1. No category

CY 2015 Medicare Physician Fee Schedule
Proposed Rule
July 31, 2014
© 2014, AAMC-UHC-FPSC®
Page 1
Housekeeping
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© 2014, AAMC-UHC-FPSC®
Page 2
Questions
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© 2014, AAMC-UHC-FPSC®
Page 3
Agenda
• The Big Picture
• Payment Policies
• Payment Update, RVU and GPCI Changes
• Chronic Care Management Code
• Expansion of Telehealth Services
• Transition to 0-day Global Codes
• Other Policies of Interest
• Quality and Efficiency Policies
• Value Modifier, PQRS, Physician Compare
• MSSP ACO
• Other Payment/Policy Changes
• Open Payments/ “Sunshine Act”
4 © 2014, AAMC-UHC-FPSC®
Page 4
2015 Medicare Physician Fee Schedule
Proposed Rule
•
Displayed on July 3; published in Federal Register 7/11
http://www.gpo.gov/fdsys/pkg/FR-2014-07-11/pdf/2014-15948.pdf
•
Supplemental materials (including RVU data)
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices-Items/CMS-1612-P.html
•
Comments due September 2; Final rule expected November 1
– Draft comment letter distributed ~Aug 26
We are seeking your feedback on the proposals!
5 © 2014, AAMC-UHC-FPSC®
Page 5
The Big Picture:
Payment Policies
•
Physician Update Stable through March
• Jan-Mar 2015: 0% update
• BUT CF changes from $35.8228 to $35.7977 due to
budget neutrality adjustments
• Apr-Dec 2015: Estimated 20.9% reduction
• Requires congressional action to avoid reduction
•
Payment/RVU Changes
•
•
•
•
•
New chronic care management code
Transition of 10- and 90-day global codes to 0-day global codes
Updated MP RVUs, 2nd year of GPCI updates
Expanded telehealth
Other Items of Note
• Modifications to Open Payments/ “Sunshine Act”
• Revised process for determining payment for new/revised codes
6 © 2014, AAMC-UHC-FPSC®
Page 6
Big Picture:
Estimated Impact of RVU Changes
CMS’ Projected Impact on Allowable Charges by Specialty
Largest Expected Increases
Largest Expected Decreases
•
•
•
•
•
•
•
•
•
•
•
•
Cardiology +1%
Family Practice +2%
Geriatrics +1%
Hematology/Oncology +1%
Internal Medicine +2%
Independent Labs +3%
Ophthalmology (-2%)
Radiology (-2%)
Radiation Oncology (-4%)
Radiation therapy Ctrs (-8%)
Dx Testing facility (-2%)
Portable x-ray (-3%)
Source: Table 60, Fed. Reg. 79, p.40523
7 © 2014, AAMC-UHC-FPSC®
Page 7
The Big Picture:
Quality and Efficiency
•
•
Up to 9% at risk for 2017 (EHR, PQRS, and Value Modifier)
Value modifier:
• Expands to all physicians, ACOs, non-physician practitioners
• Amount at risk doubles from 2% to 4%
•
PQRS:
• Cross-cutting measures requirement for registry/claims reporting
• Changes to GPRO Web/ACO reporting including new measures
•
MSSP ACO
• Proposal to give credit for improvement
•
Physician Compare
• All PQRS measures for groups/individuals and all reporting mechanisms
may be reported
• Benchmarks added to Physician Compare
8 © 2014, AAMC-UHC-FPSC®
Page 8
FPSC Will Be Offering Solutions To Help
Members Prepare for 2015
For All FPSC Participants
•
•
•
Model payments for non-face-to-face chronic care management services
Evaluate changes to 10- and 90-day global surgery codes
Develop member-specific Medicare Impact Analyses based on changes in the
final Physician Fee Schedule
For FPSC Quality & Efficiency Module Participants
•
•
•
•
August 6: Session on 2015 Proposed Fee Schedule Rule for PQRS group
reporting and Physician Value Modifier
Mid-August: GPRO Web benchmarking
Early September: Review of 2013 QRUR
Fall: 2013 QRUR Benchmarking project
– Executive summary and drill down reports
© 2014, AAMC-UHC-FPSC®
Page 9
Medicare Physician Fee Schedule Proposed Rule CY2015
PAYMENT POLICIES
© 2014, AAMC-UHC-FPSC®
Page 10
Reminder: Regulation v. Legislation
Regulation
(CMS)
• Regulations implement existing law
• Example:
• CMS can modify the RVUs and the GPCI weights
• Changes to PQRS or EHR measures
• Modifying non-statutory policies related to
payment
• Medicare PFS Proposed Rule is part of the
regulatory process
• Law requires comment on proposals and agency
to respond to comments
• Final rule in November
© 2014, AAMC-UHC-FPSC®
Legislation
(Congress)
• Congress creates new laws and can use legislation
to change existing laws or policies. President must
sign bill; if bill vetoed by President only becomes
law if Congress overrides veto (2/3 House and
Senate)
• Example:
• Physician update formula (SGR) is written in law.
It requires Congressional action to overturn the
20.9% reduction scheduled for April 1, 2015
• Extending the GPCI work floor also requires
legislation
• SGR repeal or patches determine the “size” of the
pot and any potential savings to pay for increased
update
• Potential “savings” could include cuts to
academic enterprise: IME, HOPD cuts
Page 11
Reminder: ACA Incentives Sunset
• Medicaid Primary Care Payment
• Pays no lower than Medicare rates for Medicaid
primary care services
• Ends in 2014
• Primary Care Incentive Payment (PCIP)
• 10% bonus on PC services by Primary Care Providers
• Ends in 2015
• HPSA Surgical Incentive Payment
• 10% bonus for major surgical procedures by general
surgeons in HPSAs
• Ends in 2015
© 2014, AAMC-UHC-FPSC®
Page 12
2015 Physician Update, Conversion Factor and
GPCI Work Floor
• Protecting Access to Medicare Act of 2014 does the
following until March 31, 2015
– Continues 0% update for physician update
– Extends GPCI work floor
• Congress needs to sign legislation to prevent an
additional 20.9% cut to CF and prevent the work floor
from expiring April 1, 2015
• 2015 Conversion Factor for the first three months has a
slight decrease due to budget neutrality adjustments
– New CF: $35.7977
© 2014, AAMC-UHC-FPSC®
Page 13
RVUs and GPCIs
• Malpractice RVUs updated
– Same methodology as before
– Corrected error in ophthalmology data  decrease in
aggregate ophthalmology $$
• PE RVUs
– Adopted recommendation to shift radiology inputs
from film to digital
• GPCIs
– 2nd year of implementing 2014 GPCI update
– New codes for Virgin Islands
© 2014, AAMC-UHC-FPSC®
Page 14
Proposed Revisions to Chronic Care
Management Codes
•
•
Finalized in 2014 PFS final rule
For services furnished to patients with two or more complex chronic
conditions expected to last at least 12 months or until death
Chronic Care
Management
(CY2015)
Transitional
Care
Management
(CY2013)
New codes in
future
rulemaking
Increased
Value on PC
and Care
Management
(Fed. Reg., p. 40364-40368)
© 2014, AAMC-UHC-FPSC®
Page 15
Chronic Care Management (CCM)
Services furnished to patients with two or more chronic
conditions expected to last at least 12 months; 20 minutes
or more; per 30 days.
$41.92 per patient per month
Proposed Scope of services include:
•
•
•
•
•
Access to care management services 24/7
Management of care transitions
Coordination with home and community based providers
Provider-patient communication via phone, secure messaging, or
other non-face-to-face methods.
PLUS others (full list on p. 40368)
*Written consent required from patient to perform and bill for services*
© 2014, AAMC-UHC-FPSC®
Page 16
Important Proposed Changes to CCM
General Supervision Requirement
– Clinical staff can perform services under “general” supervision
instead of “direct” at any time
• Previously time was only counted if the service was outside normal business
hours
• Clinical staff must still meet all other “incident to” provisions
Other major changes
– Clinical staff do not need to be direct employees
– Services must be furnished with the use of a EHR or HIT platform that is
accessible to all practice providers
© 2014, AAMC-UHC-FPSC®
Page 17
Expansion Telehealth Services
CMS Proposes to add 7 CPT and HCPCS Codes:
•
•
•
•
•
•
•
90845 - psychoanalysis
90846 – family psychotherapy (without patient present)
90847 – family psychotherapy (with patient present)
99345 – prolonged service requiring direct patient contact; first hour
99355 – prolonged services requiring direct patient contact; each
additional 30 minutes
G0438 – initial annual wellness visit
G0439 – subsequent annual wellness visit
List of Medicare codes and descriptors available at
www.cms.gov/telehealth
(Fed. Reg., p. 40356-40359)
© 2014, AAMC-UHC-FPSC®
Page 18
Transition to 0-Day Global Codes
CMS feels current 10 and 90 day global codes are not
accurately valued.
– Particular concern over accuracy of assumptions around “typical
case” post-op E/M services
Proposal:
• Transition 10-day global codes to 0-day in 2017
• Transition 90-day global codes to 0-day in 2018
“0-day global” maintains “same day” packaging of pre- and
post-op services
– Bill separately for each E/M visit and service outside that day
(including administering patient cost-sharing)
(Fed. Reg., p. 40341-40346)
19 © 2014, AAMC-UHC-FPSC®
Page 19
Transition to 0-Day Global Codes
• Proposal does not address teaching physician
documentation rules
– Current guidelines:
The teaching surgeon determines which postoperative visits are considered key
or critical and require his or her presence. If the postoperative period extends
beyond the patient’s discharge and the teaching surgeon is not providing the
patient’s follow-up care, then instructions on billing for less than the global
package in §40 apply
• If the global surgery period goes away, will the teaching
physician now be required to see and exam every postop patient if the post-op visit is to be billed as an E/M
visit?
© 2014, AAMC-UHC-FPSC®
Page 20
Transition to 0-Day Global Codes
CMS seeks comments on how to efficiently obtain accurate data to:
Revalue or adjust wRVUs for current global codes to reflect typical
resources involved in furnishing services, including pre-and post-op care on
day of procedure
How to determine the number and level of post-op E/M visits
And comments on how to best approach the proposed transition:
How to mitigate the separate payment of E/M visits does not incentivize
otherwise unnecessary office visits during post-op period;
How to determine appropriate valuation for new, revised or potentially
misvalued 10 or 90 day global codes before implementation of the proposal
A faster or slower transition
21 © 2014, AAMC-UHC-FPSC®
Page 21
New Modifier Code for Off-Campus
Provider-Based Facilities
•
•
•
Reference to MedPAC concerns about higher payments
to hospital-based facilities than freestanding clinics
Last year, asked for preference on how to collect info
about off-campus and got no consensus
Proposal:
•
Starting 1/1/15, use HCPCS modifier for services furnished in
off-campus provider-based department, reported on:
• CMS-1500 (for physician services)
• UB-04 (CMS Form 1450) (for hospital outpatient services)
(Fed. Reg., p. 40332-40334)
22 © 2014, AAMC-UHC-FPSC®
Page 22
Hospital Campus Definition
•
Definition of “on-campus”:
“We define a hospital campus to be the physical area
immediately adjacent to the provider’s main buildings,
other areas and structures that are not strictly
contiguous to the main buildings but are located within
250 yards of the main buildings, and any other areas
determined on an individual case basis, by the CMS
regional office.” (emphasis added)
• Full definition at §413.65
© 2014, AAMC-UHC-FPSC®
Page 23
Revisions to Process for Determining Payments for
New and Revised Codes
•
•
CMS proposes to modify current process for establishing
payments on new and revised CPT codes (also in OPPS
proposed rule), effective 2016
Why?
–
–
–
Previously reviewed RVUs every 5 years and had a specific rule
to proposed rule which allowed for public comments
New consolidated process review CPT codes each year. Lack of
public comments for some codes prior to Jan. 1 implementation
date
Codes paid on “interim final” basis until next year
(Fed. Reg., p. 40363-40364)
© 2014, AAMC-UHC-FPSC®
Page 24
Revisions to Process for Determining Payments for
New and Revised Codes (Continued)
• Proposed Revised Process:
• Revised/changed CPT codes received too late for
inclusion in proposed rule (example single CPT is split
into 2 new CPT codes)
–
–
–
–
•
Delay adoption of new codes
Create and use HCPCS G-codes that mirror the predecessor codes
Include proposal in following year’s proposed rule
Administrative burden?
“Wholly New Services”:
–
–
Will “make every effort to work the AMA CPT Editorial Panel” to get the
codes in time for the proposed rule
If not in time, will establish interim final value for 1 year (i.e. follow
current process)
© 2014, AAMC-UHC-FPSC®
Page 25
New and Revised CPT Codes, cont.
• CMS specifically interested in your answers to:
•
•
•
•
•
•
Is this proposal preferable to the current process?
Better to move forward now or delay implementation of
new policy beyond CY 2016?
Alternatives to using HCPCS G-codes?
Is the proposal appropriate re: wholly new services?
How should CMS define new services?
Any other classes of services (other than new services)
that should remain on an interim final schedule?
26© 2014, AAMC-UHC-FPSC®
Page 26
Seeking Feedback on Other Policies
•
Moderate sedation (Fed. Reg., p. 40349)
– 300 diagnostic and therapeutic procedures include moderate sedation
(Appendix G codes)
– CMS noted increase in separate anesthesia services being billed
– CMS seeking feedback on:
• How to pay accurately when moderate sedation is furnished but avoid
duplicative payments when anesthesia is furnished separately
• If moderate sedation were to be paid separately, how should it be reported
and valued? How should CMS remove sedation from existing RVUs?
•
Secondary Interpretation (Fed. Reg., p. 40370)
– Medicare can pay for “second interpretation” of existing radiology
images in “unusual circumstances” (billing modifier -77)
– CMS seeking comments on if there is an expanded set of
circumstances to allow more routine payment for a second interpretation
© 2014, AAMC-UHC-FPSC®
Page 27
Questions on Payment Proposals?
•
•
•
•
•
•
RVUs, Conversion Factor, SGR
Chronic Care Management code
Telehealth Services
0-Day Global Payments
Off-Campus Facilities
Other:
– New/revised code process, moderate
sedation, secondary interpretation
© 2014, AAMC-UHC-FPSC®
Page 28
Medicare Physician Fee Schedule Proposed Rule CY2015
QUALITY AND EFFICIENCY
POLICIES
© 2014, AAMC-UHC-FPSC®
Page 29
PFS Payment Shifts Over Time
Potential Incentives
2015
2016
2017
2018
2019
Mcare/Mcaid EHR Incentivea
Varies
Varies
Mcaid Only
Mcaid Only
Mcaid Only
Value-Modifier (Max incentive) b
+1.0(x)
+2.0(x)
+4.0(x)
(proposed)
TBD
TBD
Potential Reductions
2015
2016
2017
2018
2019
Medicare EHR Incentive
-1.0% or
-2.0%c
Up to -2.0%
Up to -3.0%
Up to 4.0%d
Up to 5.0%d
PQRS
-1.5%
-2.0%
-2.0%
-2.0%
-2.0%
Value-modifier (Max reduction)b
-1.0%
-2.0%
-4.0%
(proposed)
TBD
TBD
-4.5%
-6%
-9%
Total Possible Reduction
Starting in 2015: no more PQRS incentives; no more e-Rx penalties
a Medicare and Medicaid incentives and penalties vary by stage individual professional is at. For Medicare, eligible professionals (EPs)have to attest by 2014 to
earn any incentives. For Medicaid, EPs can earn their first incentive through 2016.
b Adjustment could be positive or negative. VM incentive is multiplied by an adjustment factor (x) TBD. There is an additional 1x for practices with high risk
populations that receive incentives. No maximum adjustment is defined in legislation.
c Penalty increases to 2% if EP is subject to 2014 eRx penalty and Medicare EHR Incentive.
d AFTER 2017, the penalty increases by 1 percent per year (to a max of 5%) if min 75% of EPs are not participating; otherwise max is 3%
© 2014, AAMC-UHC-FPSC®
Page 30
Major Proposals for Value Modifier (VM)
• Increased amount at risk
– Max penalty doubles from 2 percent to 4 percent
• Expansion of VM to:
– Groups of all sizes (including solo practitioners)
– All PQRS eligible professionals
– Pioneer/MSSP ACOs, Comprehensive Primary Care Initiative, other
CMS initiatives
• Changes to cost measure methodology
– Attribution adjustment
– Partial year enrollees
(Fed. Reg., p. 40492-40516)
© 2014, AAMC-UHC-FPSC®
Page 31
Proposed 2017 Value Modifier
Physician-Based Value Modifier Applies to ALL Groups
and ALL PQRS Eligible Professionals including MSSP
and Pioneer ACOs
•
•
•
2015 PQRS
Reporting
Group Reporting;
50% of EPs in
TIN; OR
Solo practitioner
NO
Automatic
-4.0% Penalty in 2017
(and if you consider the 2%
PQRS penalty, the total
reduction is 6%)
YES
Solo practitioners and
groups with 2-9 EPs
Eligible for Upward or
Neutral Adjustment based
on Performance
© 2014, AAMC-UHC-FPSC®
Groups of 10+ EPs
Eligible for Upward, Neutral
or Downward Adjustment
Based on Performance
(Max reduction is -4%)
Page 32
Amount at Risk Doubles for 2017 VM
• Quality Tiering - 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).
• This approach identifies statistically significant outliers and assigns them to their respective cost
and quality tiers.
Low cost
Average cost
High cost
High quality
+4.0x*
+2.0x*
+0.0%
Average quality
+2.0x*
+0.0%
-2.0%
Low quality
+0.0%
-2.0%
-4.0%
* Eligible for an additional +1.0x if Average beneficiary risk score in the top 25% of all beneficiary risk
scores
• Based on 2012 performance for large group practices
• 80% would have no adjustment
• 9% would have an upward adjustment
• 11% would have a downward adjustment
Source: CMS
© 2014, AAMC-UHC-FPSC®
Page 33
33
2017 Value Modifier Measures
Quality Measures
– PQRS reported measures
– 3 claims-based outcome
measures
• Acute prevention quality indicators
composite
• Chronic prevention quality
indicators composite
• All cause readmission (change)
Cost Measures
– Cost measures – not condition
specific
• Total cost per capita
• Medicare Spending per Beneficiary
– Per capita costs for 4 condition
populations
•
•
•
•
COPD
Heart Failure
Coronary Artery Disease
Diabetes
NEW LOGIC for Per Capita
Measures!
Cost measures risk-adjusted and price-standardized
© 2014, AAMC-UHC-FPSC®
Page 34
Total Per Capita Changes
Two proposed modifications based on NQF feedback
1. Revised attribution methodology
– Assumes NPs, PAs, and CNS are primary care
– Step 1: Patient assigned on plurality of Primary Care Services by
physicians, NPs, PA, or CNS
– Step 2: If patient is not assigned in step 1, then use all services
by non-primary care physicians
2. Includes partial year enrollees
– Includes patients new to Medicare
– Includes patients who die during the year
© 2014, AAMC-UHC-FPSC®
Page 35
Including ACOs, Other Models
in the VM
• MSSP ACOs
– Use “average cost” for TINs and solo practitioners that are in
MSSP ACOs
– ACO GPRO Web submissions used for quality. VM
benchmarks, not ACO benchmarks will be used to calculate
quality score
– Multiple scenarios documenting rules what happens if TINs
move in and out of ACOs. General rule- “do not ‘track’ or ‘carry’
an individual’s performance from one TIN to another TIN”
• See Table 56 in proposed rule for more detail
• Pioneer ACOs and other models
– Specific scenarios for Pioneer ACOs
– Guidelines for other models
© 2014, AAMC-UHC-FPSC®
Page 36
Informal Review Process for VM
• 2015 adjustment, practices have until end of
January to submit request
– Any error in quality composite will be reclassified as
‘average quality’
– Any error in cost composite, cost composite will be
recalculated
• 2016 adjustment and beyond
– Must submit request 30 days after QRUR report
dissemination
– Both quality and cost composites will be recalculated.
© 2014, AAMC-UHC-FPSC®
Page 37
Episodes of Care/QRUR Reports
• Future VM could include episodes of care
– Special supplemental QRUR available on
IACS portal for groups with 100+ EPs
– Episode of care QRUR based on 2012 data
• 2013 QRURs expected at the end of
August
© 2014, AAMC-UHC-FPSC®
Page 38
Major Proposals for Physician Quality
Reporting System (PQRS)
Starting in 2015, EPs can no longer earn incentives for PQRS
reporting. Reporting is required to avoid PQRS and VM penalties
• “Cross-cutting” measures requirement
– For individuals or groups with a Medicare “face-to-face encounter”
reporting through claims or registry must report at least 2 cross-cutting
measures
•
GPRO Web
– Revised attribution methodology
– Reduced sample size for larger group practices
– Measure changes
•
Qualified Clinical Data Registries
– Option for individuals only
– Must report at least 3 outcome measures or (2 outcome, plus 1 patient
experience or resource measure)
(Fed. Reg., p. 40391-40474)
© 2014, AAMC-UHC-FPSC®
Page 39
PQRS Cross-Cutting Measures
• New requirement to report cross-cutting
measures for these reporting mechanisms
– Individual claims
– Individual registry
– Group registry reporting
• EPs or groups that have at least 1 face-toface encounter must report at least 2 of
the 18 measures in the cross-cutting
measure set
© 2014, AAMC-UHC-FPSC®
Page 40
PQRS Cross-Cutting Measure Set
Tobacco Use and Help with Quitting Among
Adolescents
Preventive Care and Screening; Tobacco Use:
Screening and Cessation Intervention
Childhood Immunization Status
Preventive Care and Screening: Screening for
Clinical Depression and Follow-up Plan
Documentation of Current Medications in the
Medical Record
Preventive Care and Screening: BMI
Screening and Follow-Up
Closing the Referral Loop: Receipt of
Specialist Report
Medication Reconciliation
Preventive Care and Screening: Influenza
Immunization
Pneumonia Vaccination Status for Older Adults
Preventive Care and Screenings: Screening
for High Blood Pressure and Follow-up
Falls: Screening for Fall Risk
Care Plan
Pain Assessment and Follow-up
Functional Outcome Assessment
CAHPS for PQRS Clinician/Group Survey
Controlling High Blood Pressure
Screening for Hepatitis C (HCV) for Patients at
High Risk
(Table 21, Fed. Reg., p. 40404 – 40409)
© 2014, AAMC-UHC-FPSC®
Page 41
PQRS – Reporting Requirement Changes
GPRO
• Proposed earlier registration deadline of June 30 of the reporting year
QCDR
• If reporting via QCDR, it is proposed to require at least 3 outcomes
measures or a resource use, patient experience, or efficiency measure.
• Maximum number of non-PQRS measures reported increased from 20
to 30.
Registry
• Proposed to push back reporting deadline to March 31 of the year
following the reporting period (ex: March 31, 2016 for 2015 reporting)
EHR
• Proposed to require groups to provide CMS with their EHR certification
number
CMS seeks comment on whether to allow more frequent submission
of PQRS data in the future
42 © 2014, AAMC-UHC-FPSC®
Page 42
PQRS – Group Reporting
GPRO Web Interface
• Report on all measures within interface and include data for first 248
consecutively ranked and assigned beneficiaries (groups of 25 or more)
– If pool of beneficiaries is less than 248, report on 100% of assigned beneficiaries
Registry – 2 or more EPs
• Report on 9 measures covering 3 NQS domains and report for at least
50% of Medicare FFS patients
EHR Direct and Submission Vendor – 2 or more EPs
• 9 measures covering 3 NQS domains
• If CEHRT does not contain data for at least 9 measures and 3 domains,
group reports measures for which they have Medicare Data
© 2014, AAMC-UHC-FPSC®
Page 43
Other Group Web Items
• For those using GPRO web, CMS to follow beneficiary
attribution methodology used by Value Modifier.
• For groups of 100+ EPs, CMS again proposes to require them
to select a CMS-certified vendor to administer the CAHPS
survey on their behalf.
– CMS also proposes that groups off 100+ be required to pay for this,
not CMS
– CAHPS would remain optional for groups of less than 100 EPs, although
groups of 25+ EPs need to report CG-CAHPS starting in 2018.
© 2014, AAMC-UHC-FPSC®
Page 44
Physician Compare
See Table 20 of the Federal Register for Summary of Proposed Data for
Public Reporting in 2015 and 2016 (Pg. 40391)
Key proposals:
• For 2015 data collection – all measures/reporting mechanisms can
be reported
– But can be changed due to technical feasibility
•
Creating composite scores using 2015 data and reporting in 2016
– CAD, diabetes, general surgery, oncology, preventive care, arthritis, total knee
•
Creation of benchmarks of 30th – 90th percentile corresponding to
minimum v. maximum performance
•
CMS proposes to publicly report all measures found statistically
significant in the Downloadable file.
© 2014, AAMC-UHC-FPSC®
Page 45
Questions on Quality & Efficiency
Proposals?
• Value Modifier
• PQRS
• Physician Compare
© 2014, AAMC-UHC-FPSC®
Page 46
Medicare Physician Fee Schedule Proposed Rule CY2015
MSSP ACO PROPOSALS
© 2014, AAMC-UHC-FPSC®
Page 47
Medicare Shared Savings Program (MSSP)
Recognizing Year-to-Year Improvements
• CMS proposes to add a quality improvement measure to award
participants for quality improvement to each of the existing four quality
domains.
– Bonus would be achieved in a domain if statistically significant levels are achieved
– Calculation would be similar to how Medicare Advantage quality improvement
measurement is calculated (t-test)
Alignment with EHR Incentive Program
• EPs participating in ACO who extract data from CEHRT would satisfy
eCQM component of Meaningful Use
Quality Performance Benchmarks
• CMS proposes changes to determining when measures are considered
“topped out”
• When national FFS data results in the 90th percentile for a measure being
greater than or equal to 95%, CMS proposes to use flat percentages for
the measure when the 60th percentile is greater than 80%.
© 2014, AAMC-UHC-FPSC®
Page 48
MSSP – Changes to Quality Measures
•
CMS Proposes to grade ACOs on 37 measures instead of the current 33
effective 2015 reporting period.
– Data would be reported in early 2016
Proposed New Measures
CAHPS Stewardship of patient resources
SNF 30 day all-cause readmission
All-cause unplanned readmission for
patients w/ Diabetes
All-cause unplanned readmission for
patients w/ heart failure
All-cause unplanned readmission for
patients w/ multiple chronic conditions
Depression remission at 12 months
Diabetes measure for foot exam
Diabetes measure for eye exam
Coronary artery disease: symptom
management
Coronary artery disease: beta blocker
therapy
Coronary artery disease: antiplatelet
therapy
Documentation of current quality
measures
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Medicare Physician Fee Schedule Proposed Rule CY2015
OTHER PROPOSALS
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Proposed Changes to the
“Sunshine Act” Regulations
• Regulations implementing ACA provisions that require
applicable manufacturers and group purchasing
organizations (GPOs) to report payments and other
transfers of value to physicians and teaching hospitals,
and ownership or investment interests held by physicians
• Reports are provided to CMS annually, then made
publicly available on the CMS Open Payments website
• CMS has proposed 4 changes to the rules for CY2015
(affecting reporting of all payments made in 2015)
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Proposed Sunshine Changes
• Remove definition of “covered device” because it is
duplicative of another defined term (§403.902)
• Remove the entire subsection exempting reporting of
payments to speakers at an accredited CME event if
certain conditions are met (§403.904(g))
• Revising a section to require reporting of a marketed
name of a product when applicable (§403.904(c)(8))
• Creating distinct reporting categories for stock, stock
option, and any other ownership interest (§403.904(d)(3))
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Changes to the CME
Reporting Exclusion
Current rule excludes certain payments made where the
applicable manufacturer is “unaware” of the identity of the
covered recipient
– CMS proposes that the specific CME exclusion be removed, but that when an
applicable manufacturer provides CME funding but does not select or pay the
speaker (or covered recipient) directly, CMS would consider those payments
excluded from reporting
Alternative approaches CMS considered include:
1) Expanding the list of accrediting organizations in the current
exclusion to include additional continuing education providers
2) Including specific CME accreditation, certification and enforcement
standards
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CME Changes to be Discussed
AAMC is holding a webinar on this issue to discuss the proposed
revisions and get member institution reactions and suggestions
Friday, August 1, 2014 at 1:00 P.M. EDT
• Register for the webinar here:
https://aamc5.webex.com/aamc5/onstage/g.php?t=a&d=665210367
You may also contact Heather Pierce directly for input on this issue or
questions related to the Sunshine Act implementation:
hpierce@aamc.org
(202) 478-9926
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Questions/Feedback
Questions about PFS Proposals
Mary Wheatley, mwheatley@aamc.org, 202-862-6297
Evan Collins, ecollins@aamc.edu, 202-828-0552
FPSC Projects Related to PFS
Dave Troland, troland@uhc.edu, 312-775-4357
Will Dardani, dardani@uhc.edu, 312-775-4510
FPSC Projects Q&E Projects
Shaifali Ray, ray@uhc.edu, 312-775-4305
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