Fact Sheets

Proposed Changes for Calendar Year 2014 Physician Quality Programs And The Value Based Payment Modifier

Proposed Changes for Calendar Year 2014 Physician Quality Programs and The Value Based Payment Modifier

OVERVIEW

On July 8, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (MPFS) on or after Jan. 1, 2014.  The proposed rule also proposes changes to several of the quality reporting initiatives that are associated with PFS payments, including the Physician Quality Reporting System (PQRS), as well as changes to the Physician Compare tool on the Medicare.gov website.  Finally, the proposed rule includes proposals for implementing the value-based payment modifier (Value Modifier) required by the Affordable Care Act that would affect payment rates to certain groups based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service program.

This fact sheet discusses the proposed changes to these quality reporting programs and the continued phase-in of the Value Modifier. A separate fact sheet, also issued today, discusses the proposed changes to payment policies for services furnished under the PFS.

PHYSICIAN QUALITY REPORTING SYSTEM

The Physician Quality Reporting System (PQRS) is a pay-for-reporting program that uses a combination of incentive payments and downward payment adjustments to promote reporting of quality information by eligible professionals (EPs). The program provides an incentive payment through 2014 to EPs and group practices who satisfactorily report data on quality measures for covered professional services furnished to Medicare Part B fee-for-service beneficiaries during the applicable reporting period.  Beginning in 2015, a downward payment adjustment will apply to EPs who do not satisfactorily report data on quality measures for covered professional services.  

In the CY 2014 PFS proposed rule, CMS proposes the following updates to the PQRS:

Summary of Proposed PQRS Measures: For 2014, we are proposing to add 47 new individual measures and 3 measures groups to fill existing measure gaps and to retire a number of claims-based measures to encourage reporting via registry and EHR-based reporting mechanisms.

Reporting PQRS Measures as Individual EPs: CMS established certain requirements for the 2014 PQRS incentive, which is the final year that incentive payments may be earned under the PQRS, in the CY 2013 PFS final rule.  However, we are proposing to make the following changes to these requirements:

• Increasing the number of measures that must be reported via the claims and registry-based reporting mechanisms from 3 to 9
• Changing the reporting threshold for reporting individual measures via registry to require that eligible professionals report on 50% of the eligible professional’s applicable patients rather than 80%
• Eliminating the reporting option to report on  claims-based measures groups

We are proposing that if an EP meets the criteria for the 2014 PQRS incentive, this will serve to satisfy the reporting for the 2016 PQRS payment adjustment (in other words, EPs who meet the criteria for the 2014 PQRS incentive will automatically avoid the downward payment adjustment for 2016).  In addition, we are retaining the criterion established in the CY 2013 PFS final rule that an EP using the claims-based reporting mechanism may report 3 measures on 50% of the eligible professional’s applicable patients for the 2016 PQRS payment adjustment.    

PQRS Reporting Using Clinical Data Registries:

The American Taxpayer Relief Act of 2012 allows eligible professionals to be treated as satisfactorily submitting data on quality measures for covered professional services if the eligible professional satisfactorily participates in a qualified clinical data registry.

• Under this clinical data registry option, EPs report the measures used by the clinical data registry instead of those on the PQRS measure list.  Eligible professionals may report measures on all patients, regardless of whether or not they are Medicare Part B FFS patients.  For the 2014 PQRS incentive and 2016 PQRS payment adjustment, we are proposing that eligible professionals using clinical data registries would meet the criteria for satisfactory participation by reporting on at least 9 measures to the registry covering at least 3 of the National Quality Strategy domains, and report each measure for at least 50% of the eligible professional’s applicable patients.  At least one of the measures must be an outcome measure.  

Reporting PQRS Measures as a Group Practice under the Group Practice Reporting Option (GPRO):

In the CY 2013 PFS final rule, we finalized the requirements for meeting the criteria for satisfactory reporting using the registry, EHR, and GPRO web interface reporting mechanisms for the 2014 PQRS incentive under the GPRO.  However, we are proposing to make the following changes to the requirements for group practices that we previously finalized for the 2014 PQRS incentive:

• Eliminate the option for group practices of 25 to 99 EPs to report PQRS measures via the GPRO web interface.  That is, only groups with 100 or more EPs could use the GPRO web interface.
• Propose a new reporting mechanism, the certified survey vendor reporting mechanism, that would allow a group comprised of 25 or more eligible professionals to count reporting of CG CAHPS survey measures towards meeting the criteria for satisfactory reporting for the 2014 PQRS incentive and the 2016 PQRS payment adjustment.   
• For groups reporting individual measures via registry, propose to increase the number of measures that must be reported from 3 to 9 and propose a 50% threshold instead of a 80% threshold, which is also proposed for the individual satisfactory reporting criteria for the 2014 PQRS incentive.

We are proposing that if a group practice reporting through one of the GPRO reporting options (including ACOs in the Medicare Shared Savings Program) meets the criteria for the 2014 PQRS incentive, this will serve to satisfy the reporting for the 2016 PQRS payment adjustment (in other words, group practices that meet the criteria for the 2014 PQRS incentive will automatically avoid the downward payment adjustment for 2016).  

THE MEDICARE EHR INCENTIVE PROGRAM

In the CY 2014 PFS proposed rule, we propose additional options for eligible professionals (EPs) to report clinical quality measures (CQMs) under the Medicare EHR Incentive Program beginning in 2014.  

Medicare EHR Incentive Program CQM Reporting Using Qualified Clinical Data Registries:

We are proposing an option for EPs to submit CQM information using qualified clinical data registries (as defined for PQRS) for purposes of meeting the CQM reporting component of meaningful use (MU) for the Medicare EHR Incentive Program beginning in 2014.  EPs would have to use certified EHR technology, as required under the Medicare EHR Incentive Program, and report on CQMs that were included in the EHR Incentive Program Stage 2 final rule.

Comprehensive Primary Care Initiative – Proposed Additional Group Reporting Option:

The Comprehensive Primary Care Initiative (CPCI), under the authority of Section 3021 of the Affordable Care Act, is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. The CPCI uses a subset of the CQMs finalized in the Stage 2 final rule. In a continuing effort to align quality reporting programs and innovation initiatives, we are proposing to add a group reporting option to the Medicare EHR Incentive program beginning in CY 2014 for EPs who are part of a CPCI practice site that successfully submit at least 9 CQMs covering 3 domains.  We are proposing that each of the EPs in the CPCI practice site would satisfy the CQM reporting component of meaningful use if the practice site successfully submits and meets the reporting requirements of the CPCI.

Reporting of Electronically Specified Clinical Quality Measures for the Medicare EHR Incentive Program:

The electronic specifications for the clinical quality measures that were finalized under the Medicare EHR Incentive Program for use by EPs beginning in CY 2014 are updated routinely to account for issues such as changes in billing and diagnosis codes and changes in medical practices.  We propose that EPs who seek to report clinical quality measures electronically under the Medicare EHR Incentive Program must use the most recent version of the electronic specifications for the clinical quality measures and have CEHRT that is tested and certified to the most recent version of the electronic specifications for the clinical quality measures. EPs who do not wish to report clinical quality measures electronically using the most recent version of the electronic specifications (for example, if their CEHRT has not been certified for that particular version) would be allowed to report clinical quality measure data to CMS by attestation for the Medicare EHR Incentive Program.

PHYSICIAN COMPARE WEBSITE

The PFS proposed rule outlines the next phase of the plan to publicly report physician performance information on Physician Compare. For 2014, we propose to expand this reporting by publicly reporting all measures collected through the GPRO web interface for groups of all sizes participating in the 2014 PQRS GPRO and for ACOs participating in the Medicare Shared Savings Program.  These data would include measure performance rates for measures included in the 2014 PQRS GPRO web interface that met the minimum sample size of 20 patients, and that prove to be statistically valid and reliable. As previously finalized, we will provide a 30-day preview period prior to publication of quality data on Physician Compare so that group practices and ACOs can view their data as it will appear on Physician Compare before it is publicly reported. We also propose to publicly report certain measures that groups report via registries and EHRs for the 2014 PQRS GPRO.  

CMS has begun to collect patient experience survey data - the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) - for group practices participating in the PQRS GPRO and ACOs participating in the Medicare Shared Savings Program, starting with survey data for 2013. We intend to publicly report these measures on Physician Compare in 2014 for data collected for CY 2013 for group practices with 100 or more eligible professionals participating in PQRS GPRO through the GPRO web interface and for ACOs reporting through the GPRO web interface. For CY 2014, we also intend to continue public reporting of these CG-CAHPS data for PQRS GPRO group practices of 100 or more eligible professionals participating in the GPRO web interface and for ACOs reporting through the GPRO web interface.  

MEDICARE SHARED SAVINGS PROGRAM (SHARED SAVINGS PROGRAM)

Alignment with PQRS:

To continue to align with PQRS, ACOs will report through a CMS web interface on behalf of eligible professionals and must meet the criteria for the 2014 PQRS incentive to satisfactorily report to avoid the 2016 PQRS payment adjustment.

Benchmarking:

Previously, CMS indicated that we would use national Medicare Advantage and FFS Medicare performance data, and seek to incorporate actual ACO performance into establishing quality benchmarks for the program.  We are now proposing to including data submitted by the Shared Savings Program and Pioneer ACOs to set the benchmark for the 2014 performance period.  In addition, we are proposing a method to increase the spread of tightly clustered to continue to provide incentives to improve quality and provide achievable benchmarks for newly formed ACOs.  Finally, we are proposing to increase the scoring for the CG CAHPs survey measure modules within the patient experience of care domain, so that the CAHPS survey measure modules carry greater weight within the patient experience of care domain.   

PHYSICIAN VALUE-BASED PAYMENT MODIFIER AND THE PHYSICIAN FEEDBACK PROGRAM

Value Modifier for Items and Services Paid Under the PFS:

The Affordable Care Act requires us to establish a value-based payment modifier that provides for differential payment to a physician or group of physicians under the PFS based upon the quality of care furnished to Medicare beneficiaries compared to the cost of that care during a performance period.  Further, the statute requires that we begin applying the value-based payment modifier on January 1, 2015, with respect to items and services furnished by specific physicians and groups of physicians (as determined by the Secretary) and to apply it to all physicians and groups of physicians beginning not later than Jan. 1, 2017.  

By law, payments made under the value-based payment modifier must be budget neutral meaning that upward payment adjustments for high performance will balance the downward payment adjustments applied for poor performance. In this rule, we propose additions and refinements to the existing value-based payment modifier policies.  These proposals continue our phased-in implementation of the value-based payment modifier by reinforcing our emphasis on quality measurement, alignment with the PQRS, physician choice, and shared accountability.  Specifically, this proposed rule includes the following proposals:

Proposed Performance Period:

CMS previously established CY 2014 as the performance period for the value-based payment modifier adjustments that will apply during CY 2016.  We believe it is important, however, to propose the performance period for the value-based payment modifier that will apply in CY 2017, when all physicians and groups of physicians will be subject to the value-based payment modifier as required under section 1848(p) of the Act.  We propose that CY 2015 be the performance period for the value-based payment modifier that will apply during CY 2017.  

Proposed Group Size:

We propose to lower the group size threshold from groups of physicians of 100 or more eligible professionals that are subject to the value-based payment modifier in CY 2015 to groups of physicians with 10 or more eligible professionals for 2016.    We estimate that this proposal would cause approximately 17,000 groups and nearly 60 percent of physicians to be affected by the value-based payment modifier in CY 2016.  

Proposals for Setting the Value-Based Payment Modifier Adjustment Based on PQRS Participation:

We propose a two-category approach for establishing the CY 2016 value-based payment modifier based on how a group of physicians participates in the PQRS.  We propose that Category 1 would include those groups of physicians with 10 or more eligible professionals that meet the satisfactory reporting criteria through the PQRS GPRO for the CY 2016 PQRS payment adjustment.  In addition, CMS proposes that if a group of physicians subject to the CY 2016 value-based payment modifier does not participate in the PQRS GPRO, at least 70 percent of the eligible professionals billing under the group must meet the satisfactory reporting for the CY 2016 PQRS payment adjustment, in order to be included in Category 1 and avoid a downward payment adjustment under the value-based payment modifier.  This proposal allows EPs in those groups to continue to report data for the PQRS individually if they so choose.  Groups of physicians with 10 or more eligible professionals that do not meet either of these two standards will be in Category 2 and be subject to an automatic downward payment adjustment under the value-based payment modifier.

In addition, CMS proposes to make quality-tiering (which is the method for evaluating performance on quality and cost measures for the value-based payment modifier) mandatory for groups with 10 or more EPs.  However, we propose that groups of physicians with between 10 and 99 eligible professionals will not be subjected to a downward payment adjustment (that is, they will either receive an upward or neutral adjustment) determined under the quality-tiering methodology.  Groups of physicians with 100 or more EPs, however, would either receive upward, neutral, or downward adjustments under the quality-tiering methodology.  We believe this new approach to implementing quality-tiering would reward groups of physicians that provide high-quality/low-cost care, reduce program complexity, and more fully engage groups of physicians in our plans to implement the value-based payment modifier.

We also propose to use for the CY 2016 value-based payment modifier all of the PQRS measures that would be available to be reported under the various PQRS reporting mechanisms in CY 2014, including quality measures reported by individuals EPs in a group through qualified clinical data registries, to calculate a group of physicians’ value-based payment modifier in CY 2016 to the extent that a group of physicians submits data on these measures.  In addition, we propose that groups of 25 or more eligible professionals would be able to elect to have the patient experience of care measures collected through the PQRS CG-CAHPS survey for CY 2014 included in their value-based payment modifier for CY 2016.

Value Modifier Payment Adjustments:

CMS proposes to increase the downward adjustment under the value-based payment modifier from 1.0 percent in CY 2015 to 2.0 percent for CY 2016.  That is, for CY 2016, a -2.0 percent value-based payment modifier would apply to groups of physicians subject to the value-based payment modifier that fall in Category 2.  In addition, we propose to increase the maximum downward adjustment under the quality-tiering methodology to -2.0 percent for groups of physicians subject to the CY 2016 value-based payment modifier that fall in Category 1 and are classified as low quality/high cost and to set the adjustment to -1.0 percent for groups classified as either low quality/average cost or average quality/high cost. 

 
Proposal to Include the Medicare Spending per Beneficiary Measure in the Value-Based Payment Modifier Cost Composite:

We are proposing to include the Medicare Spending per Beneficiary (MSPB) measure as an additional measure in the cost composite of the value-based payment modifier beginning with CY 2016.  The measure includes all Medicare Part A and Part B payments during an MSPB episode.  An MSPB episode spans from 3 days prior to an index admission at a subsection (d) hospital through 30 days post discharge with certain exclusions. The MSPB measure is already included in the Hospital Inpatient Quality Reporting Program and in the Hospital-Value-based Purchasing Program. This measure would be included in the total per capita costs for all attributed beneficiaries domain along with the total per capita cost measure.  Each measure would be weighted equally in the domain.  We propose not to convert the MSPB amount to a ratio as is done to compute a hospital’s MSPB measure, but rather use the MSPB amount as the measure’s performance rate.

We propose to attribute an MSPB episode to a group of physicians subject to the value-based payment modifier, when any eligible professional in the group bills a Part B Medicare claim for a service rendered during an inpatient hospitalization that is an index admission for the MSPB measure.  

We propose that a group of physicians would have to be attributed a minimum of 20 MSPB episodes during the performance period to have their performance on this measure included in the value-based payment modifier cost composite.  We believe that including the MSPB in the value-based payment modifier would help to align performance incentives across the delivery system.  

Proposed Refinements to the Cost Measure Benchmarking Methodology:

In the CY 2013 PFS final rule, we established a policy to create a cost composite for each group of physicians subject to the value-based payment modifier.  We have since examined the distribution of the cost composite scores among all groups of physicians and solo practitioners to determine whether comparisons at the group level are appropriate once we apply the value-based payment modifier to smaller groups and solo practitioners.  We found that our current peer grouping methodology could have varied impacts on different physician specialties.  Thus, we propose to refine our current peer group methodology to account for physician specialty mix.  

Physician Feedback Program

For the last two years, we have provided annual Quality and Resource Use Reports (QRURs) to groups of physicians to provide feedback on the quality of care furnished, and the cost of that care, to Medicare beneficiaries.  We will continue to use the annual QRURs to explain how the value-based payment modifier would affect payment under the PFS.  In September 2013, we anticipate making available to all groups of 25 or more eligible professionals, based on 2012 data.  In 2014, we anticipate providing group QRURs to all groups of eligible professionals.  In addition, we are seeking ways to provide groups of physicians with more frequent and timely performance data on the quality and cost measures incorporated in the value-based payment modifier.

The proposed rule will be published in the July 19, 2013 Federal Register.  CMS will accept comments on the proposed rule until Sep. 6, 2013, and will review and respond to all comments in a final rule with comment period to be issued by Nov. 1, 2013.

To view the proposed rule, see:

http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

For more information on PQRS, visit: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

For more information on the Medicare and Medicaid EHR Incentive Programs, visit: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

For more information on Physician Compare, visit: http://www.medicare.gov/find-a-doctor/provider-search.aspx

# # #