1. The Value Modifier and Quality Resource Use Report (QRUR) The Medicare Report Card is Here for Physicians
Christopher Rawlings, CPA, CMA, CHFP, MBA
Associate Administrator
CAMC Physicians Group

2. Report quality information
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
CMS
Eligible Professionals (EPs)
Payment Adjustments

3. 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

4. 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.

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

6. 2015 Incentive Payments and 2017 Payment Adjustments
PQRS
VALUE MODIFIER
EHR Incentive
Program
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 of
10+ EPs: -9.0%
Payment adj.
-2.0% of MPFS
2-9 EPs & solo
10+ EPs
Medi-
care
Inc.
Caid
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)
-3.0% of MPFS
PQRS
REPORTING
NON-
(Up or
Neutral Adj)
PQRS-REPORTING (Down Adj)
+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
*The above payment adjustments and incentives apply to MDs, DOs, DDM, Oral Surgery, Podiatry, Ophthalmology, and Chiropractic.

7. 2015 Incentive Payments and 2017 Payment Adjustments
PQRS
Pay Adj.
VALUE MODIFIER
Groups of 2+ EPs
EHR INCENTIVE PROGRAM
Total
Adjust-ments
Medicare
Incentive
Medicaid
Pay Adj.
Practitioner
-2.0% of MPFS
Physician Assistant
Nurse Practitioner
Certified Nurse Midwife
Certified Registered Nurse Anesthetist
Clinical Nurse Specialist
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologists
**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
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
Therapists
Physical therapist
Occupational Therapist
Qualified Speech-Language Therapist
-2.0% of MPFS
See above
N/A
N/A
N/A
-2.0% of MPFS

8. Physician Fee Schedule

10. TWO M & M’S What Method will you use to report?
What Measures will you report?
Claims
CMS Qualified Registry
EHR/DSV
QCDR
GPRO-Web Interface – EHR and Registry
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.
QCDR is a CMS-approved entity (such as a registry, certification board, collaborative, etc.) that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. It is not limited to PQRS measures, can submit CAHPS, NQF, PQRS, boards or specialty societies, or measures used in regional quality collaborations. QCDRs report across payers, not just Medicare. Still report 9 measures over 3 domains for 50% of pt’s. Also must report 2 outcome measures and if the QCDR does not have 2, then the QCDR must possess at least 1 outcome measure and 1 of the following other type of measure: 1 resource use, OR patient experience of care, OR efficiency appropriate use, OR patient safety measure.

11. Participation Statistics

12. 2015 Reporting Methods SUMMARY TABLE Method Individual EPs Groups
Claims X
Registry-Individual Measures
Registry-Measure Groups
Certified EHR-Direct
Certified EHR-Data Submission Vendor
Qualified Clinical Data Registry
GPRO Web Interface
25+ EPs
Certified CAHPS for PQRS Survey Vendor-*This is done in combination with other reporting methods.
100+ required
2-99 Optional

13. 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)

14. The Medicare Report Card
QRUR
The Medicare Report Card

15. How to obtain your Mid-Year QRUR
The 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.
**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.

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

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

18. Sample QRUR Summary report

19. OU Physician’s QRUR Based on 7,101 Patients

20. (sample QRUR from OU)

21. Attributed Beneficiaries (sample QRUR from OU)

22. Attribution of Patients
A Two Step Process
Patients are assigned to the group practice that provided the plurality of primary care services* rendered by primary care physicians.†
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.

24. Value Based Modifier CY 2017 (based on 2015 performance)

25. QRUR Six Cost Measures: Quality Outcome Measures:
1. Per Capita Costs for All Attributed Beneficiaries
2. 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 Failure
6. Medicare Spending per Beneficiary (MSPB).
Quality Outcome Measures:
1. All Cause Readmission
2. Composite of Acute Prevention Quality Indicators (bacterial pneumonia, urinary tract infection, dehydration)
3. Composite of Chronic Prevention Quality Indicators (COPD, heart failure, diabetes)

27. Cost Measures Calculation

28. (sample QRUR from OU)
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.

29. Quality Composite Calculation

30. Quality Outcome Measures

31. What’s Next? H.R. 2

32. PHYSICIAN COMPARE