1. Physician Value- Based Payment Modifier under the Medicare Physician Fee Schedule
Physician Feedback and Value-Based Modifier Program
American Medical Group Association,
May 13th, 1PM ET

2. Overview of Physician Feedback Program and Value-based Modifier
Presentation Agenda
Overview of Physician Feedback Program and Value-based Modifier
Explain how participation in the Physician Quality Reporting System (PQRS) affects the VM calculation
Describe the VM and PQRS deadlines
Describe policies for calculating and applying the Value Modifier (VM)
Answer questions about the VM policies
1. Share policies finalized in the November 2012 Final PFS Rule- i.e. who the VM will apply to in 2015; methodology
2. Review the timeframe and deadlines for groups of physicians that the VM will be apply to in 2015
3. Explain how participation in PQRS affects a group’s participation in the VM
4. Answer questions/Request submission of comments
5. Summary Overview:
We designed our final VM policies to:
Provide groups of physicians with 100 or more eligible professionals an option that their VM be “0” or be calculated using a tiering approach if they are successful PQRS reporters OR have a -1% payment reduction if not a successful PQRS reporter or did not report
For those electing a tiering approach, focus our payment adjustment (both upward and downward) on those groups of physicians that are outliers; that is on those that are significantly different from the national mean
Align the VM with PQRS and utilize Medicare claims data to reduce administrative burden on groups of physicians.

3. What is the Physician Feedback Program?
The Physician Feedback Program provides physicians with comparative information about the quality and cost of care delivered to their Medicare fee-for-service (FFS) patients, through feedback reports, also known as QRURs.
December 2012 – April 2013
Over 31,000 reports were made available to physician groups of 25+ EPs in nine states (CA, IA, IL, KS, MI, MO, MN, NE and WI) based on 2011 data
54 groups of physicians that reported measures via the PQRS GPRO web interface during 2011
September 2013 – February 2014
Reports for groups nationally of 25+ EPs based on 2012 data
Previews quality and cost performance on measures used to compute the VM
ACA required Medicare to establish a value-based payment modifier that based on the quality of care furnished compared to cost.
Statute requires the phase in to begin in 2015 and be completed by 2017.
Applying the VM to all groups of physicians with 100 or more eligible professionals will is a reasonable way to phase in the VM. This is a change from our proposal which applied the VM to groups of 25+ EPs.
The VM will be applied to the Medicare paid amounts for the items and services under the Physician Fee Schedule. In doing so, beneficiary cost sharing or co insurance is not affected.
The VM will be applied to MDs/DOs payments only in 2015.
CMS finalized 2013 as the initial performance period in the 2012 PFS final rule. In this final rule, we finalized CY 2014 as the performance period to be applied in 2016.
This will give CMS time after the close of the performance period to allow groups of physicians to: submit quality data, calculate the Value Modifier, and inform groups of eligible providers what their Value Modifier will be for 2015.
We need a full 12 months of data to ensure its reliability.

4. What is the Value-Based Modifier?
VM assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule
Begin phase-in of VM in 2015, phase-in complete by 2017
For 2015, apply VM to physician payment in groups of 100+ eligible professionals (EPs)
Performance period for 2015 VM is calendar year 2013
CMS will use future QRURs to provide physician groups with the information about how the VM affects their payment
ACA required Medicare to establish a value-based payment modifier that based on the quality of care furnished compared to cost.
Statute requires the phase in to begin in 2015 and be completed by 2017.
Applying the VM to all groups of physicians with 100 or more eligible professionals will is a reasonable way to phase in the VM. This is a change from our proposal which applied the VM to groups of 25+ EPs.
The VM will be applied to the Medicare paid amounts for the items and services under the Physician Fee Schedule. In doing so, beneficiary cost sharing or co insurance is not affected.
The VM will be applied to MDs/DOs payments only in 2015.
CMS finalized 2013 as the initial performance period in the 2012 PFS final rule. In this final rule, we finalized CY 2014 as the performance period to be applied in 2016.
This will give CMS time after the close of the performance period to allow groups of physicians to: submit quality data, calculate the Value Modifier, and inform groups of eligible providers what their Value Modifier will be for 2015.
We need a full 12 months of data to ensure its reliability.

5. Defining a Group and Determining its Size
Definition of a group of physicians
A single Tax Identification Number (TIN)
Determination of group size
Step 1: Query Medicare’s Provider Enrollment, Chain and Ownership System (PECOS) to identify groups of physicians with 100+ EPs as of October 15, 2013
Step 2: Remove groups from the October 15, 2013 list if the groups did not have 100+ EPs that billed under the group’s TIN during 2013.
We will NOT add groups to the October 15 list
A group is a single TIN
Determine group size through a two-step process
Step 1: The October 15 PECOS-generated list includes the potential groups that could be subject to the VM. Groups can look at their enrollment data in PECOS to determine their size and we encourage them to do so. We also encourage groups to ensure their PECOS enrollment data is up to date.
Step 2: To ensure the group actually had 100+ EPs during 2013, Medicare will analyze claims for services furnished during calendar year 2013 through at least February 28, 2014 and we will remove a group from the October 15 list that did not have 100+ EPs that billed under the group’s TIN during 2013.

6. Who is an Eligible Professional (EP)?
Physicians
MD, Doctor of Osteopathy, Doctor of Podiatric Medicine, Doctor of Optometry, Doctor of Dental Surgery, Doctor of Dental Medicine, Doctor of Chiropractic
Practitioners
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Certified Nurse Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional, Audiologists
Therapists
Physical Therapist, Occupational Therapist, Qualified Speech-Language Therapist

7. The Value Modifier Will Not Apply to:
Physicians who are NOT paid under the Medicare Physician Fee Schedule:
Rural Health Clinics
Federally Qualified Health Centers
Critical Access Hospitals (for physicians electing method II billing)
For 2015 and 2016, to groups of physicians participating in:
Medicare Shared Savings Program ACOs
Pioneer ACO model
Comprehensive Primary Care Initiative
The VM does not apply to services that physicians furnish in Rural health Clinics, Federally qualified health centers, and Critical Access Hospitals (CAHs) billing under method 2 because they are not considered as being paid under the PFS.
The VM does not apply to: Physicians in Accountable Care Organizations (ACO) that participate in the Medicare Shared Savings Plan, Pioneer ACOs.
Note: For ACOs, Medicare will not apply the VM to the ACO TIN (the parent) as well to the ACO Participant TINS (e.g., the children if it is collaboration of many physician TINs).

8. Value Modifier and the Physician Quality Reporting System (PQRS)
For 2015 Groups of physicians with ≥ 100 eligible professionals
PQRS Reporters
(Groups self-nominating for GPRO web-interface, registries, or administrative claims)
Non PQRS Reporters (groups not self-nominating to participate in the PQRS GPRO and not reporting at least one measure)
Elect Quality Tiering calculation
No Election
Upward, no, or downward adjustment based on quality tiering
0.0%
(no adjustment)
-1.0%
(downward adjustment)
Reporting is a necessary first step towards improving quality.

9. Timeline for VM that Applies to Payment Starting January 1, 2015
December 1, January 31
Self-nominate for PQRS GPRO and ERx GPRO
July 15 – October 15
Self-nominate for PQRS GPRO; elect quality-tiering approach to the VM
January 1
VM applied to physicians in groups of > 100 EPs
1st Quarter
Complete submission of 2013 information for PQRS
2013
2014
2015
September 16
Retrieve 2012 Physician Feedback report
3rd Quarter
Retrieve 2013 Physician Feedback report
2013 Starting Dec 1, 2012 – January 31, 2013, groups can self-nominate for PQRS GPRO reporting mechanism (web interface and registries, but not administrative claims). Also can self-nominate for E-prescribing GPRO.
July – October 15: Self-nominate* to participate as a group in the PQRS by selecting reporting mechanism (Administrative Claims option is only available during this period); decide whether to elect quality-tiering approach to the VM.
* Only an authorized member of the group needs to self-nominate the group.
Mid-September: Retrieve Physician Feedback report that shows 2012 performance and how the VM would apply based on 2012 data.
2014
First Quarter: Complete submission of 2013 information for PQRS .
Third Quarter: Retrieve Physician Feedback report showing 2013 performance and how VM applies starting 1/1/2015.
Informal review process available until 2/28/2015.
2015
January 1: VM applies to payment for items and services provided by physicians in groups of 100 or more eligible professionals.

10. Reporting Quality Data at the Group Level
Groups with 100+ EPs MUST select one of the following PQRS quality reporting mechanisms to avoid the -1.0% VM adjustment.
PQRS Reporting Mechanism
Type of Measure
1. GPRO Web interface
Measures focus on preventive care and care for chronic diseases (aligns with the Shared Savings Program)
2. GPRO using CMS-qualified registries
Groups select the quality measures that they will report through a PQRS-qualified registry.
3. Administrative Claims Option for 2013
Measures focus on preventive care and care for chronic diseases (calculated by CMS from administrative claims data)
Why Report PQRS Quality Data
The group has to choose one method.
PQRS GPRO using the web-interface
Quality measures that focus on preventive care and care for prevalent and costly chronic diseases in the Medicare population
PQRS GPRO using registries
Quality measures of their own selection that they report through PQRS qualified registries
PQRS Administrative Claims Option [For 2013 only]
Quality measures that focus on preventive care and care for chronic diseases calculated from administrative claims data. N

11. What Cost Measures will be used for Quality-Tiering?
Total per capita costs measures (Parts A & B)
Total per capita costs for beneficiaries with four chronic conditions:
Chronic Obstructive Pulmonary Disease (COPD)
Heart Failure
Coronary Artery Disease
Diabetes
All cost measures are payment standardized and risk adjusted
Total per capita costs include all payments under Medicare Parts A and B (excludes Part D and Hospice costs).
Total per capita costs are risk adjusted for patient demographics, prior health conditions, Medicaid eligibility status, reason for Medicare eligibility, and ESRD status.
Payments are price standardized.
To ensure fair cost comparisons, the payment standardization methodology:
Eliminates :
Medicare geographic adjustments such as:
Geographic practice cost index (GPCI)
Hospital wage index
Medicare disproportionate share (DSH) payments
Supplemental payments to hospitals that treat a high share of poor and uninsured patients.
Indirect graduate medical payments ( IME)
Supplemental payments to hospitals that receive Indirect graduate medical payments
Incremental payments for community hospitals and Medicare-dependent hospitals above their base payment.
Certain rural add on payments for inpatient psychiatric hospitals and inpatient rehab facilities.
Incentive payments for physicians who furnish care in Health Professional Shortage Areas (HPSAs)
Substitutes a national amount when services are paid using a state fee schedule.

12. Quality-Tiering Methodology
Use domains to combine each quality measure into a quality composite and each cost measure into a cost composite
Once we have data, we will construct a quality and cost composite by classifying measures into the following domains
Quality Composite
The quality measures used in the VM (PQRS and administrative claims measures) are classified into one of the National Quality Domains (Clinical Care, Patient Experience, Patient Safety, Care Coordination, Efficiency).
Each quality measure within each domain is weighted equally.
Each domain is weighted equally to form a quality composite.
If there is no measures in a domain, the remaining domains are equally weighted.
Cost Composite
The five cost measures are grouped into two domains:
total overall costs ( total per capita measure)
total costs for beneficiaries with specific conditions ( total per capita costs for beneficiaries with COPD, CAD, DM and HF).
Each measure within each domain is weighted equally.
Each domain is weighted equally to form a cost composite.

13. Quality Tiering Approach
Each group receives two composite scores (quality of care; cost of care), based on the group’s standardized performance (e.g. how far away from the national mean).
This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers.
Quality/cost
Low cost
Average cost
High cost
High quality
+2.0x*
+1.0x*
+0.0%
Medium quality
-0.5%
Low quality
-1.0%
Once we have data, we will construct a quality and cost composite by classifying measures into the following domains
Quality Composite
The quality measures used in the VM (PQRS and administrative claims measures) are classified into one of the National Quality Domains (Clinical Care, Patient Experience, Patient Safety, Care Coordination, Efficiency).
Each quality measure within each domain is weighted equally.
Each domain is weighted equally to form a quality composite.
If there is no measures in a domain, the remaining domains are equally weighted.
Cost Composite
The five cost measures are grouped into two domains:
total overall costs ( total per capita measure)
total costs for beneficiaries with specific conditions ( total per capita costs for beneficiaries with COPD, CAD, DM and HF).
Each measure within each domain is weighted equally.
Each domain is weighted equally to form a cost composite.
*Eligible for an additional +1.0x if reporting clinical data for quality measures and average beneficiary risk score in the top 25 percent of all beneficiary risk scores. In 2013, all groups of 25 or more eligible professionals will receive a 2012 QRUR with their tier assignment based on 2012 data.

14. Actions for Groups of 100+ Eligible Professionals for the 2015 VM
1. Participate as a GROUP in PQRS in 2013
Self nominate as a group during the period of July 15 - October 15, 2013
Select a PQRS GPRO reporting mechanism
Web interface
CMS-qualified registry
Administrative claims
Note: Groups whose physicians participate as individuals in PQRS must self nominate as a group and elect administrative claims for the VM
Decide whether to elect the quality tiering approach to calculate the VM by October 15,
Register online for PQRS GPRO

15. Actions for Groups of 100+ Eligible Professionals for the 2015 VM
Online Registration for PQRS GPRO (a two step process)
One member of each group must obtain/modify user access to register on behalf of the group.
Obtain user access starting June 3,2013 at
Once user access is received, the group member can access the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System to register the group from July 15, 2013 to October 15, 2013 at:
We would like to co-host a webinar with AMGA during July or August:
To review the steps to obtain an Individuals Authorized Access to CMS Computer Systems (IACS) account
To register via the PV-PQRS Registration System

16. Does CMS have Your Current Information?*
Information for the VM and Physician Feedback reports comes from the Provider Enrollment, Chain and Ownership System (PECOS)
Your medical specialty
The state in which you practice
The location of your practice
Group practice affiliations
How to contact you
Please update your information at:
PECOS is Medicare’s primary source of information for physician, healthcare professional and group practice information such as specialty, group practice affiliation, contact information, and location(s). It is critical that individual physicians routinely check PECOS to update their own personal and professional information, authorized representatives for organizations and group practices also need to make sure information is correct. Contact information is just one example of vital information that becomes obsolete quickly. keep your organization’s information in PECOS up to date and accurate.  Please go there now to ensure your information is current:

17. THANK YOU!
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