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Thomas Walke, PhD
Marjorie Kanof, MD
Health Policy Alternatives, Inc.
How Medicare Data Impacts Your
Practice
November 6, 2015
Questions for Today
• What information is out there that can be useful to examining Medicare payment issues related to the podiatry specialty?
• What information is available on podiatrists that provide services to Medicare beneficiaries?
• What are some of the initial data needs with respect to alternative payment models?
2
Public Use Data Files on Medicare Physician
Payment, Utilization, and Quality
• Data from the Physician Fee Schedule (PFS) Proposed and Final Rules
• Data from the PFS Contractor Files
• Medicare Physician Data File: Medicare Provider Utilization and Payment Data: Physicians and Other Supplier Public Use File
• Physician Compare Data
3
DATA FROM THE PROPOSED
AND FINAL PFS RULES
4
PFS Proposed and Final Rule: Key Data Files
• Addendum B Relative Value Units
• CY 2014 Utilization Data – Specialty, HCPCs, Modifier, Facility, Allowed Charges,
Services (discounted, undiscounted)
• Practice Expense (PE) Input Files – Direct PE input data
– Indirect Practice Cost Indices
– Physician Time
• Other assorted files – Codes subject to various PFS adjustments (e.g., Multiple
Procedure Payment Reduction)
– HCPCS Defined as Misvalued for Target
5
PFS Proposed and Final Rule Data: Addendum B
Relative Value Units and Related Information
6
PFS Proposed and Final Rule Data:
Medicare Utilization File
• 2014 latest
• Requires analysis
using Excel or
Statistical Software
Allows one to examine
for a specialty:
• the utilization by code
• how usage of code
compares with other
specialties
7
PFS Proposed and Final Rule Data:
Practice Expense Input Files
8
Example for 11721 (Debride nail 6 or more)
DATA FROM THE PFS
CONTRACTOR FILES
9
PFS Contractor Files: Summary
• Medicare rate calculation files that CMS provides to contractors for use in processing claims
• Relative Value File (updated quarterly)
– RVUs for more than 10,000 physician services
– Fee schedule status indicator
– Payment adjustment indicators
• Geographic Practice Cost Indices file
– Details GPCIs for 89 total PFS localities used to adjust payments based on geographic area.
10
PFS Contractor File: National RVU File
11
Application of PFS Data: Medicare
Snapshot of Podiatry Specialty, 2016
HCPCS Description
2014
Volume of
Services
(millions)
Estimated 2016
Total Medicare
Allowed
Charges, All
Settings
(millions)
% of
Estimated
Total
Medicare
Allowed
Charges
% Change in 2016
Estimated Medicare
Pay Compared with
2015
11721
Debride nail 6 or
more
7.3 $329.3 17% 2.1%
99213
Office/outpatient
visit est
4.3 $316.6 16% 1.0%
99203
Office/outpatient
visit new
1.1 $123.4 6% 0.5%
11056
Trim skin lesions 2
to 4
1.9 $112.9 6% 1.1%
99212
Office/outpatient
visit est
2.2 $95.1 5% 0.5%
11750 Removal of nail bed
0.2 $27.7 1% -30.8%
All other codes
14.4 $980.3 49% 0.8%
Total
31.5 $1,985.34 100.0% 0.4%
Source: HPA analysis of 2016 Medicare Physician Fee Schedule Proposed Rule 12
DATA FROM THE PFS MEDICARE
PHYSICIAN DATA FILE
13
• Referred to “officially” as the Medicare Provider Utilization and Payment Data: Physicians and Other Supplier Public Use File
• First released on April 9, 2014 contains never-before-seen data on Medicare Part B fee-for-service payments to physician and other health care providers in 2012
• What does it include? – Provider information for more than 950,000 providers who
participate in Medicare (e.g., names, credentials, gender, provider type.. )
– Service information by Healthcare Common Procedure Coding System (HCPCS) (e.g., number of services provided, number of Medicare beneficiaries served, and service setting)
– Payment information on $90 billion paid out to Medicare beneficiaries in 2013 (e.g., includes average Medicare payment after deductible and coinsurance)
Medicare Physician Data File: Background
14
Source: http://graphics.wsj.com/medicare-billing/#/name=&special=Podiatry&city=&state=, accessed October 15, 2015.
• Data available in raw
form on the CMS
website
• Other sites, such as
the Wall Street
Journal have search
engines that make it
easier to lookup
particular providers
and drill down for
more detail.
Medicare Physician Data File: Podiatry
Example
15
Medicare Physician Data File: Podiatry
Example (Con’t)
16
Medicare Physician Data File:Podiatry Example
(Con’t)
17
Medicare Physician Data File: Potential Uses
and Concerns
Potential Uses of Physician Data File
• Greater program
transparency
• Source of information for
consumers and providers
• Use of data by state,
commercial payers and
federal audit agencies,
investigative journalists.
Potential Concerns about Use of Data
• Data can be misleading!
Multiple providers are
allowed to bill using the same
NPI (e.g., group practices)
• Does not include data on
services performed on 10 or
fewer beneficiaries
• Extremely large dataset and
difficult to manipulate without
statistical software
18
QUALITY DATA FROM
PHYSICIAN COMPARE
19
Physician Compare: Podiatry
Example
20
Physician Compare: Limited Quality Information
Posted (for now)
Individual EPs have a green check on their profile page:
• Satisfactorily report under PQRS
• Successfully participate in Electronic Prescribing (eRx) Incentive program;
• Participate in EHR Incentive program; or
• Report as part of the 2013 PQRS Cardiovascular Prevention measures group in support of Million Hearts®.
Group Practices have a green check on their profile page:
• Satisfactorily report under the Group Practice Reporting Option (GPRO); or
• Successfully participate in the eRx Incentive program.
21
Physician Compare: Benchmarking and Star
Ratings
• CMS finalized its 2016 proposal to adopt the Achievable Benchmark of Care (ABCTM) methodology
• CMS plans to use the benchmark to “systematically assign stars for the Physician Compare 5-star rating”
• CMS provides additional details in the final rule about how the methodology would work.
22
DATA NEEDS FOR ADVANCED
PAYMENT MODELS
23
Advanced Payment Models: Data
Needs • More granular data – patient-based data
• Broader Perspective (what settings are affected) – All Part A and B Services
– Hospital
– Physician
– LTC
– DME
– Part B Drugs
• Provider Control
24
Part A and Part B Payment for Surgical Procedure
(30 days pre/90 days post-admission)
65%
18%
18%
3%
5% 12%
1%
Admission
Re-admission
Other Physicians
Surgeon
Hospital OPD
Post-Acute Care
DME
Concluding Observations
• Abundance of payment and utilization data available for Medicare policy analysis
• Limited quality data available and posted
• Be aware of information being reported on you from the Physician Data file or on Physician Compare
• Continue to examine the feasibility of advanced payment models/bundling
26
While I can explain the meaning of life, I don’t dare try to
explain how the Medicare system works.
27
Time for your questions?