Getting Ready for Physician Value-Based Purchasing

Transcription

1 Getting Ready for Physician Value-Based Purchasing Patrick J. Torcson, MD, MMM, SFHM Chair SHM Performance Measurement and Reporting Committee Director of Hospital Medicine, St. Tammany Parish Hospital Getting Ready for Physician Value- Based Purchasing 1. ABC s of Medicare 2. CMS Value-Based Purchasing Agenda: Physician Quality Reporting System (PQRS) Physician Feedback Program Value Based Payment Modifier 3. Future Trends in Physician Payment 4. Summary and Conclusions The ABC s of CMS Medicare Part A Hospital payments FICA UB04 Inpatient Prospective Payment System $200 Billion Annual Spending Medicare Part B Physician Payments Premium based Form 1500 Physician Fee Schedule $110 Billion Annual Spending 1

2 CMS Influence: Mission: CMS is a constructive force and trustworthy partner for the continual improvement of health and healthcare for all Americans. Largest payer for healthcare in US: 45 million beneficiaries Sets national agenda for healthcare payment and policy. CMS Challenges: Unsustainable cost increases Modern Healthcare Untrustworthy Quality of Care Sources: modified from C. Buck, GE; Dr. Sam Nussbaum, Wellpoint IRS Phone-in Tax Advice Defects per million Overall Health Care Quality in U.S. (Rand Study 2003) NBA Free-throws Fair Reliability High Reliability Airline baggage handling U.S Airline flight fatalities/ U.S. Industry Best of Class Adopted from M. Sollek, Premera (69%) 2 (31%) 3 (7%) 4 (.6%) 5 (.002%) level (% Defects) 6 (.00003%) 2

3 The Value Equation: Value = Quality Cost IOM: Crossing the Quality Chasm Even among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systemically improve the quality of care, and may even prevent such actions. IOM, Crossing the Quality Chasm, p

4 Executive Order 13410: Directs Federal Agencies to: 1. Encourage adoption of health information technology standards for interoperability 2. Increase transparency in healthcare quality measurements 3. Increase transparency in healthcare pricing information 4. Promote quality and efficiency of care, which may include pay for performance CMS Quality Agenda: Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care Value-Based Purchasing payment based on quality Tools and initiatives for promoting better quality, while avoiding unnecessary costs CMS Physician VBP Plan FFS Physician Feedback Program Physician Quality Reporting System Value-Based Payment Modifier 4

5 PQRS Basics Formerly PQRI Voluntary Program Pay for Reporting (PFR) Statutory Authority: 2006 Tax Relief and Health Care Act (TRHCA) 259 Physician-Level Performance Measures 3 to 5 Measures for Each Specialty PQRS Participation 1. Performance Measure Selection 2. Implementation and Documentation of Measures 3. Performance Reporting 4. Bonus 5. Feedback Reports Performance Measures Definition: Whether or how often a process of care or outcome of care occurs. Source: Professional Societies NCQA JCAHO AHRQ Insurance Plans AMA If the MDs don t develop quality measures, the MBA s will. * Michael Leavitt, Secretary of Health & Human Services; AMN Dec 4,

6 AMA Physicians Consortium for Performance Improvement (PCPI) Physician-led initiative to facilitate quality improvement Provides performance measurement tools to practicing physicians Membership of more than 50 professional societies CMS, JCAHO, AHRQ (includes SHM) Working Agreement with CMS to develop 3 to 5 measures for 39 specialties Desirable Attributes of Performance Measures High priority for maximizing health Financially important Demonstrated variation in care Based on established clinical guidelines Meaningful and interpretable to user Well defined specifications Documented reliability and validity Allowance for risk Proven feasibility AMA Physicians Consortium for Performance Improvement Performance Measure Life Cycle Development (AMA Physician Consortium For Performance Improvement) Endorsement (National Quality Forum) Implementation (CMS, Private Health Plans) 6

7 Technical Construction of a Measure Denominator Defines eligible population Age, diagnosis, includes exclusions Numerator Process: evidence based diagnostic or therapeutic intervention Outcome: survival, biologic status of patient Percentage or Rate: divide number who correctly received care by number eligible to receive care 2013 PQRS Performance Measures for Hospitalists (10) 5. HF: ACE/ARB for LVSD* 47. Advance Care Plan 76. CVC Insertion Protocol 187. Stroke: Thrombolytic Therapy 228. HF: LV Function Testing* *Registry Only 2013 PQRS Performance Measures for Hospitalists (cont.) 31. Stroke: DVT Prophylaxis 32. Stroke: DC on Antiplatelet Therapy 33. Stroke: Anticoagulation for A Fib* 35. Stroke: Screening for Dysphagia 36. Stroke: Consideration of Rehab *Registry Only 7

8 PQRS Reporting Options 1. Claims-Based Reporting 3 measures, 50% of the cases in which the measure was reportable 2. Registry Reporting CMS Qualified Registry 3. Electronic Medical Record Reporting CEHRT 4. Maintenance of Certification Additional 0.5% bonus of Total Allowable Medicare Charges for participating in MOC program and reporting performance measures Physician Billing Process Step 1: Patient Encounter Documentation Step 2: Charge Capture ICD 9 Diagnosis Code CPT Evaluation and Management Code (E&M) Step 3: Claim Submission HCFA Form

9 PQRS Claims Reporting Process Step 1: Select 3 Performance Measures, must report 50% Step 2: Patient Encounter and Documentation Step 3: Charge Capture ICD 9 Diagnosis Code CPT E&M Code Step 4: Quality Data Codes (QDC) CPT Category II Performance Codes G Codes Step 5: Claims Submission HCFA Form 1500 What Are QDC s? Add on codes - indicates that a specific quality action or outcome was or was not done 1. CPT Category II Codes Developed by the AMA to mirror performance measures Facilitates reporting at time of service (rather than retrospective chart review) 2. G Codes part of CMS HCPCS Temporary codes Taxonomy of CPT II Codes 0000F Composite Measures 0500F Patient Management 1000F Patient History 2000F Physical Examination 3000F Diagnostic Processes/Results 4000F Preventive and Other Interventions 5000F Follow-Up and Other Outcomes 6000F Patient Safety 9

10 CPT II Exclusion Modifiers 1P Exclusion due to Medical Reasons Not indicated or contraindicated 2P Exclusion due to Patient Reasons Patient declined 3P Exclusion due to System Reason Resources not available Insurance limitations 8P Exclusion due to Reporting Reasons PQRS Performance Measure Specifications Numerator: Unique CPT Category II Performance Code or G Code Process: evidence based diagnostic or therapeutic intervention Outcome: survival, biologic status of patient Denominator: Defines eligible population and exclusions ICD 9 Code plus E&M Service Code PQRS Reporting Example Measure #47 Advance Care Plan Description: Percentage of patients aged 65 years and older with documentation of a surrogate decisionmaker or advance care plan in the medical record. Eligible Cases (Denominator): No ICD-9 required E & M 99221, 99222, (numerous others) Reporting Options (Numerator): 1123F: Surrogate decision maker or advance care plan documented 1124F: Not documented for patient reasons 1123F-8P: Reporting exclusion 10

11 PQRS Reporting Example Measure #47 Advance Care Plan History and Physical: Surrogate decision maker or advance care plan documented. HCFA 1500, line 24D: Denominator: E&M Service Code 99221, 99222, or (numerous others) Numerator: CPT II Performance Code 1123F PQRS #47 Advance Care Plan PQRS Registry Reporting Step 1: Choose a CMS Qualified Registry Step 2: Select 3 Performance Measures, must report 80% Step 3: ICD 9/E&M Cross Reference Step 4: Add QDC CPT II or G Codes Step 5: Report results to registry 11

12 ICD 9/CPT Cross Reference PQRS #31:Stroke: DVT Prophylaxis ICD X CPT QDC 4070F 4070F-1P 4070F-2P 4070F-8P PQRS Measure 31 Quality Data Code Reporting Options: 4070F: DVT prophylaxis received by end of hospital day F with 1P: Documentation of medical reason for not administering 4070F with 2P: Documentation of patient reason for not administering 4070F with 8P: DVT prophylaxis not received, reason not otherwise specified PQRS Registry 12

13 CMS Qualified Registries PQRS Bonus Payment Percentage of Total Allowable Medicare Charges: % % % % % negative1.5% payment adjustment (non participating physicians will receive only 98.5% of their Total Allowable Medicare Charges for the year) negative 2% payment adjustment PQRS and Hospitalists Bonus Calculation Example Mean Gross Charges for Hospitalist (2011 MGMA/SHM Survey) $444,453 Medicare as % of Payer Mix 33% Total Allowable Medicare Charges $146, % PQRS Bonus (2011) $1, % PQRS Bonus (2012 to 20014) $ % PQRS Negative Payment Adjustment (2015) 2% PQRS Negative Payment Adjustment (2016) -$2, $2,

14 PQRS Incentive Bonus 14

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16 Physician Compare Website ACA Section 10331: Starting 2013 requires public reporting of physician performance to include: PQRS results Patient health outcomes and functional status Assessment of continuity and coordination of care and care transitions Efficiency measures Assessment of patient experience and patent and family engagement Assessment of safety, effectiveness and timeliness of care CMS Physician VBP Plan FFS Physician Feedback Program Physician Quality Reporting System Value-Based Payment Modifier Physician Feedback Program Statutory Authority 2008 Medicare Improvements for Patients and Providers Act (MIPPA) Sec 131(c): The Secretary shall establish a Physician Feedback Program under which the Secretary shall use claims data to provide confidential reports to physicians that measure the resources involved in furnishing care. The Secretary may include information on the quality of care furnished by the physician (or group of physicians) in such reports Affordable Care Act (ACA) Section 3003(a): Continues and expands the Physician Feedback Program 16

17 What are QRUR s? Part of CMS Physician Feedback Program Provides meaningful and actionable information to physician so they can improve care Comparative data on cost of care and quality for care for Medicare Beneficiaries Change physician reimbursement to reward value rather than volume Physician payment adjustments using QRUR s begin 2015 QRUR in Evolution Phase I (2009): Reports on per capita and episode-based cost of care from 2007 claims data 1600 physicians in 12 geographic areas Phase II (2010): Includes 12 chronic condition ambulatory measures from Generating Medicare Physician Quality Performance Measures Results GEM QRUR Evolution (cont.) Phase III (2012): 56,000 physicians in Iowa, Nebraska, Kansas and Missouri 2011 PQRS results 28 HEDIS Measures Per capita total cost and peer cost-comparison for DM, CHF, CAD, COPD and Prostate Ca Phase IV ( ): Add physicians in Minnesota, Michigan, California, Wisconsin and Illinois Eventually QRUR s to every physician 17

18 QRUR Performance Highlights I. Quality of Care PQRS Results Medicare Claims Results: COPD Bone, Joint and Muscle Disorders Cancer Diabetes GYN Heart Conditions, HIV Mental Health Prevention Medication Management 18

19 QRUR Performance Highlights (cont.) II. Cost of Care Attribution Models Directed: > 35% E&M Visits Influenced: < 35% E&M Visits; > 20% Cost Contributed: < 35% E&M Visits; < 20% Cost Total Per Capita Costs QRUR Attribution On Average, 26 different physicians treated each of the Medicare patients for whom you submitted any claim. QRUR: Quality 19

20 QRUR: Cost QRUR: Chronic Disease Cost 20

21 Hospital Medicine and QRURs: 1. HM not a Medicare designated specialty categorized as Internal Medicine. 2. HM disadvantaged by quality/cost measurement methodology. 3. Promote attribution models fitting for HM. 4. Proactive development of quality measures that align performance and reimbursement. 5. Advocacy for SHM membership. 21

22 CMS Physician VBP Plan FFS Physician Feedback Program Physician Quality Reporting System Value-Based Payment Modifier Value-Based Payment Modifier: What Is It? 1. P4P: Physician payment based on quality of care. 2. Budget Neutral: payment will increase for some but decrease for others - aggregate Medicare spending for physician services will not change. 3. The Best Worst Choice to balance physician autonomy with accountability needed for safe and high quality care Millenson, Qual Saf Health Care. 2004;13: Limitations of the Current Medicare Physician Fee Schedule: 1. No incentives to focus on the relative cost or value of each service furnished or ordered. 2. No incentives to focus on the cumulative cost of a physician s own services and the services beneficiaries receive from other providers. 3. No incentives to focus on the quality and outcomes of the care furnished to beneficiaries. MedPAC, Report to Congress: Reforming the Delivery System, Chapter 1 (June 2008). 22

23 Value of Physician Services COST QUALITY Physician Performance is All Over the Map 50th %ile MD Quality Index (outcomes or % adherence to EBM) Lower Higher High Quality High Cost Low Quality High Cost (Worst) High Quality Low Cost (Best) Low Quality Low Cost Higher MD Longitudinal Cost Index Lower (total cost per case mix-adjusted treatment episode or chronic illness yr) 50th %ile 2006 A. Milstein MD Adapted from Regence Blue Shield 68 Goals of VBM: Improving Quality Risk adjusted outcome and patient experience measures Core set of measures appropriate to provider category Information collection with minimal burden to providers Measures endorsed by multi-stakeholder organization 23

24 Goals of VBM: Lower per-capita Growth in Expenditures Reward providers for reducing unnecessary expenditures and hold responsible for excess expenditures In reducing expenditures continually improve the quality of care delivered Apply cost reducing and quality improving, redesigned care processes to entire patent population Physician Branding High Quality, Low Cost BEST High Quality, High Cost Low Quality, Low Cost Low Quality, High Cost WORST The Value Based Payment Modifier Statutory Authority 2008 Medicare Improvements for Patients and Providers Act (MIPPA) Sec 1848(p): The Secretary shall establish a payment modifier that provides for differential payment to a physician or a group of physicians based upon the quality of care furnished compared to cost during a performance period Affordable Care Act (ACA) Section 3007: Adds to the requirement for a value modifier. 24

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29 The Goals of P4P: Redesign Systems to Improve Quality and Efficiency Reduce Errors Reduce Costs Advance Information Technology Broaden Delivery of Care Beyond the Office Put Direct Responsibility on Physician Practices to get it right the first time Improving the quality of care ultimately requires changes in the behavior of individual physicians. Epstein et al, N Engl J Med. 2004;350:

30 Expert Consensus on Physician P4P: There s no question that pay for performance will work Thomas Scully, CMS Administrator Wall Street Journal May 2003 Evidence suggests pay for performance can work but also can fail. Meredith Rosenthal, Harvard School of Public Health Oct 21, 2006 I am always entranced when intelligent people become mesmerized by an idea that is patently stupid. Nowhere has this phenomenon been more in evidence than in the pay for performance mania that is absolutely sweeping the nation. William G. Plested III, MD, AMA President American Medical News Feb 19, 2007 Pay-for-Performance Programs in Family Practices in the United Kingdom 76 Clinical Quality Indicators covering 10 chronic diseases $3.2 Billion new money to program 83.4% median reported achievement $40,200 increased gross income for average FP (baseline $122K to $131K) financial incentives should be aligned to physicians professional values to avoid serious distortions of care. Doran et al, N Engl J Med. 2006;355: The effect of financial incentives on the quality of health care provided by primary care physicians Objective: To examine the effect of payment changes on the quality of care by PCP s Main Results: 7 studies; smoking cessation, patient assessment of quality, cervical ca screening; mammography; DM outcomes, immunizations, Chlamydia screening, asthma medications Conclusion: there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. Scott et al, Cochrane Library. Published Online Sept 7,

31 Does Performance Based Remuneration for Individual Health Care Practitioners Affect Patient Care? A Systematic Review Purpose: To evaluate the effect of P4P targeting individual health care providers. Study Selection: 2 reviewers identified 30 randomized controlled trials; interrupted time series; uncontrolled and controlled before-after studies; and cohort comparisons. Conclusion: The effect of P4P targeting individual practitioners on quality of care and outcomes remains largely uncertain. Implementation of P4P models should be accompanied by robust evaluation plans. Sherilyn et al, Ann Int Med. 2012;157: Why pay for performance may be incompatible with quality improvement The concept of P4P rests on flawed assumptions about medicine, measurement and motivation. Rewards can undermine motivation and worsen performance on complex cognitive tasks, especially when motivation is high to begin with. Despite a dearth of robust evidence that P4P is effective, payers charge ahead with implementing everywhere an intervention that has not been proven to work anywhere. We are worried that P4P may not work simply because tit changes the mindset needed for good doctoring. Woolhandler et al, BMJ 2012;345:e5015 doi 31

32 The National Commission on Physician Payment Reform 12 specific recommendations focused on: Eliminating FFS payment Blueprint for transitioning to value-based payment over 5 years Transparency in how physicians are paid and services reimbursed How to eliminate the SGR Getting Ready for Physician Value- Based Purchasing: 1. Recognize implications of budget neutrality. 2. New skills and competencies: Understand quality data and attribution models Implementation of PI methods Public policy advocacy around the rulemaking process 3. PQRS Reporting: platform for physician VBP. 4. Groups of 100+: decide now how to report. Ultimately, however, what a physician does or does not do depends on the Hippocratic Oath, ethics, and morals. Robert H. Brook, MD, ScD, RAND Corporation 32

33 Getting Ready for Physician Value-Based Purchasing Patrick J. Torcson, MD, MMM, SFHM 33