Overview of the 2017 Value-Based Payment Modifier

Overview of the 2017 Value-Based Payment Modifier

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• The VM assesses both the quality of care furnished and the cost of that care during a performance period.

• The VM is an adjustment made on a per-claim basis to Medicare payments for items and services furnished under the Medicare Physician Fee Schedule (PFS).– High quality and/or low cost groups and solo practitioners can qualify for

upward adjustments– Low quality and/or high cost groups and solo practitioners, including

those that fail to satisfactorily report under the Physician Quality Reporting System (PQRS) are subject to downward adjustments

• The VM is applied at the Taxpayer Identification Number (TIN) level and applies to all physician groups and physicians (and beginning in 2018, to all non-physician eligible professionals (EPs)) billing under the TIN.

What is the Value-Based Payment Modifier (VM)?

What is the Value-Based Payment Modifier (VM)?

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The following table outlines how and when the VM will be applied:

What is the VM? (cont.)What is the VM? (cont.)

Performance Period

VM Payment Adjustment Period

VM Applied To

2013 2015 Physicians in groups with 100 or more EPs

2014 2016 Physicians in groups with 10 or more EPs

2015 2017 Physician solo practitioners and physicians in groups with 2 or more EPs; VM for physicians participating in the Medicare Shared Savings Program will be based on the ACO’s quality data and average cost; VM for physicians participating in the Pioneer ACO Model, Comprehensive Primary Care Initiative, or other similar Innovation Center models or CMS initiatives will be set to average quality and average cost

To be finalized in future rulemaking

2018 Physicians AND non-physician EPs who are solo practitioners or in groups with 2 or more EPs

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• PhysicianDoctor of Medicine, Doctor of Osteopathy, Doctor of Podiatric Medicine, Doctor of Optometry, Doctor of Dental Surgery, Doctor of Dental Medicine, and Doctor of Chiropractic

• PractitionerPhysician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant), Certified Nurse Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional, and Audiologist

• TherapistPhysical Therapist, Occupational Therapist, and Qualified Speech-Language Therapist

What is an Eligible Professional (EP)?What is an Eligible Professional (EP)?

2017 VM and the 2015 PQRS2017 VM and the 2015 PQRS

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CY 2017 VM payment adjustment, for physicians in groups with 2+ EPs and physician solo practitioners

PQRS Reporters – 3 types1a. Group reporters : Register for a PQRS GPRO (Web Interface, registry, or EHR) AND meet the criteria to avoid the 2017 PQRS payment adjustment OR1b.Individual reporters in the group: at least 50% of EPs in the group report PQRS measures as individuals AND meet the criteria to avoid the 2017 PQRS payment adjustment2. Solo practitioners: Report PQRS measures as individuals AND meet the criteria to avoid the 2017 PQRS payment adjustment

Non-PQRS Reporters1. Groups: Do not avoid the 2017 PQRS payment adjustment as a group OR do not meet the 50% threshold option as individuals2. Solo practitioners: Do not avoid the 2017 PQRS payment adjustment as individuals

Mandatory Quality-Tiering Calculation

Physicians in groups with 2-9 EPs and physician solo

practitioners

Physician in groups with 10+ EPs

Upward or no VM adjustment based on

quality-tiering(+0.0% to +2.0x )

Upward, no, or downward VM adjustment based on

quality-tiering(-4.0% to +4.0x)

-2.0% (for physicians in groups with 2-9 EPs and physician solo practitioners)

-4.0% (for physicians in groups with 10+ EPs)

(Automatic VM downward adjustment)

Note: The VM payment adjustment is separate from the PQRS payment adjustment and payment adjustments from other Medicare sponsored programs.

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2016 VM and the 2014 PQRS2016 VM and the 2014 PQRS

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CY 2016 VM payment adjustment, for physicians in groups with 10+ EPs

PQRS Reporters – 2 types1a. Group reporters: Register for a PQRS GPRO (Web Interface, registry, or EHR) AND meet the criteria to avoid the 2016 PQRS payment adjustment

OR1b. Individual reporters in the group: at least 50% of EPs in the group report PQRS measures as individuals AND meet the criteria to avoid the 2016 PQRS payment adjustment

Non-PQRS ReportersGroups do not avoid the 2016 payment adjustment as a group OR do not meet the 50% threshold option as individuals

Mandatory Quality-Tiering

Calculation

Physicians in groups with 10-99 EPs

Physicians in groups with 100+ EPs

Upward or no VM adjustment based on quality-tiering

(+0.0% to +2.0x )

Upward, no, or downward VM adjustment based on

quality-tiering(-2.0% to +2.0x )

-2.0% (Automatic VM downward

adjustment)

Note: The VM payment adjustment is separate from the PQRS payment adjustment and payment adjustments from other Medicare sponsored programs.

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2015 VM and the 2013 PQRS 2015 VM and the 2013 PQRS

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CY 2015 VM payment adjustment, for physicians in groups with 100+ EPs

PQRS Reporters Groups register for PQRS GPRO Web Interface or registry AND report at least one measure OR elect the CMS-calculated administrative claims option

Non-PQRS ReportersGroups do not register for a PQRS GPRO OR do not report at least one measure via the Web Interface or a registry

Upward, no, or downward VM adjustment based on

quality-tiering(-1.0% to +2.0x )

0.0%(No VM adjustment)

-1.0% (Automatic VM downward

adjustment)

Note: The VM payment adjustment is separate from the PQRS payment adjustment and payment adjustments from other Medicare sponsored programs.

No Election Elect Quality-Tiering

Calculation

• Quality Measures:– Groups with 2 or more EPs: Measures reported through the PQRS Group Practice

Reporting Option (GPRO) selected by the group OR individual PQRS measures reported by at least 50% of the EPs in the group (50% threshold option)

– Solo practitioners: Individual PQRS measures reported by the solo practitioner – Three claims-based outcome measures: All-Cause Readmission, Composite of

Preventable Hospitalizations for Acute Conditions, and Composite of Preventable Hospitalizations for Chronic Conditions

– CAHPS for PQRS survey measures (Applicable only for groups that elect to use their 2015 CAHPS results in the calculation of their 2017 VM)

• Cost Measures:– Total per capita costs measure (Parts A & B)– Total per capita costs for beneficiaries with 4 chronic conditions (COPD, HF, CAD, and

DM) – Medicare Spending Per Beneficiary measure (3 days before and 30 days after an

inpatient hospitalization): Attributed to the group or solo practitioner providing the plurality of Part B services during the hospitalization

– All cost measures are payment-standardized, risk-adjusted, and adjusted for the specialty mix of the EPs in the group

What Measures will be Used to Calculate the 2017 VM?

What Measures will be Used to Calculate the 2017 VM?

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VM Calculation VM Calculation

• Use domains equally weighted to combine each quality measure’s standardized score into a quality composite and each cost measure’s standardized score into a cost composite.

• Each composite is classified into “high”, “average”, or “low” based on whether the score is one standard deviation higher or lower than the benchmark and is statistically significantly different from the benchmark.

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• An automatic -2.0% VM downward adjustment will be applied for not meeting the satisfactory reporting criteria to avoid the 2017 PQRS payment adjustment.

• Under quality-tiering, the maximum upward adjustment is up to +2.0x (‘x’ represents the upward VM payment adjustment factor).

• Groups with 2-9 EPs and physician solo practitioners are held harmless from any downward adjustments under quality-tiering in 2017.

2017 VM Policies for Groups with 2-9 EPs and Solo Practitioners

2017 VM Policies for Groups with 2-9 EPs and Solo Practitioners

* Eligible for an additional +1.0x if reporting PQRS quality measures and average beneficiary risk score in the top 25 percent of all beneficiary risk scores

CY 2017 VM AmountsCost/Quality Low Quality Average Quality High Quality

Low Cost +0.0% +1.0x* +2.0x*

Average Cost +0.0% +0.0% +1.0x*

High Cost +0.0% +0.0% +0.0%

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• An automatic -4.0% VM downward adjustment will be applied for not meeting the satisfactory reporting criteria to avoid the 2017 PQRS payment adjustment.

• Under quality-tiering, the maximum upward adjustment is up to +4.0x (‘x’ represents the upward VM payment adjustment factor), and the maximum downward adjustment is -4.0%.

2017 VM Policies for Groups with 10+ EPs2017 VM Policies for Groups with 10+ EPs

CY 2017 VM AmountsCost/Quality Low Quality Average Quality High Quality

Low Cost +0.0% +2.0x* +4.0x*

Average Cost -2.0% +0.0% +2.0x*

High Cost -4.0% -2.0% +0.0%

* Eligible for an additional +1.0x if reporting PQRS quality measures and average beneficiary risk score in the top 25 percent of all beneficiary risk scores

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• Decide whether and how to participate in the PQRS in 2015– Group reporting - Register for the 2015 PQRS GPRO between

April 1, 2015 and June 30, 2014 • http://

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html

– Individual reporting – No registration necessary • Decide which PQRS measures to report and understand the measure

specifications– http://

www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip

• Review quality measure benchmarks under the VM – http://

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

• Download your 2013 Quality and Resource Use Report (QRUR) now, 2014 Mid-Year QRUR (April 2015), and 2014 QRUR (Late Summer 2015) at: https://portal.cms.gov

– http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html

Actions for Groups with 2+ EPs and Solo Practitioner in 2015 for the 2017 VM

Actions for Groups with 2+ EPs and Solo Practitioner in 2015 for the 2017 VM

Timeline for Phasing In the VM Timeline for Phasing In the VM

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January 1VM applied to physicians in groups of > 100 EPs

1st QuarterComplete submission of 2014 information for PQRS

January 1VM applied to physicians in groups of > 10 EPs

2014 PQRS GPRO

Registration Period

4/1/2014 - 10/3/14

2015 PQRS GPRO

Registration Period

4/1/15 - 6/30/15

September 30, 2014Retrieve 2013 QRUR that includes 2015 VM adjustment information (All physician groups and physician solo practitoners)

Late Summer 2015Retrieve 2014 QRUR that includes 2016 VM adjustment information(All groups and solo practitioners)

2014 20182017

January 1VM applied to physician solo practitioners and physicians in groups of > 2 EPs

2016 PQRS GPRO

Registration Period

Spring - 6/30/16

Late Summer 2016Retrieve 2015 QRUR that includes 2017 VM adjustment information(All groups and solo practitoners)

2017 PQRS GPRO

Registration Period

Spring - 6/30/17

20162015

January 1VM applied to physician & non-physician EPs in groups of > 2 EPs and physician & non-physician EP solo practitioners

Late Summer 2017Retrieve 2016 QRUR that includes 2018 VM adjustment information(All groups and solo practitoners)

2018 PQRS GPRO

Registration Period

Spring - 6/30/18

Late Summer 2018 Retrieve 2017 QRUR that includes 2019 VM adjustment information (All groups and solo practitoners)

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• For VM and QRUR questions, contact the Physician Value Help Desk:

o Phone: 1(888) 734-6433 (select option 3)o Monday – Friday: 8:00 am – 8:00 pm EST

• For PQRS and IACS questions, contact the QualityNet Help Desk:

o Phone: (866) 288-8912 (TTY 1-877-715-6222)o Monday – Friday: 8:00 am – 8:00 pm ESTo Email: qnetsupport@hcqis.org

• VM and QRUR: http://www.cms.gov/PhysicianFeedbackProgram

• PQRS Program: http://www.cms.gov/PQRS

• PQRS Payment Adjustment: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html

• PQRS GPRO: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html

Technical Assistance InformationTechnical Assistance Information

AppendixAppendix

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Appendix A: VM Policies for 2015, 2016, and 2017

Appendix A: VM Policies for 2015, 2016, and 2017

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Value Modifier

Components

2015Finalized Policies

2016 Finalized Policies

2017 Finalized Policies

Performance Year 2013 2014 2015

Group Size 100+ EPs 10+ EPs 2+ EPs and solo practitioners

Quality-Tiering Optional: Groups with 100+ EPs that elect quality-tiering can receive upward, neutral, or downward VM adjustment.

Mandatory: Groups with 10-99 EPs receive only the upward or neutral VM adjustment (no downward adjustment).

Groups with 100+ EPs can receive upward, neutral, or downward VM adjustment.

Mandatory: Groups with 2-9 EPs and solo practitioners receive only the upward or neutral VM adjustment (no downward adjustment).

Groups with 10+ EPs can receive upward, neutral, or downward VM adjustment.

Peer Group for Categorizing Quality and Cost Composites

Groups with 100+ EPs Groups with 10+ EPs Groups with 2+ EPs and solo practitioners

Available Quality Reporting Mechanisms

GPRO Web Interface, Qualified PQRS Registry, CMS-calculated Administrative Claims

GPRO Web Interface, Qualified PQRS Registry, EHR, or 50% of EPs report under the PQRS as individuals

Same as 2016

Appendix A: VM Policies for 2015, 2016, and 2017 (cont.)

Appendix A: VM Policies for 2015, 2016, and 2017 (cont.)

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Value ModifierComponents

2015Finalized Policies

2016 Finalized Policies

2017 Finalized Policies

Outcome Measures

NOTE: Performance on the outcome measures and measures reported through one of the PQRS reporting mechanisms will be used to calculate a quality composite score for the TIN for the VM.

• All Cause Readmission

• Composite of Acute Prevention Quality Indicators: (bacterial pneumonia, urinary tract infection, dehydration)

• Composite of Chronic Prevention Quality Indicators: (chronic obstructive pulmonary disease (COPD), heart failure, diabetes)

Same as 2015 Same as 2015

Patient Experience of Care Measures

N/A CAHPS for PQRS: Optional for groups with 25+ EPs; Required for groups with 100+ EPs reporting via Web Interface.

Groups may elect to include their 2014 CAHPS results in the calculation of the 2016 VM.

CAHPS for PQRS: Optional for groups with 2-99 EPs; Required for all groups with 100+ EPs.

Groups may elect to include their 2015 CAHPS results in the calculation of the 2017 VM.

Appendix A: VM Policies for 2015, 2016, and 2017 (cont.)

Appendix A: VM Policies for 2015, 2016, and 2017 (cont.)

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Value ModifierComponents

2015Finalized Policies

2016 Finalized Policies

2017 Finalized Policies

Cost Measures • Total per capita costs measure (annual payment standardized and risk-adjusted Part A and Part B costs)

• Total per capita costs for beneficiaries with four chronic conditions: COPD, Heart Failure, Coronary Artery Disease, Diabetes

• Same as 2015, and• Medicare Spending Per

Beneficiary measure (includes Part A and B costs during the 3 days before, through 30 days after discharge following an inpatient hospitalization)

Same as 2016

Benchmarks • Cost: 100+ EP TINs are compared against groups of 100+ EPs

• Quality: No differentiation by group size (“compared to everyone”)

No differentiation by group size (“compared to everyone”) for both cost and quality measures

No differentiation by group size (“compared to everyone”) for both cost and quality measures

Maximum Payment at Risk

-1.0% -2.0% -2.0% (Groups with 2-9 EPs and solo practitioners)-4.0% (Groups with 10+ EPs)

Application of the VM to Participants of the Shared Savings Program, Pioneer ACO Model, and the CPC Initiative

Not Applicable Not Applicable Shared Savings Program: VM based on the ACO’s quality data and average cost; Pioneer ACO Model and the CPC Initiative: average quality/average cost

Appendix A: VM Policies for 2015, 2016, & 2017 (cont.)

Appendix A: VM Policies for 2015, 2016, & 2017 (cont.)

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Value Modifier

Components

2015Current Policy

2015 Finalized Policy

2016, 2017 Finalized Policy

VM Informal Review Process:

Timeline

Not specified. After the dissemination of the annual Physician Feedback reports, a group of physicians may contact CMS to inquire about its report and the calculation of the value-based payment modifier.

• Deadline of February 28, 2015 for a group to request correction of a perceived error made by CMS in the 2015 VM payment adjustment.

Establish a 60 day period that would start after the release of the QRURs for the applicable reporting period for a group or solo practitioner (as applicable) to request correction of a perceived error made by CMS in the determination of the group or solo practitioner’s VM for that payment adjustment period.

VM Informal Review Process:

If CMS made an error

Not specified • Classify a TIN as “average quality” in the event we determine that we have made an error in the calculation of quality composite.

• Recompute a TIN’s cost composite if CMS made an error in its calculation.

• Adjust a TIN’s quality tier.

• Recompute a TIN’s quality composite in the event we determine that we have made an error in the calculation of quality composite.

• Otherwise, the same as 2015.