The document discusses the Value-Based Payment Modifier (VM) program which adjusts Medicare payments for physicians and other eligible professionals based on quality and cost of care. Key points: - The VM assesses quality and cost of care provided under Medicare and adjusts payments accordingly. - For 2015 it applies to groups with 100+ eligible professionals, expanding to groups of 10+ in 2016 and all physicians by 2017. - Eligible professionals include physicians as well as other practitioners. Physicians are subject to the VM payment adjustments while other practitioners are included in defining group size. - The VM is related to other quality programs like PQRS and EHR incentives, with varying incentives and payment adjustments based on participation

1. Value
Based
Modifier
Friday
June
13,
2014
Disclaimer:
Nothing
that
we
are
sharing
is
intended
as
legally
binding
or
prescrip7ve
advice.
This
presenta7on
is
a
synthesis
of
publically
available
informa7on
and
best
prac7ces.

2. • Overview
of
the
Value
Modifier
• Dis5nc5on
between
Medicare
Physicians
and
Eligible
Professionals
• Rela5on
to
Other
Quality
Program
Incen5ves
and
Payment
Adjustments
• “50
Percent”
Threshold
Op5on
• Quality
and
Cost
Measures
• Quality-­‐Tiering
• Decision
Tree
Topics

3. Value-­‐Based
Payment
Modifier

4. • Sec5on
3007
of
the
Affordable
Care
Act
mandated
that,
by
2015,
CMS
begin
applying
a
value
modifier
under
the
Medicare
Physician
Fee
Schedule
(MPFS)
• VM
assesses
both
quality
of
care
furnished
and
the
cost
of
that
care
under
the
MPFS
• For
2015,
CMS
will
apply
the
VM
to
groups
of
physicians
with
100
or
more
eligible
professionals
(EPs)
• For
2016,
CMS
will
apply
the
VM
to
groups
of
physicians
with
10
or
more
EPs
• Phase-­‐in
to
be
completed
for
all
physicians
by
2017
• Implementa5on
of
the
VM
is
based
on
par5cipa5on
in
Physician
Quality
Repor5ng
System
(PQRS)
What
is
the
Value-­‐Based
Payment
Modifier
(VM)?

5. Dis5nc5on
between
Medicare
Physicians
and
Eligible
Professionals

6. PQRS
Value
Modifier
EHRIncenEve
Program
Eligible
for
Incen5ve
Subject
to
Payment
Adjustment
Included
in
Defini5on
of
"Group"
(1)
Subject
to
VM
(2)
Eligible
for
Medicare
Incen5ve
Eligible
for
Medicaid
Incen5ve
Subject
to
Medicare
Payment
Adjustment
Medicare
Physicians
Doctor
of
Medicine
x
x
x
x
x
x
x
Doctor
of
Osteopathy
x
x
x
x
x
x
x
Doctor
of
Podiatric
Medicine
x
x
x
x
x
x
Doctor
of
Optometry
x
x
x
x
x
x
Doctor
of
Oral
Surgery
x
x
x
x
x
x
x
Doctor
of
Dental
Medicine
x
x
x
x
x
x
x
Doctor
of
Chiroprac5c
x
x
x
x
x
x
PracEEoners
Physician
Assistant
x
x
x
x
Nurse
Prac55oner
x
x
x
x
Clinical
Nurse
Specialitst
x
x
x
Cer5fied
Registered
Nurse
Anesthe5st
x
x
x
Cer5fied
Nurse
Midwife
x
x
x
x
Clinical
Social
Worker
x
x
x
Clinical
Psychologist
x
x
x
Registered
Die5cian
x
x
x
Nutri5on
Professional
x
x
x
Audiologists
x
x
x
Therapists
Physical
Therapist
x
x
x
Occupa5onal
Therapist
x
x
x
Qualified
Speech
Language
Eligible
Professionals

7. • The
size
of
a
group
is
determined
by
how
many
EPs
comprise
the
group
• Defini5on
of
Group:
A
single
Tax
Iden5fica5on
Number
(TIN)
with
2
or
more
individual
EPs
(as
iden5fied
by
Individual
Na5onal
Provider
Iden5fier
(NPI))
who
have
reassigned
their
billing
rights
to
the
TIN
• An
EP
is
defined
as
any
of
the
following;
• A
physician
• A
physician
assistant,
nurse
prac55oner,
clinical
nurse
specialist,
cer5fied
registered
nurse
anesthe5st,
cer5fied
nurse-­‐midwife,
clinical
social
worker,
clinical
psychologist,
registered
die55an
or
nutri5on
professional
• A
physical
or
occupa5onal
therapist
or
a
qualified
speech-­‐language
pathologist
• A
qualified
audiologist
How
Is
a
Group
Prac5ce
Defined?

8. • Physicians
include:
• MDs
/
DOs
• Doctor
of
dental
surgery
or
dental
medicine
• Doctor
of
podiatric
medicine
• Doctor
of
optometry
• Chiropractor
VM
Will
Be
Applied
to
Physician
Payment
Only

9. Rela5on
to
Other
Quality
Program
Incen5ves
and
Payment
Adjustments

10. PQRS
Value
Modifier
EHRIncenEve
Program
IncenEve
Pay
Adjustment
10
-­‐
99
EPs
100+
EPs
Medicare
Inc.
Medicaid
Inc.
Medicare
Pay
Adj
PQRS-­‐
ReporEng
Non-­‐PQRS
ReporEng
PQRS-­‐
ReporEng
(UP
or
Neutral
Adj)
PQRS
-­‐
ReporEng
(Down
Adj)
Non-­‐PQRS
ReporEng
MD
&
DO
0.5%
of
MPFS
-­‐2.0%
of
MPFS
+2.0(x),
+1.0(x),
or
neutral
-­‐2.0%
of
MPFS
+2.0(x),
+1.0(x),
or
neutral
-­‐1.0%
or
-­‐2.0%
of
MPFS
-­‐2.0%
of
MPFS
$4,000
-­‐
$12,000
(based
on
when
EP
1st
ajested
to
MU
$8,500
or
$23,000
(based
on
when
EP
first
ajested
-­‐2.0%
of
MPFS
DDM
Oral
Surgery
Podiatry
N/A
Optometry
ChiropracEc
2014
Incen5ves
and
2016
Payment
Adjustments
Physicians

11. PQRS
Value
Modifier
EHRIncenEve
Programe
IncenEve
Pay
Adjustment
Groups
of
10+
EPs
Medicare
Inc.
Medicaid
Inc
Medicare
Pay
Adjustment
PracEEoners
Physician
Assistant
0.5%
MPFS
-­‐2.0%
MPFS
Eps
included
in
the
defini5on
of
"group"
to
determine
group
size
for
applica5on
of
the
value
modifier
in
2016
(10
or
more
Eps);
VM
only
applied
to
reimbursement
of
PHYSICIANS
in
the
group
NA
Depends
on
first
ajesta5on
NA
Nurse
PracEEoner
Clinical
Nurse
Specialist
NA
CerEfied
Registered
Nurse
AnestheEst
Depends
on
first
ajesta5on
CerEfied
Nurse
Midwife
NA
Clinical
Social
Worker
Reigistered
DieEcian
NutriEon
Professional
Audiologist
Therapists
Physical
Therapy
See
above
See
Above
See
Above
NA
NA
OccupaEonal
Therapist
2014
Incen5ves
and
2016
Payment
Adjustments
Non-­‐Physician
Providers

12. Value
Modifier
Components
2015
Finalized
Policies
2016
Finalized
Policies
Performance
Year
2013
2014
Group
Size
100+
10+
Available
Quality
ReporEng
Mechanisms
GPRO-­‐Web
Interface,
CMS
Qualified
Registries,
AdministraEve
Claims
GPRO-­‐Web
Interface
(Groups
of
25+
Eps),
CMS
Qualified
Registries,
EHRs,
and
50%
of
Eps
reporEng
individually
Outcome
Measures
NOTE:
The
performance
on
the
ouotcome
measures
and
measures
reported
through
the
PQRS
reporEng
mechanisms
will
be
used
to
calculate
a
quality
composite
score
for
the
group
for
the
VM.
All
Cause
Readmission,
Composite
of
Acute
PrevenEon
Quality
Indicators:
(bacterial
pneumonia,
urinary
tract
infecEon,
dehydraEon)
Composite
of
Chronic
PrevenEon
Quality
indicators:
(COPD,
heart
failure
and
diabetes)
Same
as
2015
PaEent
Experience
Care
Measures
N/A
PQRS
CAHPS:
opEon
for
groups
of
25+
EP;
required
for
groups
of
100+
EP
reporEng
via
Web
Interface
Value
Modifier
Policies
for
2015
&
2016

13. Value
Modifier
Components
2015
Finalized
Policies
2016
Finalized
Policies
Cost
Measures
Total
per
capita
costs
measure
(annual
payment
standardized
and
risk-­‐adjusted
Part
A
and
Part
B
costs,
does
not
include
Part
D
costs)
Total
per
capita
costs
for
beneficiaries
with
four
chronic
condiEons:
COPD,
Heart
Failure,
Coronary
Artery
Disease
and
Diabetes
Same
as
2015
and:
Medicare
Spending
Per
Beneficiary
measure
(includes
Part
A
and
B
costs
druing
the
3
days
berfore
and
30
days
aher
an
inpaEent
hospitalizaEon)
Benchmarks
Group
Comparison
SSpecialty
Adjusted
Group
Cost
Quality
Tiering
opEonal
Mandatory:
Groups
of
10
-­‐
99
EPs
receive
only
the
upward
(or
neutral)
adjustment,
no
downward
adjustment.
Groups
of
100+
both
the
upward
and
downward
adjustment
apply
(or
neutral
adjustment).
Payment
at
Risk
-­‐1.00%
-­‐2.00%
Value
Modifier
Policies
for
2015
&
2015

14. • Groups
with
10+
EPs
may
select
one
of
the
following
PQRS
GPRO
quality
repor5ng
mechanisms
and
meet
the
criteria
for
the
2016
PQRS
payment
adjustment
to
avoid
the
2.0%
VM
adjustment
Repor5ng
Quality
Data
at
the
Group
Level
PQRS
ReporEng
Mechanism
Type
of
Measure
1.
GPRO
Web
interface
(Groups
of
25+
EP)
Measures
focus
on
prevenEve
care
and
care
for
chronic
diseases
2.
GPRO
using
CMS-­‐qualified
registries
Groups
select
the
quality
mesures
that
they
will
report
through
a
PQRS
-­‐
qualified
registry.
3.
GPRO
using
Electronic
Health
Record
Quality
measures
data
extracted
from
a
qualified
electronic
health
record
product
for
a
subset
of
proposed
2014
PQRS
quality
measures.

15. “50
Percent”
Threshold
Op5on

16. • If
a
group
does
not
seek
to
report
quality
measures
as
a
group,
CMS
will
calculate
a
group
quality
score
if
at
least
50
percent
of
the
eligible
professionals
within
the
group
report
measures
individually.
– At
least
50%
of
EPs
must
successfully
avoid
the
2016
QRS
payment
adjustment
– EPs
may
report
on
measures
available
to
individual
EPs
via
the
following
repor5ng
mechanisms:
• Claims
• CMS
Qualified
Registries
• Electronic
Health
Record
• Clinical
Data
Registries
(new
for
2014)
Repor5ng
Quality
Data
at
the
Individual
Level
–
50%
Threshold
Op5on

17. • Two-­‐step
process:
• CMS
will
query
the
PECOS
system
to
iden5fy
groups
of
physicians
with
10
or
more
EPs
as
of
October
15,
2014
• Generates
a
list
of
poten5al
groups
that
could
be
subject
to
the
VM
• CMS
will
analyze
claims
for
services
furnished
during
the
2014
performance
year
through
at
least
February
2015
• Remove
groups
from
the
October
PECOS
list
that
did
not
have
10
or
more
EPs
that
billed
under
the
group’s
TIN
during
2014
• Groups
will
NOT
be
added
to
the
October
PECOS
list
aqer
that
query
How
Does
CMS
Determine
Whether
a
Group
of
Physicians
Has
10
or
More
EPs?

18. Quality
and
Cost
Measures

19. • Total
per
capita
costs
measures
(Parts
A
&
B)
• Total
per
capita
costs
for
beneficiaries
with
4
chronic
condi5ons:
• Chronic
Obstruc5ve
Pulmonary
Disease
• Heart
Failure
• Coronary
Artery
Disease
• Diabetes
• Medicare
Spending
Per
Beneficiary
(MSPB)
measure
(3
days
prior
and
30
days
aqer
an
inpa5ent
hospitaliza5on)
ajributed
to
the
group
providing
the
plurality
of
Part
B
services
during
the
hospitaliza5on
• All
cost
measures
are
payment
standardized
and
risk
adjusted.
• Each
group’s
cost
measures
adjusted
for
specialty
mix
of
the
EPs
in
the
group
What
Cost
Measures
will
be
used
for
Quality-­‐Tiering?

20. • 5
Total
Per
Capita
Cost
Measures
• Iden5fy
all
beneficiaries
who
have
had
at
least
one
primary
care
service
rendered
by
a
physician
in
the
group
• Followed
by
a
two-­‐step
assignment
process
1. assign
beneficiaries
who
have
had
a
plurality
of
primary
care
services
(allowed
charges)
rendered
by
primary
care
physicians.
2. For
beneficiaries
that
remain
unassigned,
assign
beneficiaries
who
have
received
a
plurality
of
primary
care
services
(allowed
charges)
rendered
by
any
eligible
professional
• MSPB
measure
–
ajribute
the
hospitaliza5on
to
the
group
of
physicians
providing
the
plurality
of
Part
B
services
during
the
inpa5ent
hospitaliza5on
Cost
Measure
Ajribu5on

21. Quality-­‐Tiering

22. • Each
group
receives
two
composite
scores
(quality
and
cost)
• CMS
uses
the
following
steps
to
create
each
composite:
• Create
a
standardized
score
for
each
measure
)performance
rate
–
benchmark
/
standard
devia5on)
• Equally
weight
each
measures'
standardized
score
within
each
domain.
• Equally
weight
each
domain’s
score
into
the
composite
score.
How
Does
CMS
Use
the
Quality
and
Cost
Measures
to
Create
a
Value
Modifier
Payment
Adjustment?

23. • Use
domains
to
combine
each
quality
measure
into
a
quality
composite
and
each
cost
measure
into
a
cost
composite
Quality-­‐Tiering
Methodology
Chart
from
CMS
website

24. • Each
group
receives
two
composite
scores
(quality
of
care;
cost
of
care),
based
on
the
group’s
standardized
performance
(how
far
away
from
the
na5onal
mean).
• Group
cost
measures
are
adjusted
for
specialty
composi5on
of
the
group
• This
approach
iden5fies
sta5s5cally
significant
outliers
and
assigns
them
to
their
respec5ve
cost
and
quality
5ers.
Quality-­‐Tiering
Approach
for
2016
(Based
on
2014
PQRS
Performance)
Low
Cost
Average
Cost
High
Cost
High
quality
Average
quality
Low
quality
+2.0x*
+1.0x*
+0.0%
+1.0x*
+0.0%
-­‐1.0%
+0.0%
-­‐1.0%
-­‐2.0%

25. • VM
for
2016
will
be
applied
to
Medicare
paid
amounts
to
items
and
services
billed
under
the
Physician
Fee
Schedule
at
the
TIN
level
• Beneficiary
cost-­‐sharing
not
affected
• Applied
to
the
items
and
services
billed
by
physicians
under
the
TIN,
but
not
to
other
eligible
professionals
• If
a
physician
changes
from
one
TIN
in
a
performance
year
to
another
TIN
in
a
payment
adjustment
year,
VM
would
be
applied
to
the
TIN
that
either
met
or
did
not
meet
the
VM
qualifica5on.
The
upward
/
downward
does
not
follow
the
EP
but
follows
the
TIN.
Downward
VM
Payment
Adjustment
in
2016

26. Decision
Tree

27. PQRS
Par5cipa5on
in
2014
for
Individuals
and
Groups
of
2
–
9
EPs
Individual
EPs
and
Groups
of
2-­‐9
EPs

28. PQRS
Par5cipa5on
in
2014
for
Individuals
and
Groups
of
2
–
9
EPs
Individual
EPs
and
Groups
of
2-­‐9
EPs
Did
EP
or
group
meet
2014
PQRS
incen5ve
criteria

29. PQRS
Par5cipa5on
in
2014
for
Individuals
and
Groups
of
2
–
9
EPs
Individual
EPs
and
Groups
of
2-­‐9
EPs
Did
EP
or
group
meet
2014
PQRS
incen5ve
criteria
All
EPs
earn
0.5%
PQRS
incen5ve
(addi5onal
0.5%
available
for
successful
MOC
par5cipa5on
for
eligible
physicians)
ALSO
avoids
the
PQRS
payment
adjustment
Did
EP
or
group
meet
criteria
to
avoid
2016
PQRS
payment
adjustment?

30. PQRS
Par5cipa5on
in
2014
for
Individuals
and
Groups
of
2
–
9
EPs
Individual
EPs
and
Groups
of
2-­‐9
EPs
Did
EP
or
group
meet
2014
PQRS
incen5ve
criteria
All
EPs
earn
0.5%
PQRS
incen5ve
(addi5onal
0.5%
available
for
successful
MOC
par5cipa5on
for
eligible
physicians)
ALSO
avoids
the
PQRS
payment
adjustment
Did
EP
or
group
meet
criteria
to
avoid
2016
PQRS
payment
adjustment?
You
will
avoid
the
2016
PQRS
payment
adjustment

31. PQRS
Par5cipa5on
in
2014
for
Individuals
and
Groups
of
2
–
9
EPs
Individual
EPs
and
Groups
of
2-­‐9
EPs
Did
EP
or
group
meet
2014
PQRS
incen5ve
criteria
All
EPs
earn
0.5%
PQRS
incen5ve
(addi5onal
0.5%
available
for
successful
MOC
par5cipa5on
for
eligible
physicians)
ALSO
avoids
the
PQRS
payment
adjustment
Did
EP
or
group
meet
criteria
to
avoid
2016
PQRS
payment
adjustment?
You
will
avoid
the
2016
PQRS
payment
adjustment
All
EPs
will
be
subject
to
the
2016
PQRS
payment
adjustment
of
-­‐2.0%

32. PQRS
Par5cipa5on
in
2014
for
Individuals
and
Groups
of
2
–
9
EPs
Individual
EPs
and
Groups
of
2-­‐9
EPs
Did
EP
or
group
meet
2014
PQRS
incen5ve
criteria
All
EPs
earn
0.5%
PQRS
incen5ve
(addi5onal
0.5%
available
for
successful
MOC
par5cipa5on
for
eligible
physicians)
ALSO
avoids
the
PQRS
payment
adjustment
Did
EP
or
group
meet
criteria
to
avoid
2016
PQRS
payment
adjustment?
You
will
avoid
the
2016
PQRS
payment
adjustment
All
EPs
will
be
subject
to
the
2016
PQRS
payment
adjustment
of
-­‐2.0%
EPs
and
Groups
of
2-­‐9
EPs
are
NOT
subject
to
the
VM
in
2016

33. VM
/
PQRS
Par5cipa5on
in
2014
for
Individuals
and
Groups
of
10+
EPs
Groups
of
10+
EPs
Do
you
plan
to
report
PQRS
in
2014?

34. Groups
of
10+
EPs
Do
you
plan
to
report
PQRS
in
2014?
NO
ALL
EPs
in
group
will
be
subject
to
the
2016
PQRS
payment
adjustment
of
-­‐2.0%
All
Physicians
in
group
will
be
subject
to
the
2016
Value
Modifier
downward
adjustment
of
-­‐2.0%

35. Groups
of
10+
EPs
Do
you
plan
to
report
PQRS
in
2014?
NO
ALL
EPs
in
group
will
be
subject
to
the
2016
PQRS
payment
adjustment
of
-­‐2.0%
All
Physicians
in
group
will
be
subject
to
the
2016
Value
Modifier
downward
adjustment
of
-­‐2.0%
Does
the
group
plan
to
report
to
PQRS
as
a
group?
Yes
Yes
All
EPs
earn
0.5%
PQRS
incen5ve
and
avoids
2016
PQRS
payment
adjustment

36. Groups
of
10+
EPs
Do
you
plan
to
report
PQRS
in
2014?
NO
ALL
EPs
in
group
will
be
subject
to
the
2016
PQRS
payment
adjustment
of
-­‐2.0%
All
Physicians
in
group
will
be
subject
to
the
2016
Value
Modifier
downward
adjustment
of
-­‐2.0%
Does
the
group
plan
to
report
to
PQRS
as
a
group?
Yes
Yes
All
EPs
earn
0.5%
PQRS
incen5ve
and
avoids
2016
PQRS
payment
adjustment
No
Does
group
plan
to
meet
criteria
to
avoid
2016
PQRS
payment
adjustment
Yes
Group
will
avoid
the
2016
PQRS
payment
adjustment
No

37. Groups
of
10+
EPs
Do
you
plan
to
report
PQRS
in
2014?
NO
ALL
EPs
in
group
will
be
subject
to
the
2016
PQRS
payment
adjustment
of
-­‐2.0%
All
Physicians
in
group
will
be
subject
to
the
2016
Value
Modifier
downward
adjustment
of
-­‐2.0%
Does
the
group
plan
to
report
to
PQRS
as
a
group?
Yes
Yes
All
EPs
earn
0.5%
PQRS
incen5ve
and
avoids
2016
PQRS
payment
adjustment
No
Does
group
plan
to
meet
criteria
to
avoid
2016
PQRS
payment
adjustment
Yes
Group
will
avoid
the
2016
PQRS
payment
adjustment
No
Physicians
in
Groups
of
10
–
99
EPs:
Subject
to
upward
or
neutral
VM
adjustment
Physicians
in
Groups
of
100+
EPs:
Subject
to
upward,
neutral
or
downward
VM
adjustment

38. • rhonda.yongue@quirkhealthcare.com
Q&A
Chart
from
CMS
website