1. The CMS Value-Based Payment Modifier
What Medicare Eligible Professionals Need to Know in 2014

2. Topics Overview of the Value Modifier
Distinction between Medicare Physicians and Eligible Professionals
Relation to Other Quality Program Incentives and Payment Adjustments
“50 Percent” Threshold Option
Quality and Cost Measures
Quality-Tiering
Accessing Your QRUR Reports

3. Value-Based Payment Modifier

4. What is the Value-Based Payment Modifier (VM)?
Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS)
VM assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule
For CY 2015, CMS will apply the VM to groups of physicians with 100 or more eligible professionals (EPs)
For CY 2016, CMS will apply the VM to groups of physicians with 10 or more EPs
Phase-in to be completed for all physicians by 2017
Implementation of the VM is based on participation in Physician Quality Reporting System

5. Distinction between Medicare Physicians and Eligible Professionals

6. Eligible Professionals
PQRS
Value Modifier
EHR Incentive Program
Eligible for Incentive
Subject to Payment Adjustment
Included in Definition of “Group” (1)
Subject to VM (2)
Eligible for Medicare Incentive
Eligible for Medicaid Incentive
Subject to Medicare Payment Adjustment
Medicare Physicians
Doctor of Medicine X
Doctor of Osteopathy
Doctor of Podiatric Medicine
Doctor of Optometry X 
Doctor of Oral 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. How Is a Group Practice Defined?
The size of a group is determined by how many EPs comprise the group
Definition of Group: A single Tax Identification Number (TIN) with 2 or more individual EPs(as identified by Individual National Provider Identifier [NPI]) who have reassigned their billing rights to the TIN
An EP is defined as any of the following:
A physician
A physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist; a certified registered nurse anesthetist; a certified nurse-midwife; a clinical social worker; a clinical psychologist; or a registered dietitian or nutrition professional
A physical or occupational therapist or a qualified speech-language pathologist
A qualified audiologist

8. VM Will Be Applied to Physician Payment Only
Physicians include:
MDs / DOs
Doctor of dental surgery or dental medicine
Doctor or podiatric medicine
Doctor of optometry
Chiropractor

9. Relation to Other Quality Program Incentives and Payment Adjustments

10. 2014 Incentives and 2016 Payment Adjustments
PQRS
Value Modifier
EHR Incentive Program
Incentive
Pay Adj
10-99 EPs
100+ EPs
Medicare Inc.
Medicaid Inc.
Medicare Pay Adj
PQRS-Reporting
Non-PQRS Reporting
PQRS-Reporting (Up or Neutral Adj)
PQRS-Reporting (Down Adj)
MD & DO
0.5% of MPFS (1.0% with MOC)
-2.0% of MPFS
+2.0 (x), +1.0(x), or neutral
-1.0% or % of MPFS
$4,000-$12,000 (based on when EP 1st demo MU)
$8,500 or $21,250 (based on when EP did A/I/U)
DDM
Oral Sur
Pod.
N/A
Opt.
Chiro.

11. 2014 Incentives and 2016 Payment Adjustments
PQRS
Value Modifier
EHR Incentive Program
Incentive
Pay Adj.
Groups of 10+ EPs
Medicare Inc.
Medicaid Inc.
Medicare Pay Adj.
Practitioners
Physician Assistant
0.5% of MPFS
-2.0% of MPFS
EPs included in the definition of “group” to determine group size for application of the value modifier in 2016 (10 or more EPs); VM only applied to reimbursement of physicians in the group
N/A
$8,500 or $21,250 (based on when EP did A/I/U)
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologits
Therapists
Physical Therapist
See above
Occupational Therapist
Qualified Speech-Language Therapist

12. Value Modifier Policies for 2015 & 2016
Components
2015
Finalized Policies
2016
Performance Year
2013
2014
Group Size
100+
10+
Available Quality Reporting Mechanisms
GPRO-Web Interface, CMS Qualified Registries, Administrative Claims
GPRO-Web Interface (Groups of 25+ EPs), CMS Qualified Registries, EHRs, and 50% of EPs reporting individually
Outcome Measures
NOTE: The performance on the outcome measures and measures reported through the PQRS reporting mechanisms will be used to calculate a quality composite score for the group 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
Patient Experience Care Measures
N/A
PQRS CAHPS: option for groups of 25+ EPs; required for groups of 100+ EPS reporting via Web Interface

13. Value Modifier Policies for 2015 & 2016
Components
2015
Finalized Policies
2016
Cost Measures
Total per capita costs measure (annual payment standardized and risk-adjusted Part A and Part B costs, does not include Part D 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 and 30 days after an inpatient hospitalization)
Benchmarks
Group Comparison
Specialty Adjusted Group Cost
Quality Tiering
Optional
Mandatory
Groups of EPs receive only the upward (or neutral) adjustment, no downward adjustment. Groups of 100+ both the upward and downward adjustment apply (or neutral adjustment).
Payment at Risk
-1.0%
-2.0%

14. Reporting Quality Data at the Group Level
Groups with 10+ EPs may select one of the following PQRS GPRO quality reporting mechanisms and meet the criteria for the CY 2016 PQRS payment adjustment to avoid the 2.0% VM adjustment
PQRS Reporting Mechanism
Type of Measure
1. GPRO Web interface (Groups of 25+ EPs)
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. GPRO using EHR
Quality measures data extracted from a qualified EHR product for a subset of proposed 2014 Physician Quality Reporting System quality measures.

15. “50 Percent” Threshold Option

16. Reporting Quality Data at the Individual Level - 50% Threshold Option
If a group does not seek to report quality measures as a group, CMS will calculate a group quality score if at least 50 percent of the eligible professionals within the group report measures individually.
At least 50% of EPs must successfully avoid the 2016 PQRS payment adjustment
EPs may report on measures available to individual EPs via the following reporting mechanisms:
Claims
CMS Qualified Registries
EHR
Clinical Data Registries (new for CY 2014)

17. How Does CMS Determine Whether a Group of Physicians Has 10 or More EPs?
Two-step process:
CMS will query the Provider Enrollment, Chain, and Ownership System (PECOS) to identify groups of physicians with 10 or more EPs as of October 15, 2014
Generates a list of potential groups that could be subject to the VM
CMS will analyze claims for services furnished during the CY 2014 performance year through at least February 28, 2015
Remove groups from the October 15 PECOS list that did not have 10 or more EPs that billed under the group’s TIN during 2014
Groups will NOT be added to the October 15 PECOS list

18. Quality and Cost Measures

19. What Quality Measures will be Used for Quality Tiering?
Measures reported through the GPRO PQRS reporting mechanism selected by the group OR individual measures reported by at least 50% of the eligible professionals within the group (50% threshold option)
Three outcome measures:
All Cause Readmission
Composite of Acute Prevention Quality Indicators (bacterial pneumonia, urinary tract infection, dehydration)
Composite of Chronic Prevention Quality Indicators (COPD, heart failure, diabetes)
PQRS CAHPS Measures for 2014 (Optional)
Patient Experience of Care measures
For groups of 25 or more eligible professionals
Required for groups of 100+ EPS reporting via Web Interface

20. What Cost Measures will be used for Quality-Tiering?
Total per capita costs measures (Parts A & B)
Total per capita costs for beneficiaries with 4 chronic conditions:
Chronic Obstructive Pulmonary Disease (COPD)
Heart Failure
Coronary Artery Disease
Diabetes
Medicare Spending Per Beneficiary (MSPB) measure (3 days prior and 30 days after an inpatient hospitalization) attributed to the group providing the plurality of Part B services during the hospitalization
All cost measures are payment standardized and risk adjusted.
Each group’s cost measures adjusted for specialty mix of the EPs in the group.

21. Cost Measure Attribution
5 Total Per Capita Cost Measures
Identify all beneficiaries who have had at least one primary care service rendered by a physician in the group.
Followed by a two-step assignment process
assign beneficiaries who have had a plurality of primary care services (allowed charges) rendered by primary care physicians.
for beneficiaries that remain unassigned, assign beneficiaries who have received a plurality of primary care services (allowed charges) rendered by any eligible professional
MSPB measure – attribute the hospitalization to the group of physicians providing the plurality of Part B services during the inpatient hospitalization

22. Quality-Tiering

23. Each group receives two composite scores (quality and cost)
How Does CMS Use the Quality and Cost Measures to Create a Value Modifier Payment Adjustment
Each group receives two composite scores (quality and cost)
CMS uses the following steps to create each composite:
Create a standardized score for each measure (performance rate – benchmark / standard deviation)
Equally weight each measure’s standardized score within each domain.
Equally weight each domain’s score into the composite score.

24. Quality-Tiering Methodology
Use domains to combine each quality measure into a quality composite and each cost measure into a cost composite
Clinical Care
Quality of
Care
Composite
Score
Patient Experience
Population/Community Health
Patient Safety
VALUE
MODIFIER
AMOUNT
Care Coordination
Efficiency
Total per capita costs (plus MSPB)
Cost
Composite
Score
Total per capita costs for beneficiaries with specific conditions

25. Quality-Tiering Approach for 2016 (Based on 2014 PQRS Performance)
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).
Group cost measures are adjusted for specialty composition of the group
This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers.
Low cost
Average cost
High cost
High quality
+2.0x*
+1.0x*
+0.0%
Average quality
-1.0%
Low quality
-2.0%
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.

26. Downward VM Payment Adjustment in 2016
VM for CY 2016 will be applied to Medicare paid amounts to items and services billed under the Physician Fee Schedule at the TIN level
Beneficiary cost-sharing not affected
Applied to the items and services billed by physicians under the TIN, but not to other eligible professionals
If physician changes from TIN (A) in performance year (CY 2014) to TIN (B) in payment adjustment year (CY2016), VM would be applied to TIN (B) for physician’s items and services billed under TIN (B) during CY 2016

27. PQRS Participation in 2014 for Individuals and Groups of 2-9 EPs
Individual EPs and Groups of 2-9 EPs
Did EP or group meet 2014 PQRS incentive criteria? No
Yes
All EPs earn 0.5% PQRS incentive (additional 0.5% available for successful MOC participation for eligible physicians); ALSO avoids 2016 PQRS payment adjustment
Did EP or group meet criteria to avoid 2016 PQRS payment adjustment?
Yes No
You will avoid the 2016 PQRS payment adjustment
All EPs will be subject to the 2016 PQRS payment adjustment of -2.0%
EPs and Groups of 2-9 EPs are not subject to the Value Modifier in 2016 (will be subject in 2017, based on PQRS participation)

28. How Does PQRS Participation Affect the Value Modifier?
Groups 10+ EPs
Yes
Do you plan to report for PQRS in 2014? No
Does the group plan to report PQRS as a group?
Yes No
Does group meet 50% threshold?
Does group plan to meet 2014 PQRS incentive criteria?
Yes No
Yes No
All EPs earn 0.5% PQRS incentive (additional 0.5% available for successful MOC participation for eligible physicians); ALSO avoids 2016 PQRS payment adjustment
At least 50% of Individual EPs in group report satisfactorily and meet the criteria to avoid 2016 PQRS payment adjustment .
All EPs in group will be subject to the 2016 PQRS payment adjustment of -2.0%
All physicians in group will be subject to the 2016 Value Modifier downward adjustment of -2.0%
Does group plan to meet criteria to avoid 2016 PQRS payment adjustment?
Yes No
Group will avoid the 2016 PQRS payment adjustment
Physicians in Groups of EPs: Subject to upward or neutral VM adjustment
Physicians in Groups of 100+ EPs: Subject to upward, neutral or downward VM adjustment

29. Quality and Resource Use Reports (QRURs)

30. Quality and Resource Use Reports (QRURs)
The QRURs are annual reports that provide groups of physicians with:
Comparative information about the quality of care furnished, and the cost of that care, to their Medicare fee-for-service (FFS) patients
Beneficiary-specific information to help coordinate and improve the quality and efficiency of care furnished
Information on how the provider group would fare under the value-based payment modifier (VBM)
2012 QRURs are produced and made available to all groups of physicians with 25 or more eligible professionals (EP)
Late Summer 2014: QRURs for all Groups and Solo Practitioners

31. How Can I Access My Report and Drill-Downs?
1. Navigate to the Portal
Go to
2. Login to the Portal
Select Login to CMS Secure Portal
Accept the Terms and Conditions and enter your IACS User ID and Password to login.
3. Enter the Portal
Click the PV-PQRS tab, and select the QRUR-Reports option.

32. How Can I Access My Report and Drill-Downs?
4. Complete Role Attestation
Choose the applicable option to complete your request access (“I plan to use this data in my capacity as a…”
5. Navigate to the Folders Report
Choose your QRUR or drill-down report from the applicable reports folder
6. Select Your Medical Group Practice
After the report opens, select a Medical Group Practice and click Run Document

33. How Can I Access My Report and Drill-Downs?
7. Export the QRUR
You can view the QRUR online, as well as export and print the report to a Portable Document File (.pdf)
8. Export Drill-Down Reports
You can view drill-down reports online, as well as export and print the reports to either a .pdf or an Excel file

34. How Can I Use the 2012 QRUR?
Verify the EPs billing under your group’s TIN during 2012
Determine how your group would fare under the Value Modifier (Performance Highlights)
Examine the number of beneficiaries attributed to your group and the basis for their attribution
Understand how your group’s performance on quality and cost measures compares to other groups
Understand which attributed beneficiaries are driving your group’s cost measures
Understand which beneficiaries are driving your group’s performance on the three hospital-related care coordination quality measures
Identify those beneficiaries that are in need of greater care coordination

35. What Information Is Included on the Performance Highlights Page?
Your Quality Composite Score
Your Cost Composite Score
Your Beneficiaries’ Average Risk Score
Your Quality Tiering Performance Graph
Your Payment Adjustment Based on Quality Tiering
(payment adjustments in example based on 2015 VM implementation)

36. For More Information
Visit the CMS Physician Value Modifier policies and the annual quality and resource use reports:

37. Medicare Learning Network®
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38. Disclaimer
The content of this video was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This video was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

39. Thank You
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