3P Update: Quality and Resource Use Reports and the Value-Based Payment Modifier Program
The Physician Payment Policy Workgroup (3P), co-chaired by Richard W. Waguespack, MD, and Michael Setzen, MD, is the senior advisory body to Academy leadership and staff on issues related to socioeconomic advocacy, regulatory activity, coding or reimbursement, and practice services or management. The Health Policy staff and 3P have been busy during the first half of 2012 with a continued high level of activity, constant emails and monthly calls, working diligently and tirelessly on behalf of all members. 3P has focused on the development of future payment mechanisms and two programs the Centers for Medicare and Medicaid Services (CMS) are working on, the distribution of Quality Resource Use Reports (QRURs), and the installation of the value-based payment modifier program. By way of background, the Medicare Improvements for Patients and Providers Act of 2008 created the Physician Resource Use Measurement and Reporting Program. In 2010, the Affordable Care Act extended and enhanced the program and named it the Physician Feedback Program. The program authorizes CMS to produce annual physician QRURs. The Affordable Care Act also authorized the creation of the value-based payment modifier program, which requires the use of differential payments to physicians or groups based upon the quality of care furnished compared with cost. QRURs In early March 2012, CMS sent the first QRURs to nearly 24,000 physicians in Iowa, Kansas, Missouri, and Nebraska. Data contained in QRURs compared the cost and clinical care provided to Medicare beneficiaries in 2010 by a physician to the average costs and clinical care of other physicians in these four states. These reports contained the number of Medicare beneficiaries a physician saw during the reporting period, compared the quality of care for Medicare beneficiaries seen by a physician to other physicians based upon 28 quality measures (27 of which are National Quality Forum endorsed), and showed cost data for patients whose care the physician directed, influenced, or contributed to. This was measured by outpatient evaluation and management (E&M) office visits or total professional costs. Wisconsin Physician Services (WPS), the Medicare contractor that processes claims in the four states, emailed QRURs to one physician or employee who has been designated as the primary contact for communications from WPS. The reports were available until the first week of June. These reports, according to CMS, are intended to be informational and allow physicians to compare the quality and cost of Medicare patients’ care to physicians in their specialty and by all physicians within those states. Although they are currently informational in nature only, the reports also provided quality of care and cost information that will be used by CMS in the development of the value-based payment modifier program, which will begin to be phased in starting in 2015. Value-Based Payment Modifier Program The Affordable Care Act created the value-based payment modifier program and required the use of differential payments to physicians or groups based upon the quality of care furnished compared with cost and will apply to services physicians’ bill under the Medicare Physician Fee Schedule. Through the program, CMS will make adjustments in cost for difference in geographic rates (payment standardization) and the underlying health status of individual beneficiaries seen by a provider (risk adjustment). Although the Value-Based Modifier will not take effect until 2015, the 2015 modifier will be based upon services provided during 2013. For 2015 and 2016, the U.S. Secretary of Health and Human Services has discretion to apply the modifier to specific physicians and/ or groups of physicians they deem appropriate. In 2017, the modifier will apply to most or all physicians who submit claims through the Medicare Physician Fee Schedule. Few specifics are currently known about the program, but CMS plans on proposing methodology for the value-based modifier program during the 2013 Physician Fee Schedule rulemaking process. CMS is soliciting input from associations, including the Academy, in the development of the methodology for the modifier, and the Academy will provide input to CMS through comments and coalitions as necessary. The Academy is asking members who received and downloaded QRURs to notify the health policy unit and provide input so we can forward concerns from members to CMS officials. For example, are the performance highlights important or are there others that may be more useful? Please email feedback to healthpolicy@entnet.org. At this year’s annual meeting in Washington, DC, 3P will conduct a miniseminar on Academy Advocacy for Physician Payment: 2012 on Sunday, September 9, 2012, from 10:30 am to 11:50 am. One of the future payment strategies that will be discussed during the miniseminar is the value-based payment modifier program that will likely incorporate aspects from the initial QRURs. In the meantime, please monitor our Medicare Updates page, which can be accessed at http://www.entnet.org/Practice/Medicareupdates.cfm, for updates on these programs.
The Physician Payment Policy Workgroup (3P), co-chaired by Richard W. Waguespack, MD, and Michael Setzen, MD, is the senior advisory body to Academy leadership and staff on issues related to socioeconomic advocacy, regulatory activity, coding or reimbursement, and practice services or management. The Health Policy staff and 3P have been busy during the first half of 2012 with a continued high level of activity, constant emails and monthly calls, working diligently and tirelessly on behalf of all members. 3P has focused on the development of future payment mechanisms and two programs the Centers for Medicare and Medicaid Services (CMS) are working on, the distribution of Quality Resource Use Reports (QRURs), and the installation of the value-based payment modifier program.
By way of background, the Medicare Improvements for Patients and Providers Act of 2008 created the Physician Resource Use Measurement and Reporting Program. In 2010, the Affordable Care Act extended and enhanced the program and named it the Physician Feedback Program. The program authorizes CMS to produce annual physician QRURs. The Affordable Care Act also authorized the creation of the value-based payment modifier program, which requires the use of differential payments to physicians or groups based upon the quality of care furnished compared with cost.
QRURs
In early March 2012, CMS sent the first QRURs to nearly 24,000 physicians in Iowa, Kansas, Missouri, and Nebraska. Data contained in QRURs compared the cost and clinical care provided to Medicare beneficiaries in 2010 by a physician to the average costs and clinical care of other physicians in these four states. These reports contained the number of Medicare beneficiaries a physician saw during the reporting period, compared the quality of care for Medicare beneficiaries seen by a physician to other physicians based upon 28 quality measures (27 of which are National Quality Forum endorsed), and showed cost data for patients whose care the physician directed, influenced, or contributed to. This was measured by outpatient evaluation and management (E&M) office visits or total professional costs.
Wisconsin Physician Services (WPS), the Medicare contractor that processes claims in the four states, emailed QRURs to one physician or employee who has been designated as the primary contact for communications from WPS. The reports were available until the first week of June. These reports, according to CMS, are intended to be informational and allow physicians to compare the quality and cost of Medicare patients’ care to physicians in their specialty and by all physicians within those states. Although they are currently informational in nature only, the reports also provided quality of care and cost information that will be used by CMS in the development of the value-based payment modifier program, which will begin to be phased in starting in 2015.
Value-Based Payment Modifier Program
The Affordable Care Act created the value-based payment modifier program and required the use of differential payments to physicians or groups based upon the quality of care furnished compared with cost and will apply to services physicians’ bill under the Medicare Physician Fee Schedule. Through the program, CMS will make adjustments in cost for difference in geographic rates (payment standardization) and the underlying health status of individual beneficiaries seen by a provider (risk adjustment).
Although the Value-Based Modifier will not take effect until 2015, the 2015 modifier will be based upon services provided during 2013. For 2015 and 2016, the U.S. Secretary of Health and Human Services has discretion to apply the modifier to specific physicians and/ or groups of physicians they deem appropriate. In 2017, the modifier will apply to most or all physicians who submit claims through the Medicare Physician Fee Schedule. Few specifics are currently known about the program, but CMS plans on proposing methodology for the value-based modifier program during the 2013 Physician Fee Schedule rulemaking process.
CMS is soliciting input from associations, including the Academy, in the development of the methodology for the modifier, and the Academy will provide input to CMS through comments and coalitions as necessary. The Academy is asking members who received and downloaded QRURs to notify the health policy unit and provide input so we can forward concerns from members to CMS officials. For example, are the performance highlights important or are there others that may be more useful? Please email feedback to healthpolicy@entnet.org.
At this year’s annual meeting in Washington, DC, 3P will conduct a miniseminar on Academy Advocacy for Physician Payment: 2012 on Sunday, September 9, 2012, from 10:30 am to 11:50 am. One of the future payment strategies that will be discussed during the miniseminar is the value-based payment modifier program that will likely incorporate aspects from the initial QRURs. In the meantime, please monitor our Medicare Updates page, which can be accessed at http://www.entnet.org/Practice/Medicareupdates.cfm, for updates on these programs.