The Value Modifier and Quality Resource Use Report (QRUR)

The Medicare Report Card is Here for Physicians

Christopher Rawlings, CPA, CMA, CHFP, MBAAssociate AdministratorCAMC Physicians Group

The Physician Quality Reporting System (PQRS) is a reporting program that uses payment adjustments to promote quality reporting by eligible

physicians (EPs).

Report quality information

Payment Adjustments

Eligible Professionals (EPs)

CMS

2-Year Look Back

• CMS Payment Adjustments are based on a 2-year look back period. – 2014 PQRS performance determines the 2016

PQRS payment adjustment – 2015 PQRS performance determines the 2017

PQRS payment adjustment• Payment Adjustments in 2016 is -2.0 percent

of EP’s Part B covered professional services under Medicare PFS

The Value Modifier

The VM is one of many tools CMS is using to shift the basis for Medicare payments from volume to value. On January 26, 2015, Health and Human Services (HHS) Secretary Sylvia M. Burwell announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.

VM Applies to all providers in CY 2017 (based on 2015)

2-9 EPs & solo 10+ EPs

PQRSREPORTING

PQRS NON-REPORTING

PQRS REPORTING(Up or Neutral Adj)

PQRS-REPORTING (Down Adj)

PQRS NON- REPORTING

+2.0 (x), +1.0(x),

or neutral

-2.0% of MPFS

+4.0 (x), +2.0(x), or neutral

-2.0% or -4.0% of MPFS

-4.0% of MPFS

PQRS VALUE MODIFIER EHR Incentive Program

Payment adj.

-2.0% of MPFS

Medi-care Inc.

Medi-Caid Inc.

Medi-care Pay Adj

$4,000-$12,000 (based on when EP 1st demo MU)

$8,500 or $21,250 (based on when EP did A/I/U)$8,500 or $21,250 (based on when EP did A/I/U)

-3.0% of MPFS

Total Medicare Payment Adjustments at Risk for Non-Participa-tion in PQRS and Meaningful Use in 2017

Physicians in groups of 2-9 EPs & Solo physicians: -7.0%

Physicians in groups of10+ EPs: -9.0%

*The above payment adjustments and incentives apply to MDs, DOs, DDM, Oral Surgery, Podiatry, Ophthalmology, and Chiropractic.

2015 Incentive Payments and 2017 Payment Adjustments

Physician Assistant

Nurse Practitioner

Certified Nurse Midwife

Certified Registered Nurse Anesthetist

Clinical Nurse Specialist

Clinical Social Worker

Clinical Psychologist

Registered Dietician

Nutrition Professional

Audiologists

Physical therapist

Occupational Therapist

Qualified Speech-Language Therapist

PQRS

Pay Adj.

VALUE MODIFIER

Groups of 2+ EPs

EHR INCENTIVE PROGRAM

-2.0% of

MPFS

-2.0% of

MPFS

MedicareIncentive

MedicaidIncentive

MedicarePay Adj.

**EPs included in the definition of “group” to determine group size for application of the value modifier in 2017 (2 or more EPs). In 2017, VM only applies to payments made to physicians under the MPFS; beginning in 2018, VM will also apply to non-physician EPs

Therapists

Practitioner

N/A

$8,500 or $21,250 (based on when EP did A/I/U)

N/A

N/A

Total Medicare Payment Adjustments at Risk for Non-Participation in PQRS and Meaningful Use in 2017:

-2.0% of MPFS

Total Adjust-ments

See above N/AN/A N/A-2.0% of

MPFS

2015 Incentive Payments and 2017 Payment Adjustments

Physician Fee Schedule

TWO M & M’S

What Method will you use to report?

• Claims• CMS Qualified Registry• EHR/DSV• QCDR • GPRO-Web Interface – EHR

and Registry

What Measures will you report?

• Individual Measures – 9 measures over 3 NQS domains, including 1 cross cutting measures

• Group Measures – Registry only, 20 patients and 11 must be FFS. No Medicare Advantage.

• CAHPS – Required for 100 or more providers.

Participation Statistics

2015 Reporting Methods

Method Individual EPs Groups

Claims X

Registry-Individual Measures X X

Registry-Measure Groups X

Certified EHR-Direct X X

Certified EHR-Data Submission Vendor X X

Qualified Clinical Data Registry X

GPRO Web Interface 25+ EPs

Certified CAHPS for PQRS Survey Vendor-*This is done in combination with other reporting methods.

100+ required2-99 Optional

SUMMARY TABLE

Before determining what Method and Measures:

• Consider your patient population and the conditions most treated

• Types of care typically provided• Settings of care – office, ER, etc.• Other quality improvement programs in

use/considered (MU, ACO, Pioneer ACO, MOC)

QRURThe Medicare Report Card

How to obtain your Mid-Year QRURThe 2014 Mid-Year QRUR provides interim information about performance on the six cost and three quality outcomes measures that CMS calculates from Medicare claims and are used in the calculation of the Value Modifier. The information in the QRUR is based on care provided from July 1, 2013 through June 30, 2014, a period that precedes the actual calendar year 2014 performance period for the 2016 Value Modifier.

https://portal.cms.gov/wps/portal/unauthportal/home/

**Must have an IACS account and PV-PQRS role in IACS

**Please note the IACS system will be transitioning to the Enterprise Identity Management (EIDM) in July, 2015.

CMS PORTAL FOR QRUR: https://portal.cms.gov.

CMS PORTAL FOR QRUR: https://portal.cms.gov.

Sample QRUR Summary report

OU Physician’s QRURBased on 7,101 Patients

(sample QRUR from OU)

Attributed Beneficiaries(sample QRUR from OU)

1. Patients are assigned to the group practice that provided the plurality of primary care services* rendered by primary care physicians.†

2. If not assigned in step 1, patients are assigned to the group practice whose affiliated physicians, NPs, PAs, and clinical nurse specialists, together, provided the plurality of primary care services.*

*Primary care services include E&M visits in an office, other outpatient services, skilled nursing facility services, and those services rendered in home settings.

†Primary care physicians include family practice, general internal medicine, general practice, and geriatric medicine specialty codes.

Attribution of PatientsA Two Step Process

Value Based Modifier CY 2017 (based on 2015 performance)

QRURSix Cost Measures:1. Per Capita Costs for All Attributed Beneficiaries2. Per Capita Costs for Beneficiaries with Diabetes 3. Per Capita Costs for Beneficiaries with Chronic Obstructive Pulmonary Disease (COPD) 4. Per Capita Costs for Beneficiaries with Coronary Artery Disease (CAD) 5. Per Capita Costs for Beneficiaries with Heart Failure6. Medicare Spending per Beneficiary (MSPB).

Quality Outcome Measures:1. All Cause Readmission2. Composite of Acute Prevention Quality Indicators (bacterial pneumonia, urinary tract infection, dehydration)3. Composite of Chronic Prevention Quality Indicators (COPD, heart failure, diabetes)

Cost Measures Calculation

This information is derived from payments for all Medicare Parts A and B claims submitted by all providers who treated Medicare FFS patients attributed to your medical group practice, including providers who are not affiliated with your group. Outpatient prescription drug (Part D) costs are not included.

(sample QRUR from OU)

Quality Composite Calculation

Quality Outcome Measures

What’s Next?H.R. 2

PHYSICIAN COMPARE