Michael Schweitz, MDPresident

Coalition of State Rheumatology Organizations

THE QUALITY AND VALUE MOVEMENT:  

ACOS AND VALUE BASED PAYMENT SYSTEMS

Accountable Care Organizations (ACOs)Value-Based Payment Modifier (VBM)/Physician

Feedback ProgramPhysician Quality Reporting System (PQRS)Medicare and Medicaid EHR Incentive ProgramPhysician CompareEmerging Payment and Care Delivery Models

AGENDA

ACCOUNTABLE CARE ORGANIZATIONS

Section 3022 of the Aff ordable Care Act requires HHS to establish the Medicare Shared Savings Program (MSSP) (i.e., Accountable Care Organizations (ACOs))

ACOs ACOs are groups of physicians, hospitals, and other health care

providers who come together voluntarily to give coordinated high quality care to the Medicare patients they serve

Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors

When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program

More than 280 Medicare ACOs in operation to date Approx. 220 “Traditional” Medicare ACOs; More than 60 other ACO

models Innovation Center ACOs: Pioneer and Advanced Payment Model

ACCOUNTABLE CARE ORGANIZATIONS

October 2011 – CMS issues final rules on Medicare ACOs

Highlights Eligible Organizations

Physicians/professionals in group practice arrangements Networks of individual practices of physicians/professionals Joint ventures/partnerships of hospitals, physicians,

professionals Hospitals employing physicians/professional Other providers/suppliers may participate but would not be used

to assign patients Beneficiary Assignment

Two-step method based on plurality of “primary care services” (i.e., E/M or “offi ce visits”)

Assignment based on preliminary prospective assignment w/retrospective reconciliation

ACO HIGHLIGHTS

Highlights Quality Measurement and Performance

33 measures (used in existing programs – PQRS) 100% reporting required to be eligible for shared savings Quality domains assessed by CMS

Patient/caregiver experience (7 measures) (CG-CAHPS Survey) Care coordination/patient safety (6 measures) (CMS , AHRQ, NQF measures) Preventive health (8 measures) (NQF, NCQA, AMA-PCPI, CMS measures) At-risk population/frail elderly health (NQF, NCQA, CMS measures)

Data Sharing Aggregate data reports provided at the start of the agreement

period, quarterly aggregate data reports thereafter and in conjunction with year end performance reports

Aggregate data reports will contain a list of the beneficiaries used to generate the report.

Beneficiary identifiable claims data provided for patients seen by ACO primary care providers who have been notified and have not declined to share data

ACO HIGHLIGHTS

One-sided ModelShare in savings (50%)

during each of the three years in the agreement period

This option is available during an ACO’s initial 3-year agreement period

Two-sided Model Share in risk and

savings (60%) during each of the three years in the agreement period

ACO PAYMENT: ONE-SIDED VS. TWO-SIDED

Other ACO Payment Notes ACOs share on “fi rst dollar” once minimum savings

threshold is achieved Shared savings distributed by CMS to the ACO (not

directly to ACO participants) during an ACO’s initial 3-year agreement period

Innovation Center ACOs (ACA Section 3021)Pioneer ACO Model (32 in operation) Designed to support organizations with experience

operating as ACOs or in similar arrangements in providing more coordinated care to beneficiaries at a lower cost to Medicare

Will test the impact of different payment arrangements in helping these organizations achieve the goals of providing better care to patients and reducing Medicare costs

Advance Payment ACO Model (35 in operation) Will provide additional support to physician-owned and

rural providers participating in the Shared Savings Program who would benefit from additional start-up resources to build the necessary infrastructure, such as hiring new staff or improving information technology systems

INNOVATION CENTER ACOS

Relatively unclear how specialists fi t into the ACO framework, but we know the following: Specialists will likely be exclusive to one ACO under the

“two-step” assignment process Step 1: Beneficiaries first will be assigned to an ACO on the

basis of utilization of primary care services provided by PCPs

Step 2: Beneficiaries not seeing a PCP may be assigned to an ACO on the basis of primary care services provided by other physicians (such as specialists)

No NPI/TIN combination that has been used for purposes of patient assignment to an ACO can be associated with more than one ACO

CMS included an “Access to Specialists” module with the required CG-CAHPS Survey to monitor beneficiary access to specialists

Most specialists taking a “watch and see” approach

ACOS AND SPECIALISTS

ACO fi nal regulation widely interpreted as allowing non-primary care physicians to practice in multiple ACOs

CMS clarifi ed that it would apply exclusivity more broadly in recent FAQ document

Pertinent FAQs

QUESTION: I’m a medical specialist in solo practice and I bill for offi ce evaluation and management services that are included in the defi nition of primary care services. Is it true that I must keep my TIN exclusive to only one ACO?

ANSWER: Yes, an ACO participant TIN that bil ls for primary care services must be exclusive to a single MSSP ACO. Exclusivity under the MSSP is governed by the types of services that are furnished by the ACO providers/suppliers that bil l under the ACO participant TIN, not by whether the TIN bil ls for services furnished by primary care physicians, specialists, or a mix of providers.

ACO EXCLUSIVITY

Pertinent FAQs

QUESTION: I’m a specialist and bill for offi ce evaluation and management services (which CMS defi nes as being “primary care”) under a single TIN. Can my TIN be a participant in more than one ACO if I make sure all my patients see a primary care physician who’s not participating in my ACO? By doing this I’d make sure that no patients are assigned to my ACO based on my services.

ANSWER : No. An ACO participant TIN that bil ls for primary care services must be exclusive to a single Medicare Shared Savings Program ACO. TIN exclusivity under the Medicare Shared

Savings Program is not aff ected by whether or not non-ACO physicians also treat benefi ciaries that receive primary care services bil led by the ACO participant TIN.

Read more of CMS’ FAQs at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-FAQs.pdf

ACO EXCLUSIVITY

Analytics: Medicare & Medicaid Research Review (MMRR) 2012 Volume 2, Number 4“Statistical Uncertainty in the Medicare Shared Savings Program” Report indicates there may be greater statistical uncertainty in the

MSSP than previously recognized “The probability of an incorrect outcome is heavily dependent on

ACO enrollment size…[t]he probability of inappropriate payment denial declines as real ACO savings increase...CMS and ACOs will have to consider this uncertainty in their financial, administrative, and care management planning.”

Authors suggest analytic strategies that can be used to refine ACO payment formulas in the longer term to ensure that the MSSP (and other ACO initiatives that will be influenced by it) work as effi ciently as possible.

Read the report on CMS’ website: http://www.cms.gov/mmrr/Articles/A2012/mmrr-2012-002-04-a04.html

ACO CONCERNS

Exclusivity: Regardless of specialty, ACO participants that bill for PC services must be exclusive to a single ACO since they are the basis for assigning beneficiaries, computation of the benchmark, and quality assessment

Access to care: Patients not limited to ACO providers, but intra-ACO referrals and gatekeeper models may limit access to specialists

Distribution of shared savings: Specialty physicians continue to have doubts that shared savings will be distributed fairly among all ACO participants

ACO CONCERNS

Watch the Pioneer ACOs Letter to CMS from 32 Pioneer ACOs expressing concerns

(February 2013) Insuffi cient data for quality measures Benchmarks higher than commercial contracts Use of Medicare Advantage data in setting benchmarks

CMS rejected Pioneer’s concernsExpect additional CMS regulations to modify ACOs

Analytics, Exclusivity, Distribution of Shared Savings?Physicians should…

Closely review ACO agreements Educate their Medicare patients about ACOs

THE FUTURE OF ACOS

VALUE-BASED PAYMENT MODIFIER

AND PHYSICIAN FEEDBACK PROGRAM

Aff ordable Care Act (ACA) requires CMS to apply a value-based modifier (VBM) to physician services billed under the Medicare Fee Schedule Modifier must be based on physician quality AND cost Modifier must be applied beginning Jan. 1, 2015 to select

physicians and to all physicians no later than Jan. 1, 2017 Modifier must be applied in a budget neutral manner (i.e.,

cuts to low performers will finance bonuses to high performers)

CMS must provide confidential Physician Feedback Reports reflecting physician resource use and quality

VALUE-BASED PAYMENT MODIFIER: STATUTORY AUTHORITY

Alignment with other federal quality programs (PQRS, ACOs, etc.)

Encourage shared responsibility and systems-based care

Off er choice of quality measures and reporting mechanisms

Provide actionable information

VALUE-BASED PAYMENT MODIFIER: IMPLEMENTATION PRINCIPLES

Only LARGE GROUP PRACTICES (>100 eligible professionals) will be held accountable under VBM in 2015 EP = physicians (MD, DO, DOPM, DC, etc.), PAs,

NPs, dieticians, social workers, PT/OTs VBM applies to items/services billed by

physicians under a single tax-identification number (TIN)

Performance period for 2015 adjustment is CY2013 0% adjustment for satisfying PQRS requirements 1.0% penalty for inaction / adjustment for voluntary quality-tiering calculation

VALUE-BASED PAYMENT MODIFIER: INITIAL IMPLEMENTATION

Group Practice Reporting Options (GPRO) to avoid penalty:

GPRO Web Interface: pre-selected set of 22 measures focusing on preventive and chronic care that align with Shared Savings Program; must report at least one measure

GPRO Using CMS-Qualified Registry: groups select relevant quality measures to report through a PQRS-qualified registry; must report at least one measure

Administrative Claims Option:* 17 pre-selected measures focusing on preventive and chronic care; calculated automatically by CMS based on claims

*Only available for 2013

VALUE-BASED PAYMENT MODIFIER: REPORTING OPTIONS

Only groups that voluntary opt for the “quality-tiering approach” will be held accountable for quality and cost performance based on:

Quality measures Measures reported through selected PQRS reporting mechanism Three outcome measures: All Cause Readmission, Composite of

Acute Prevention Quality Indicators (bacterial pneumonia, UTI, dehydration), Composite of Chronic Prevention Quality Indicators (COPD, HF, diabetes)

Cost measures Total per capita costs measures (Parts A & B) Total per capita costs for beneficiaries with four chronic conditions:

COPD, HF, CAD, Diabetes

*Cost measures are payment standardized and risk adjusted. Patients are attributed to group practices that billed largest share of E/M services (“plurality of care” method)

VALUE-BASED PAYMENT MODIFIER: QUALITY TIERING APPROACH

VALUE-BASED PAYMENT MODIFIER

Group practices w/ > 100 EPs

PQRS Reporters Groups self-nominating for PQRS GPRO web-interface, registries or administrative

claims reporting

Non-PQRS ReportersGroups NOT self-nominating to participate in PQRS GPRO and

not reporting at least one measure

,, or No Adjustment

Based on Quality/Cost

Measure Composite

0.0% No

Adjustment

Elect Quality-Tiering

No Election

-1.0% Adjustment

CMS has provided confi dential feedback reports (“Quality and Resource Use Reports” or QRURs) to select physicians since 2010. Reports quantify and compare quality and costs of physicians relative to their peers.

Fall 2013: CMS will send reports to all group practices with >25 EPs to preview methodologies used to determine the VBM and help larger practices decide whether to choose quality-tiering approach

Fall 2014: CMS will send reports to all group practices with >25 EPs based on 2013 data. Reports will specify modifi er amount and will be the basis for its determination in 2015 (for practices with >100 EPs only)

CMS continues to work with specialties to improve the content and format of these reports

QUALITY AND RESOURCE USE REPORTS

2012

• Confidential feedback reports distributed to successful PQRS participants and demonstrate the type of information that will be used to calculate modifier

2013• Initial performance period (i.e.,

services provided during CY 2013 will be used to calculate 2015 payment)

2015• Beginning in 2015, modifier will apply

only to large group practices (100+ eligible professionals)

2016• As modifier is phased in over 2-year

period, CMS will continue to apply modifier to specific physicians

2017• Modifier will apply to most or all

physicians who submit claims under Medicare fee schedule

VALUE-BASED PAYMENT MODIFIER: TIMELINE

Continuing concerns Rushed timeline Inaccurate risk adjustment/attribution methodologies for

cost measures Confusing feedback reports

CMS continues to seek public feedback on implementation strategies and methodologies

Important for physicians to familiarize themselves with the PQRS and to pay attention to CMS feedback reports, regardless of whether they qualify for VBM during initial roll out

VALUE-BASED PAYMENT MODIFIER: ONGOING CONCERNS

May 16, 2012 – CSRO met with CMS senior staff to discuss concerns and off er suggestions specifi c to the VBM and the QRURs.

Limited provider education on the VBM/Physician Feedback Program

How to measure quality for providers not participating in the PQRS

Conditions being measured frequently fall outside the specialty

Validity of the QRUR data Cost measurement may prompt

negative behavior Need to highlight data relevant to

specialty Reduce the size and simplify the

QRURs

CSRO MEETS WITH CMS STAFF

CSRO, as members of the Alliance of Specialty Medicine, is engaged in an ongoing, bi-directional dialogue with senior CMS staff to improve elements of the VBM, QRURs

Face-to-face meetings (Dec. 2012/March 2013) at CMS Headquarters

User Access Training & Alliance/CMS Webinar on new QRURs (Sept 2013)

ALLIANCE OF SPECIALTY MEDICINE: SUPER USER NETWORK

PHYSICIAN QUALITY REPORTING SYSTEM

Bonus payment for reporting quality data via claims, registry, EHR up to 1.0% in 2013

Penalties in 2015 based on 2013 reporting -1.5% in 2015, -2.0% in 2016

Improvements to the program: More measures, more reporting options Less stringent reporting criteria to avoid penalty American Taxpayer Relief Act of 2012 (P.L.112-240)

permits participation in clinical data registries in lieu of traditional PQRS reporting for 2014 and beyond

CMS interested in recognizing registry reporting and other innovative, non-federal QI activities as a substitute for PQRS criteria

PHYSICIAN QUALITY REPORTING SYSTEM

BONUS/PENALTY STRUCTURE

Year PQRS

2009 2.0%

2010 2.0%

2011 1.0%-1.5%

2012 0.5%-1.0%

2013 0.5%-1.0%

2014 0.5%-1.0%

2015 No bonus (-1.5% penalty)

2016 No bonus (-2.0% penalty)

**Range in incentive payment depends on whether EP qualifies for MOC bonus

EHR INCENTIVE PROGRAM

Incentives for “meaningful use” of certifi ed EHR system Medicare: Up to $44,000 over 4 years Medicaid: Up to $63,750 NOTE: EHR incentive payments subject to 2% sequestration reduction

Phased approach Final Stage 2 (2014): More advanced clinical processes; more data exchange;

increased requirements for e-Rx and incorporating lab-results; e-transmission of patient care summaries; and enhanced patient engagement

Proposed Stage 3 (2016): Emphasis on core vs. menu options; 2x measures; higher reporting thresholds (100% compliance in some cases); testing of innovative, locally generated measures

Participation 226K physicians registered to participate in Medicare EHR Incentive Program;

still, fewer than 1 in 10 physicians used electronic records last year that met federal standards

Challenges Irrelevant measures; lack of interoperability/info exchange infrastructure;

cost; unintended coding/safety issues; rushed implementation

MEDICARE AND MEDICAID EHR INCENTIVE PROGRAM

BONUS/PENALTY STRUCTURE

Year EHR

2009 None

2010 None

2011 $18,000

2012 $12,000-$18,000

2013 $8,000-$15,000

2014 $4,000-$12,000

2015 $2,000-$8,000 (-1.0% penalty)

2016 $2,000-$4,000 (-2.0% penalty)

*Depending on total # of meaningful users after 2018, the maximum cumulative EHR penalty can reach as high as 5%; EHR incentive payments subject to 2% sequestration reduction

PHYSICIAN COMPARE

CMS Physician Compare Website http://

www.medicare.gov/find-a-doctor/provider-search.aspx 2014:

2013 PQRS quality measures reported by group practices (>25) and ACOs

2013 patient experience data for group practices (>100)/ACOs Recognition of physicians who earned a PQRS MOC Incentive

2015: Individual physician 2014 PQRS performance dataOngoing concerns with accuracy of dataPhysicians should review the accuracy of their data

and report problems to CMS

PHYSICIAN COMPARE

EMERGING MODELS

CMS’ Innovation Center develops new payment and service delivery models in accordance with statutory requirements

Focus Areas Accountable Care Bundled Payment for Care Improvement Primary Care Transformation Innovations for Medicaid and Dual-Eligibles

Innovation Center recently announced it would accept proposals for “specialty” focused demos

CSRO, as part of the Alliance of Specialty Medicine, engaged in a dialogue with Innovation Center staff on ways to encourage/facilitate the development of specialty-focused payment and delivery models

CMS INNOVATION CENTER

QUESTIONS?