As November comes to a close, there’s no better time to begin thinking about all of those year-end administrative tasks. Diana got us off to a great start last week with a very handy meaningful use to-do list. This week, we turn our attention to the physician value-based payment modifier (VM) and its sidekick the Quality and Resource Use Report (QRUR).
Once again, actually putting your hands on the QRUR is half the battle. In July, CMS sent our old friend the IACS account packing and they now require you to use an Enterprise Identity Data Management (EIDM) account to access your QRUR. Of course if you already have an IACS account you need to follow the yellow brick road to obtain an EIDM. Your journey begins here. A word of caution, this journey can take more than just a few minutes. If this is your first rodeo, make sure you have all of your practice demographics handy and the NPI/PTANs for at least 2 providers if you are not in solo practice.
Once you’ve successfully obtained the required EIDM account, the next step is to retrieve the QRUR. CMS has created another useful map to help you navigate this part of the journey. The 2014 QRUR was posted in early September. It’s basically a summary of how your practice performed in 2014 on the designated cost and quality metrics that make up the 2016 VM. As you may recall, the VM is a practice-level incentive program that modifies the Part B physician fee schedule for your entire practice. The 2016 VM will only apply to practices with at least 10 NPI providers. The program expands to include all medical practices in 2017, and the 2017 VM will reflect the work you do in 2015. Bottom line, regardless of practice size, you should jump through the necessary hoops to get your hands on the 2014 QRUR. It will be great practice for small medical groups and will let larger groups know what to expect in 2016.
As I mentioned above, the VM is unique among the CMS incentive programs we usually visit in this blog as it is administered by Tax-ID number as opposed to individual NPI number. Medicare beneficiaries are attributed to your practice using a two-tiered attribution scheme, very similar to the one used in many ACOs. Attribution is based on the plurality of primary care services rendered to the beneficiary during 2014. The first cut looks at services rendered by primary care providers. If the patient is not attributed in the first pass, services rendered by specialists are then considered.
At a very high level, a cost and a quality score are calculated for your practice. Those scores are then compared with the scores of other practices around the country. Of interest to nephrologists, 2014 represents the first time the VM comparison groups will be restricted to the same specialty. Stated another way, nephrology practices will now be compared to other nephrologists in the country, as opposed to all providers as was the case in years past.
The VM calculates a Quality Composite Score for your practice by rolling up two specific quality buckets:
- PQRS—the VM examines PQRS measures reported by the TIN, or PQRS measures reported by individual providers within the TIN. (The days of being paid to simply report these measures are behind us.)
- The three outcomes measures related to hospitalizations, which CMS captures by examining Medicare claims data for the beneficiaries attributed to your practice:
- Admissions for acute conditions (dehydration, pneumonia, UTI)
- Admissions for chronic conditions (diabetes, CHF, COPD)
- 30-day, all-cause readmission
By the way, as a sign of just how serious they are about this program, if your practice decided to ignore PQRS last year, not only will you incur the 2% PQRS penalty in 2016, but CMS will park your practice in the maximum VM penalty bucket and slap another 2% penalty on you. These penalties are additive, meaning you face a 4% haircut for your 2016 Part B book of business. While it’s too late for 2014, unless you plan to retire before January 2017, everyone reading this post should make absolutely certain they report PQRS in 2015. The consequences of not doing so will be devastating in 2017.
Your practice’s Cost Composite Score is made up of three components:
- The total Medicare Part A & B allowed charges incurred by the beneficiaries attributed to your practice in 2014 (per capita costs for attributed beneficiaries).
- The total Medicare Part A & B allowed charges incurred by specific types of beneficiaries attributed to your practice in 2014 (per capita costs for attributed beneficiaries with specific conditions). The conditions under scrutiny are diabetes, CAD, COPD, and CHF.
- Medicare Spending per Beneficiary (MSPB). A lot of confusion out there about this component of cost, but based on my read, the TIN that provides the plurality of physician services during a beneficiary’s hospital stay is stuck with the Part A & B allowable charges incurred by the beneficiary during the period that begins 3 days prior to admission and ends 30 days post discharge. Perhaps the best explanation I have seen for this one is here.
Value vs Volume
It’s difficult to give this topic the attention it deserves in a blog post. For those of you interested in taking a deeper dive into the components of the VM, I’d recommend this well-written explanation. As we’ve mentioned in the past, the shift from volume-based care to value-based care has many tentacles. Alternative payment models are an important piece of the puzzle. But whereas APMs are largely optional, the VM is mandatory. Groups with more than 10 providers will face the VM next year, and every provider is in starting in 2017. If you have not done so, do yourself a favor and navigate the steps necessary to retrieve your practice’s QRUR. It will be time well spent.
Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.