employing physicians/professional Other providers/suppliers may participate but would not be used
to assign patients Beneficiary Assignment
Two-step method based on plurality of “primary care services” (i.e., E/M or “offi ce visits”)
Assignment based on preliminary prospective assignment w/retrospective reconciliation
ACO HIGHLIGHTS
Highlights Quality Measurement and Performance
33 measures (used in existing programs – PQRS) 100% reporting required to be eligible for shared savings Quality domains assessed by CMS
Patient/caregiver experience (7 measures) (CG-CAHPS Survey) Care coordination/patient safety (6 measures) (CMS , AHRQ, NQF measures) Preventive health (8 measures) (NQF, NCQA, AMA-PCPI, CMS measures) At-risk population/frail elderly health (NQF, NCQA, CMS measures)
Data Sharing Aggregate data reports provided at the start of the agreement
period, quarterly aggregate data reports thereafter and in conjunction with year end performance reports
Aggregate data reports will contain a list of the beneficiaries used to generate the report.
Beneficiary identifiable claims data provided for patients seen by ACO primary care providers who have been notified and have not declined to share data
ACO HIGHLIGHTS
One-sided ModelShare in savings (50%)
during each of the three years in the agreement period
This option is available during an ACO’s initial 3-year agreement period
Two-sided Model Share in risk and
savings (60%) during each of the three years in the agreement period
ACO PAYMENT: ONE-SIDED VS. TWO-SIDED
Other ACO Payment Notes ACOs share on “fi rst dollar” once minimum savings
threshold is achieved Shared savings distributed by CMS to the ACO (not
directly to ACO participants) during an ACO’s initial 3-year agreement period
Innovation Center ACOs (ACA Section 3021)Pioneer ACO Model (32 in operation) Designed to support organizations with experience
operating as ACOs or in similar arrangements in providing more coordinated care to beneficiaries at a lower cost to Medicare
Will test the impact of different payment arrangements in helping these organizations achieve the goals of providing better care to patients and reducing Medicare costs
Advance Payment ACO Model (35 in operation) Will provide additional support to physician-owned and
rural providers participating in the Shared Savings Program who would benefit from additional start-up resources to build the necessary infrastructure, such as hiring new staff or improving information technology systems
INNOVATION CENTER ACOS
Relatively unclear how specialists fi t into the ACO framework, but we know the following: Specialists will likely be exclusive to one ACO under the
“two-step” assignment process Step 1: Beneficiaries first will be assigned to an ACO on the
basis of utilization of primary care services provided by PCPs
Step 2: Beneficiaries not seeing a PCP may be assigned to an ACO on the basis of primary care services provided by other physicians (such as specialists)
No NPI/TIN combination that has been used for purposes of patient assignment to an ACO can be associated with more than one ACO
CMS included an “Access to Specialists” module with the required CG-CAHPS Survey to monitor beneficiary access to specialists
Most specialists taking a “watch and see” approach
ACOS AND SPECIALISTS
ACO fi nal regulation widely interpreted as allowing non-primary care physicians to practice in multiple ACOs
CMS clarifi ed that it would apply exclusivity more broadly in recent FAQ document
Pertinent FAQs
QUESTION: I’m a medical specialist in solo practice and I bill for offi ce evaluation and management services that are included in the defi nition of primary care services. Is it true that I must keep my TIN exclusive to only one ACO?
ANSWER: Yes, an ACO participant TIN that bil ls for primary care services must be exclusive to a single MSSP ACO. Exclusivity under the MSSP is governed by the types of services that are furnished by the ACO providers/suppliers that bil l under the ACO participant TIN, not by whether the TIN bil ls for services furnished by primary care physicians, specialists, or a mix of providers.
ACO EXCLUSIVITY
Pertinent FAQs
QUESTION: I’m a specialist and bill for offi ce evaluation and management services (which CMS defi nes as being “primary care”) under a single TIN. Can my TIN be a participant in more than one ACO if I make sure all my patients see a primary care physician who’s not participating in my ACO? By doing this I’d make sure that no patients are assigned to my ACO based on my services.
ANSWER : No. An ACO participant TIN that bil ls for primary care services must be exclusive to a single Medicare Shared Savings Program ACO. TIN exclusivity under the Medicare Shared
Savings Program is not aff ected by whether or not non-ACO physicians also treat benefi ciaries that receive primary care services bil led by the ACO participant TIN.
Read more of CMS’ FAQs at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-FAQs.pdf
ACO EXCLUSIVITY
Analytics: Medicare & Medicaid Research Review (MMRR) 2012 Volume 2, Number 4“Statistical Uncertainty in the Medicare Shared Savings Program” Report indicates there may be greater statistical uncertainty in the
MSSP than previously recognized “The probability of an incorrect outcome is heavily dependent on
ACO enrollment size…[t]he probability of inappropriate payment denial declines as real ACO savings increase...CMS and ACOs will have to consider this uncertainty in their financial, administrative, and care management planning.”
Authors suggest analytic strategies that can be used to refine ACO payment formulas in the longer term to ensure that the MSSP (and other ACO initiatives that will be influenced by it) work as effi ciently as possible.
Read the report on CMS’ website: http://www.cms.gov/mmrr/Articles/A2012/mmrr-2012-002-04-a04.html
ACO CONCERNS
Exclusivity: Regardless of specialty, ACO participants that bill for PC services must be exclusive to a single ACO since they are the basis for assigning beneficiaries, computation of the benchmark, and quality assessment
Access to care: Patients not limited to ACO providers, but intra-ACO referrals and gatekeeper models may limit access to specialists
Distribution of shared savings: Specialty physicians continue to have doubts that shared savings will be distributed fairly among all ACO participants
ACO CONCERNS
Watch the Pioneer ACOs Letter to CMS from 32 Pioneer ACOs expressing concerns
(February 2013) Insuffi cient data for quality measures Benchmarks higher than commercial contracts Use of Medicare Advantage data in setting benchmarks
CMS rejected Pioneer’s concernsExpect additional CMS regulations to modify ACOs
Analytics, Exclusivity, Distribution of Shared Savings?Physicians should…
Closely review ACO agreements Educate their Medicare patients about ACOs
THE FUTURE OF ACOS
VALUE-BASED PAYMENT MODIFIER
AND PHYSICIAN FEEDBACK PROGRAM
Aff ordable Care Act (ACA) requires CMS to apply a value-based modifier (VBM) to physician services billed under the Medicare Fee Schedule Modifier must be based on physician quality AND cost Modifier must be applied beginning Jan. 1, 2015 to select
physicians and to all physicians no later than Jan. 1, 2017 Modifier must be applied in a budget neutral manner (i.e.,
cuts to low performers will finance bonuses to high performers)
CMS must provide confidential Physician Feedback Reports reflecting physician resource use and quality
VALUE-BASED PAYMENT MODIFIER: STATUTORY AUTHORITY
Alignment with other federal quality programs (PQRS, ACOs, etc.)
Encourage shared responsibility and systems-based care
Off er choice of quality measures and reporting mechanisms
Provide actionable information
VALUE-BASED PAYMENT MODIFIER: IMPLEMENTATION PRINCIPLES
Only LARGE GROUP PRACTICES (>100 eligible professionals) will be held accountable under VBM in 2015 EP = physicians (MD, DO, DOPM, DC, etc.), PAs,
NPs, dieticians, social workers, PT/OTs VBM applies to items/services billed by
physicians under a single tax-identification number (TIN)
Performance period for 2015 adjustment is CY2013 0% adjustment for satisfying PQRS requirements 1.0% penalty for inaction / adjustment for voluntary quality-tiering calculation
VALUE-BASED PAYMENT MODIFIER: INITIAL IMPLEMENTATION
Group Practice Reporting Options (GPRO) to avoid penalty:
GPRO Web Interface: pre-selected set of 22 measures focusing on preventive and chronic care that align with Shared Savings Program; must report at least one measure
GPRO Using CMS-Qualified Registry: groups select relevant quality measures to report through a PQRS-qualified registry; must report at least one measure
Administrative Claims Option:* 17 pre-selected measures focusing on preventive and chronic care; calculated automatically by CMS based on claims
*Only available for 2013
VALUE-BASED PAYMENT MODIFIER: REPORTING OPTIONS
Only groups that voluntary opt for the “quality-tiering approach” will be held accountable for quality and cost performance based on:
Quality measures Measures reported through selected PQRS reporting mechanism Three outcome measures: All Cause Readmission, Composite of
Acute Prevention Quality Indicators (bacterial pneumonia, UTI, dehydration), Composite of Chronic Prevention Quality Indicators (COPD, HF, diabetes)
Cost measures Total per capita costs measures (Parts A & B) Total per capita costs for beneficiaries with four chronic conditions:
COPD, HF, CAD, Diabetes
*Cost measures are payment standardized and risk adjusted. Patients are attributed to group practices that billed largest share of E/M services (“plurality of care” method)
VALUE-BASED PAYMENT MODIFIER: QUALITY TIERING APPROACH
VALUE-BASED PAYMENT MODIFIER
Group practices w/ > 100 EPs
PQRS Reporters Groups self-nominating for PQRS GPRO web-interface, registries or administrative
claims reporting
Non-PQRS ReportersGroups NOT self-nominating to participate in PQRS GPRO and
not reporting at least one measure
,, or No Adjustment
Based on Quality/Cost
Measure Composite
0.0% No
Adjustment
Elect Quality-Tiering
No Election
-1.0% Adjustment
CMS has provided confi dential feedback reports (“Quality and Resource Use Reports” or QRURs) to select physicians since 2010. Reports quantify and compare quality and costs of physicians relative to their peers.
Fall 2013: CMS will send reports to all group practices with >25 EPs to preview methodologies used to determine the VBM and help larger practices decide whether to choose quality-tiering approach
Fall 2014: CMS will send reports to all group practices with >25 EPs based on 2013 data. Reports will specify modifi er amount and will be the basis for its determination in 2015 (for practices with >100 EPs only)
CMS continues to work with specialties to improve the content and format of these reports
QUALITY AND RESOURCE USE REPORTS
2012
• Confidential feedback reports distributed to successful PQRS participants and demonstrate the type of information that will be used to calculate modifier
2013• Initial performance period (i.e.,
services provided during CY 2013 will be used to calculate 2015 payment)
2015• Beginning in 2015, modifier will apply
only to large group practices (100+ eligible professionals)
2016• As modifier is phased in over 2-year
period, CMS will continue to apply modifier to specific physicians
2017• Modifier will apply to most or all
physicians who submit claims under Medicare fee schedule
VALUE-BASED PAYMENT MODIFIER: TIMELINE
Continuing concerns Rushed timeline Inaccurate risk adjustment/attribution methodologies for
cost measures Confusing feedback reports
CMS continues to seek public feedback on implementation strategies and methodologies
Important for physicians to familiarize themselves with the PQRS and to pay attention to CMS feedback reports, regardless of whether they qualify for VBM during initial roll out
VALUE-BASED PAYMENT MODIFIER: ONGOING CONCERNS
May 16, 2012 – CSRO met with CMS senior staff to discuss concerns and off er suggestions specifi c to the VBM and the QRURs.
Limited provider education on the VBM/Physician Feedback Program
How to measure quality for providers not participating in the PQRS
Conditions being measured frequently fall outside the specialty
Validity of the QRUR data Cost measurement may prompt
negative behavior Need to highlight data relevant to
specialty Reduce the size and simplify the
QRURs
CSRO MEETS WITH CMS STAFF
CSRO, as members of the Alliance of Specialty Medicine, is engaged in an ongoing, bi-directional dialogue with senior CMS staff to improve elements of the VBM, QRURs
Face-to-face meetings (Dec. 2012/March 2013) at CMS Headquarters
User Access Training & Alliance/CMS Webinar on new QRURs (Sept 2013)
ALLIANCE OF SPECIALTY MEDICINE: SUPER USER NETWORK
PHYSICIAN QUALITY REPORTING SYSTEM
Bonus payment for reporting quality data via claims, registry, EHR up to 1.0% in 2013
Penalties in 2015 based on 2013 reporting -1.5% in 2015, -2.0% in 2016
Improvements to the program: More measures, more reporting options Less stringent reporting criteria to avoid penalty American Taxpayer Relief Act of 2012 (P.L.112-240)
permits participation in clinical data registries in lieu of traditional PQRS reporting for 2014 and beyond
CMS interested in recognizing registry reporting and other innovative, non-federal QI activities as a substitute for PQRS criteria
PHYSICIAN QUALITY REPORTING SYSTEM
BONUS/PENALTY STRUCTURE
Year PQRS
2009 2.0%
2010 2.0%
2011 1.0%-1.5%
2012 0.5%-1.0%
2013 0.5%-1.0%
2014 0.5%-1.0%
2015 No bonus (-1.5% penalty)
2016 No bonus (-2.0% penalty)
**Range in incentive payment depends on whether EP qualifies for MOC bonus
EHR INCENTIVE PROGRAM
Incentives for “meaningful use” of certifi ed EHR system Medicare: Up to $44,000 over 4 years Medicaid: Up to $63,750 NOTE: EHR incentive payments subject to 2% sequestration reduction
Phased approach Final Stage 2 (2014): More advanced clinical processes; more data exchange;
increased requirements for e-Rx and incorporating lab-results; e-transmission of patient care summaries; and enhanced patient engagement
Proposed Stage 3 (2016): Emphasis on core vs. menu options; 2x measures; higher reporting thresholds (100% compliance in some cases); testing of innovative, locally generated measures
Participation 226K physicians registered to participate in Medicare EHR Incentive Program;
still, fewer than 1 in 10 physicians used electronic records last year that met federal standards
Challenges Irrelevant measures; lack of interoperability/info exchange infrastructure;
cost; unintended coding/safety issues; rushed implementation
MEDICARE AND MEDICAID EHR INCENTIVE PROGRAM
BONUS/PENALTY STRUCTURE
Year EHR
2009 None
2010 None
2011 $18,000
2012 $12,000-$18,000
2013 $8,000-$15,000
2014 $4,000-$12,000
2015 $2,000-$8,000 (-1.0% penalty)
2016 $2,000-$4,000 (-2.0% penalty)
*Depending on total # of meaningful users after 2018, the maximum cumulative EHR penalty can reach as high as 5%; EHR incentive payments subject to 2% sequestration reduction
PHYSICIAN COMPARE
CMS Physician Compare Website http://
www.medicare.gov/find-a-doctor/provider-search.aspx 2014:
2013 PQRS quality measures reported by group practices (>25) and ACOs
2013 patient experience data for group practices (>100)/ACOs Recognition of physicians who earned a PQRS MOC Incentive
2015: Individual physician 2014 PQRS performance dataOngoing concerns with accuracy of dataPhysicians should review the accuracy of their data
and report problems to CMS
PHYSICIAN COMPARE
EMERGING MODELS
CMS’ Innovation Center develops new payment and service delivery models in accordance with statutory requirements
Focus Areas Accountable Care Bundled Payment for Care Improvement Primary Care Transformation Innovations for Medicaid and Dual-Eligibles
Innovation Center recently announced it would accept proposals for “specialty” focused demos
CSRO, as part of the Alliance of Specialty Medicine, engaged in a dialogue with Innovation Center staff on ways to encourage/facilitate the development of specialty-focused payment and delivery models
CMS INNOVATION CENTER
QUESTIONS?