QRUR and Value Modifier: Medicare Physician Report Card and Pay-for Performance Program AAMC Contact: Mary Wheatley mwheatley@aamc.org 202-862-6297 August 2013

What are Quality Resource Use Reports (QRUR) and Value Modifier? Medicare Report Card (confidential) Quality and cost composite measures Ranked “High”, “Average”, or “Low” for both cost and quality Quality from Physician Quality Reporting System (PQRS) data submission and supplemental claims information Cost data from claims Value-Based Physician Modifier (VM) Medicare Pay-For-Performance Program Use scores from QRUR to adjust payment upward or downward Adjustments start in 2015 for some practices; 2017 for all physicians and physician groups QRUR Report cards, based on 2012 data, expected mid-September 2013 for groups with 25 or more professionals 2

Process to Determine QRUR and VM Inputs Groups decide which PQRS/quality reporting to choose. Automatic penalty for not submitting PQRS data. Non-PQRS Outcome Measures (from claims) PQRS Data Cost Measures (from claims) + Calculation CMS Calculates Quality and Cost Composite Scores Quality Composite Score Cost Composite Score Outputs CMS releases report with benchmark data to groups. Medicare Part B payments adjusted based on scores. Private Feedback Report Pay-for-Performance Quality & Resource Use Reports (QRUR) Payment Adjustment based on scores (Quality Tiering) Gray - Data supplied by physician groups Green – Data supplied by CMS

2015 VM Affects Most Large Group Practices Group with ≥ 100 EPs/TIN in 2013?* NO Excluded from 2015 VM Included in 2017 VM * VM excludes groups participating in Pioneer or MSSP ACOs. YES 2013 Group Reporting or Admin Claims? -1.0% Penalty in 2015 NO YES Optional : Quality Tiering 0.0% Penalty (No Adjustment) in 2015 Upward or Downward adjustment based on Cost and Quality Performance

Groups Must Choose PQRS Reporting Option 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) 5

VM - Quality and Cost Measures 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 Performance reported through Quality Resource Use Report (QRUR) 6

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

Optional Quality Tiering (2015) Quality/Cost Low Cost Average Cost High Cost High Quality 2.0x* 1.0x* 0.0% Average Quality -0.5% Low Quality -1.0% *Cells eligible for high risk bonus 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 8

Timing of the 2015 VM 9 2013 Cost and Quality Performance Period Large groups (excluding ACOs) nominate themselves, submit quality data or choose administrative claims data BY OCTOBER 15 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 9

What do Practices Need to Do? 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)? Download QRUR reports to understand current Cost and Quality scores 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/ 10

Appendix: GPRO Reporting Options for Large Groups Item GPRO Web Registry EHR Administrative Claims Effective Date 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 Assignment of Patients/Beneficiaries CMS assigns using 2-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) Effect on Incentives and Penalties (Incentives require successful reporting) 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 11