Barbara J. Connors, DO, MPH

Chief Medical Officer, Region III

The Centers for Medicare and Medicaid Services

Region III

CMS

Value-Based Purchasing

Initiatives

CMS’ Quality Improvement

Roadmap

Vision: The right care for every

person every time

Make care:

Safe

Effective

Efficient

Patient-centered

Timely

Equitable

CMS’ Quality Improvement

Roadmap

Strategies Work through partnerships

Measure quality and report comparative results

Encourage adoption of effective health

information technology

Promote innovation and the evidence base for

effective use of technology

Value-Based Purchasing: Improve quality

and avoid unnecessary costs

Why VBP?

Medicare Solvency and Beneficiary Impact Expenditures up from $219 billion in 2000 to a

projected $486 billion in 2009

Part A Trust Fund Excess of expenditures over tax income in 2007

Projected to be depleted by 2019

Part B Trust Fund Expenditures increasing 11% per year over the last 6

years

Medicare premiums, deductibles, and cost-sharing are projected to consume 28% of the average beneficiaries’ Social Security check in 2010

Medicare Reimbursement Rates

Practice Variation

What Does VBP Mean to CMS?

Transforming Medicare from a passive payer to an

active purchaser of higher quality, more efficient health

care

Tools and initiatives for promoting better quality, while

avoiding unnecessary costs

Tools: measurement, payment incentives, public reporting,

conditions of participation, coverage policy, QIO program

Initiatives: pay for reporting, pay for performance,

gainsharing, competitive bidding, bundled payment, coverage

decisions, direct provider support

Value-Based Purchasing-

What it is really about:

It is about defining/rewarding

providers for the value of their

contribution to quality and

efficient care that leads to better

health outcomes.

VBP: Payment Methodologies

• Pay for Reporting

• Pay for Participation

• Pay for Care Coordination

• Pay for Process

• Pay for Outcomes

VBP Programs

Physician Quality Reporting Initiative

Physician Resource Use Reporting

Hospital Quality Initiative: Inpatient & Outpatient Pay for Reporting

Hospital VBP Plan & Report to Congress

Hospital-Acquired Conditions & Present on Admission Indicator Reporting

VBP

Towards Value-Based Purchasing

2007

•TRHCA

•74

measures

•Claims-

based only

2008

•MMSEA

•119

measures

•Claims

•4 Measures

Groups

•Registry

2009

•MIPPA

•153

measures

•Claims

•7

Measures

Groups

•Registry

•EHR-

testing

•eRx

2010

TBD

through

rule-

making

Statutory Authority

• Medicare Improvements for Patients and

Providers Act of 2008 (MIPPA)

– Section 131(d)

• Plan for Transition to Value-Based

Purchasing Program for Physicians and

Other Practitioners

• Report to Congress due May 1, 2010

Issues Paper Assumptions &

Design Principles

PVBP Planning will:– Focus on performance-based payment

– Accommodate different practice arrangements

– Recognize the contributions of members of the health professional team

– Address multiple levels of accountability

– Be at least budget neutral—across at least Medicare Parts A and B—and will seek to identify program savings

– Initially focus on traditional fee-for-service Medicare

– Have short-term and longer-term timeframes, with attention to transitions

– Avoid creating additional health care disparities and work to reduce existing disparities

– Include an ongoing evaluation process

Stakeholder Input:

Overarching Issues

• Affirmed goal and objectives

• Advocated for new payment approaches that

cut across settings and align Part A and B

payment incentives

• Agreed with the need to accommodate

different practice arrangements

• Praised attention to disparities

• Urged attention to operational transitions

Next Steps in Plan Development

• Receive direction from new leadership

• Design options– Physician Fee Schedule (PFS) overlay

• Performance-based PFS payments

• Medical Home

– Levels of accountability beyond individuals• Groups

• Accountable Care Entities

– Shared savings models

– Bundled payment arrangements

• Simulations pending availability of resources

• Opportunities for stakeholder input– PFS 2010 rulemaking

– Potential additional Listening Sessions

Medicare Improvements for Patients

and Providers Act of 2008 (MIPPA)

- Makes PQRI permanent; however

only 2009 and 2010 incentives are

funded

- Increased 2009 PQRI incentive to 2%

PQRI

• PQRI reporting focuses attention on quality of care– Foundation is evidence-based measures developed by

professionals.

– Reporting data for quality measurement is rewarded with financial incentive.

– Measurement enables improvements in care.

– Reporting is the first step toward pay-for-performance.

• Measures address various aspects of quality care– Prevention

– Chronic Care Management

– Acute Episode of Care Management

– Procedural Related Care

– Resource Utilization

– Care Coordination

2009 PQRI:

Eligible Professionals

• Physicians

– MD/DO

– Podiatrist

– Optometrist

– Oral Surgeon

– Dentist

– Chiropractor

• Therapists

– Physical Therapist

– Occupational Therapist

– Qualified Speech-Language Pathologist

• Practitioners

– Physician Assistant

– Nurse Practitioner

– Clinical Nurse

– Specialist

– Certified Registered Nurse

– Anesthetist

– Certified Nurse Midwife

– Clinical Social Worker

– Clinical Psychologist

– Registered Dietician

– Nutrition Professional

– Audiologist

PQRI Introduction:

Key Information

• No need to register: just begin

reporting.

• Must be an enrolled Medicare

provider (but need not have signed a

Medicare participation agreement).

• Need to use individual National

Provider Identifier (NPI).

PQRI Reporting

• CPT Category II codes used to report the

measure

• CPT II codes used in PQRI are referred to

as Quality Data Codes (QDCs)

• CPT II codes are non-billable

• Measures without assigned CPT II codes

may require the use of G Codes

Understanding the

Measure Construct

NUMERATOR

CPT II Code or Temporary G-code

(describes clinical action required for performance)

DENOMINATOR

ICD-9-CM & CPT Cat I Codes

(Describes eligible cases for which a clinical actionwas performed: the eligible patient population as

defined by denominator specification)

Reporting Quality Data

• Identify ICD-9 Code and CPT I code

• Chose CPT II code

• Exclusion modifiers

- 1P, 2P, 3P or 8P

• Modifiers indicate exclusions:– 1P- Exclusion due to Medical Reasons

– 2P- Exclusion due to Patient Reason

– 3P- Exclusion due to System Reason

– 8P- Action not performed, reason not otherwise specified

G Codes used for some measures

No modifiers apply with G codes

Different G Code for each clinical scenario

Reporting

• Paper based CMS 1500 claims

• Electronic 837-P claims

• Reported on the same claim as CPT I

• No registration is required to participate

• Voluntary program

Understanding the Measures:

Performance Time Frame

• Some measures have a Performance Timeframe related to the clinical action that may be distinct from the reporting frequency.

– Perform within 12 months

– Most Recent • Clinical test result needs to be obtained,

reviewed, reported one time. It need not have been performed during the reporting period.

Understanding the Measures:

Reporting Frequency

• Each measure has a Reporting Frequency

requirement for each eligible patient seen

during the reporting period

– Report one-time only

– Report once for each procedure performed

– Report for each acute episode

May have age relatedness

2009 PQRI Quality Measures

• 153 PQRI quality measures for 2009

– Includes 101 measures from the 2008 PQRI and 52

new measures

– E-prescribing measure (Measure #125) removed, as

required by MIPPA as a separate incentive program

– 18 measures reportable only through registries

– Measure specifications are available in the

Measures/Codes section of the website at

http://www.cms.hhs.gov/pqri.

2009 PQRI Reporting Periods

• 1 reporting period for claims-based

reporting of individual measures:

January 1, 2009 – December 31, 2009

• 2 reporting periods for reporting

measures groups and registry-based

reporting:

– January 1, 2009 – December 31, 2009

– July 1, 2009 – December 31, 2009

PQRI Claims-Based Process

Visit Documented in

the Medical Record

Encounter Form Coding & Billing

Carrier/MAC

NCH

Analysis Contractor National Claims

History File

Incentive

Payment

Confidential

Report

Critical

Step

N-365

Reporting Measures with Claims

Tips: Reporting Via Registry

• At least 3 individual measures must be reported;

OR

• At least 1 measures group, which, as long as Medicare Part B FFS patients are included, may also include Medicare Advantage and non-Medicare patients when reporting using the consecutive patient sample method

• 18 PQRI measures are reportable through registry only

Measure #124: (HIT): Adoption/Use of

Electronic Health Records (EHR)

2009 PQRI REPORTING OPTIONS:

CLAIMS-BASED, REGISTRY

DESCRIPTION:

• Documents whether provider has adopted

and is using health information technology.

To qualify, the provider must have adopted

and be using a certified/qualified EHR

Measure #102: Prostate Cancer: Avoidance

of Overuse of Bone Scan for Staging Low-

Risk Prostate Cancer Patients

2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY

DESCRIPTION

• Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer

Measure #104: Prostate Cancer:

Adjuvant Hormonal Therapy for High-

Risk Prostate Cancer

• 2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY

• DESCRIPTION:

• Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist)

Measure #105: Prostate Cancer:

Three-Dimensional (3D) Radiotherapy

2009 PQRI REPORTING OPTIONS:CLAIMS-BASED, REGISTRY

DESCRIPTION:

• Percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as a primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy)

Measure #143: Oncology: Medical and

Radiation – Pain Intensity Quantified

2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY

• This is a two-part measure which is paired with Measure #144: Oncology: Medical and Radiation: Plan of Care for Pain. If pain is present (CPT II code 1125F is submitted), #144 should also be reported.

DESCRIPTION:

• Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified

Measure #144: Oncology: Medical and

Radiation – Plan of Care for Pain

2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY

• This is a two-part measure which is paired with Measure #143: Oncology: Medical and Radiation: Pain Intensity Quantified. This measure should be reported if CPT II code 1125F “Pain severity quantified; pain present” is submitted for Measure #143.

• DESCRIPTION:

• Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain

Measure #156: Oncology: Radiation

Dose Limits to Normal Tissues

2009 PQRI REPORTING OPTIONS: CLAIMS-

BASED, REGISTRY

DESCRIPTION:

• Percentage of patients, regardless of age, with a

diagnosis of pancreatic or lung cancer receiving

3D conformal radiation therapy with

documentation in medical record that radiation

dose limits to normal tissues were established

prior to the initiation of a course of 3D conformal

radiation for a minimum of two tissues

2009 PQRI Measures Resources

http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage

• List of 153 2009 PQRI Measures – measure developer, reporting method

• Reporting Individual Measures via Claims

– 2009 PQRI Measures Specifications Manual for Claims and Registry and Release Notes

– 2009 PQRI Implementation Guide

• Reporting Measures Groups via Claims

– 2009 PQRI Measures Groups Specifications Manual and Release Notes

– Getting Started with 2009 PQRI Reporting of Measures Groups

– Measures Group Sample Claim

http://www.cms.hhs.gov/PQRI/30_EducationalResources.asp#TopOfPage

• MLN Matters Articles

• Fact Sheets

• Tip Sheets

• 2009 PQRI Patient-Level Measures List

Registries

• CMS received over 55 self-nomination requests for registries to become ―qualified‖ to submit quality data for possible incentive payment on behalf of their clients.

• 32 registries have been selected for ―production‖ (eligible to earn a payment incentive for their providers)

• The final list of ―qualified‖ registries is posted on the PQRI website at: http://www.cms.hhs.gov/PQRI/20_Reporting.asp#TopOfPage and go to the first download (―2008 List of Qualified Registries‖)

• CMS received over 55 self-nomination requests for registries to become ―qualified‖ to submit quality data for possible incentive payment on behalf of their clients.

• 32 registries have been selected for ―production‖ (eligible to earn a payment incentive for their providers)

• The final list of ―qualified‖ registries is posted on the PQRI website at: http://www.cms.hhs.gov/PQRI/20_Reporting.asp#TopOfPage and go to the first download (―2008 List of Qualified Registries‖)

PQRI Reporting:

Ensuring Success

• Ensure rendering professionals’ Individual

National Provider Identifier (NPI) on all claims

• Start reporting early to increase the probability of

achieving the 80 percent rate of reporting during

the reporting period.

• Report on as many measures as possible to

increase the likelihood of achieving successful

reporting.

• Ensure that quality data codes are reported on the

same claim as the diagnosis or CPT-I codes.

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

42

Benefits of PQRI Participation

• Receive confidential feedback reports to support quality improvement

• Earn a bonus incentive payment

• Make an investment in the future of the practice

– Prepare for higher bonus incentives over time

– Prepare for pay-for-performance

– Prepare for public reporting of performance results

2007 PQRI Reporting

Participation Statistics

• 109, 349 NPI/TINs – Attempted to Submit

• 101,138 NPI/TINs – Submitted a Quality Data

Code Successfully

– A feedback report is available

• 70,207 NPI/TINS – Satisfactorily Reported 1 or

more measures

– A feedback report is available

• 56,722 NPI/TINs – Earned Incentive

– A feedback report & incentive payment are available

Some Common Errors in

Claims-based Reporting

• Eligible claim submitted without QDC(s)

– Providers are not identifying all eligible claims per the measure denominator: some measures include additional sites of care other than an office visit; Medicare Secondary Payer claim without QDC

• Eligible claim submitted as a QDC-only claim (no denominator information on the claim)

– Billing software may be splitting the claim

• Ineligible claim with QDC for measure

Watch the denominator:

– Dx is incorrect or insufficient on claim for measure reported

– Surgical procedure is incorrect on claim for measure reported

– Age/gender on claim is incorrect for measure reported

2007 PQRI Experience Report

QDC Submission Attempts

• 12.15% Missing NPI

• 18.89% Incorrect HCPCS code*

• 13.93% Incorrect DX code*

• 7.24% Both incorrect HCPCS code and incorrect DX code*

• 4.97% All line items were QDCs only

*Denominator mismatch

Some Common Errors in

Claims-based Reporting

• Eligible claim with insufficient QDCs

• Eligible claim denied by carrier,

subsequently submitted but without

QDC

• Eligible claim paid partially by primary

payer submitted without

QDC as Medicare Secondary Payer

• Eligible claim without individual NPI

Top Ten Most Frequently

Reported Measures by Clinical Topic

1. Pneumonia

2. Chest Pain

3. Perioperative Care

4. Diabetes

5. ECG for Syncope

6. Coronary Artery Disease

7. Myocardial Infarction

8. Heart Failure

9. Macular Degeneration

10. Glaucoma

E-Prescribing

• The Medicare Improvements for Patients

and Providers Act of 2008 (MIPPA)

authorized an additional 2% incentive

payment to EPs who are voluntary

successful e-prescribers for program years

2009 through 2013.

What is E-Prescribing?

• The transmission, using electronic media,

of prescription or prescription-related

information between a prescriber,

dispenser, pharmacy benefit manager, or

health plan either directly or through an

intermediary, including an e-prescribing

network. E-prescribing includes, but is not

limited to, two-way transmissions between

the point of care and the dispenser.

Why e-Prescribing?

- Provides warnings and alert systems

- Provides access to pts medication history and allergies

- Reduces time on pharmacy phone calls and faxing

- Automation of renewals and authorizations

- Improves formulary adherence

- lower administrative costs

- Reduces oral miscommunications and confusion at hand offs

- Solves problem of hard to read prescriptions

Why e-Prescribing?

• 98,000 die from medical errors annually

– more than breast cancer, AIDS, or motor vehicle

accidents

• 1.5 million preventable adverse drug events

annually

– Hospitals, long-term care, outpatient encounters

– 530,000 among Medicare beneficiaries

– $877 million per year for Medicare beneficiaries

Source Institute of Medicine 1999, 2000, 2003, 2006

Getting Started in E-Prescribing

• Plan and implement a process within your practice to ensure successful claims-based reporting of the E-prescribing measure.

• Appoint a member of your team as the main contact person for trouble-shooting or fielding questions.

• Ensure that your system meets qualified e-prescribing system requirements, i.e., must employ standards adopted by the Secretary for Part D by virtue of the 2003 Medicare Modernization Act (MMA) and is capable of ALL of the following functionalities:

Getting Started

– Generating a complete active medication listincorporating electronic data received from pharmacies and pharmacy benefit managers (PBMs) if available

– Selecting medications, printing prescriptions, electronicallytransmitting prescriptions, and conducting all alerts*

– Providing information related to lower cost, therapeutically appropriate alternatives (if any).

• The availability of an e-prescribing system to receive tiered formulary information, if available, would meet this requirement for 2009.

– Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan (if available)

*An alert on an e-prescribing system is an automated prompt that indicates a potential inappropriate medication dose, route of administration, interactions, allergy concerns and warnings/cautions.

2009 Adoption and Use of

Medication E-Prescribing Measure

• E-prescribing quality measure may only be reported via a claims-based method.

• Eligible professionals (EPs) who successfully report (e-prescribers) may receive an incentive payment equal to 2% of total allowed charges for covered professional services furnished to patients enrolled in Medicare Part B* during the reporting period (January 1 through December 31, 2009).

• To qualify as a successful e-prescriber, a minimum of 10% of their Medicare Part B allowed charges must be generated from the specified denominator codes in the measure and the e-prescriber must report on at least 50% of all Medicare Part B patient encounters.

*Medicare Advantage or Private FFS patients are not included in the incentive

E-Prescribing Measure –

Denominator

Patient encounter for covered services during the reporting period (CPT or HCPCS):

• 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809

• 92002, 92004, 92012, 92014

• 96150, 96151, 96152

• 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245

• G0101, G0108, G0109

E-Prescribing Measure –

Numerator

• Prescriptions Generated via Qualified E-Prescribing System

– G8443: All prescriptions created during the encounter were generated using a qualified e-prescribing system OR

• Qualified E-Prescribing System Available, but noPrescription(s) were Generated During the Encounter– G8445: No prescriptions were generated during the encounter.

Provider does have access to a qualified e-prescribing systemOR

• E-Prescribing System Available, but not Used for One or More Prescriptions Due to Patient/System Reasons

– G8446: Provider does have access to a qualified e-prescribing system. Some or all prescriptions generated during the encounter were printed or phoned in as required by state or federal law or regulations, patient request, or pharmacy system being unable to receive electronic transmission; OR because they were for narcotics or other controlled substances

Understanding G8446

• Only allowable exceptions are delineated in

code descriptor:

– Controlled substance

– State, federal law

– Patient asks for hard copy

– Pharmacy cannot receive eRx

• Even if the clinician is not sure if the Medicare

service(s) billed for eligible denominator codes will

exceed 10% of Medicare allowed revenues, each

clinician should report the e-prescribing codes.

What is Not E-Prescribing

• Calling in a prescription

• Patient seen in ED is sent home with a written prescription

• Physician-generated faxed prescription to receiving pharmacy fax

• Sending a prescription via PDA (exception: depends on software used – must meet e-prescribing system qualifications)

• Knowingly sending a computer-generated fax initiated at the doctor’s office to a pharmacy (exception: if sent via qualified e-prescribing system and pharmacy system generates message as a fax, it is e-prescribing)

• Office visits during a global surgical period that result in a prescription

• Medicare Advantage patients (exception: some private fee-for-service plans can e-prescribe, but this does not count toward incentive payment calculation)

How eRx works

• An eligible professional decides to order a

prescription for a patient.

• The prescription is entered into an eRx

program and is transmitted to the desired

pharmacy.

• Communication also occurs between the

pharmacy benefit manager and the

physician.

eRx Communication

Professional

PharmacyPBM

SureScripts-RxHub

• This is the network where the prescription communication or messaging travels (between the 3 entities involved in eRx’ing i.e. the professional, pharmacy and PBM)

• Approximately 90% of U.S. prescriptions use the SureScripts-RxHub network

• eRx vendors using the SureScripts-RxHub network must be certified by SureScripts-RxHub

Selection of a System

• After you have checked on the part D

standards, a professional should ask the

eRx vendor if their system meets the

functionality requirements listed in our

measure?

• Ask to see each function demonstrated.

CCHIT

• CCHIT currently certifies EHRs which contain eRx

modules

– These systems meet the functionality requirements of the

measure if they have 2008 certification

• Some of the CCHIT certified programs may the

eRx component available for purchase separately

• Some products are designated ―partners‖ of

CCHIT certified EHRs

• CCHIT expects to review stand-alone systems for

certification in 2009

Part D Standards

• As part of SureScripts-RxHub’s vetting process, all vendors who are listed on the SureScripts website: http://www.surescripts.com/get-connected.aspx?ptype=physician meet the 2009 Part D standards for the functions they provide.

• If an eRx system is not on the SureScripts network, a potential customer should look at the Part D standards on the CMS website and check with the product’s vendor.

MIPPA Authorized

E-Prescribing Incentives

Year

Incentive for

Successful

E-Prescribers

Reduction for

Unsuccessful

E-Prescribers

2009 2.0%

2010 2.0%

2011 1.0%

2012 1.0% -1.0%

2013 0.5% -1.5%

2014 -2.0%

ARRA Authorized Incentives for Meaningful Use

of EHRs

Year First Payment Yr

(Subsequent payment

Yrs)

Reduction in

Fees for Non-

Use

2011 $18k ($12k, $8k, $4k,

$2k)

2012 $18k ($12k, $8k, $4k,

$2k)

2013 $15k ($12k, $8k, $4k)

2014 $12k ($8k, $4k)

2015 -1%

2016 -2%

2017 -3%

Summary of MIPPA and ARRA Authorized

Incentive Programs

YearMIPPA Authorized Incentive for

Successful E-Prescribers

ARRA Authorized Incentive for

Meaningful Use of EHR

2009

20102% Incentive

N/A

2011 1% Incentive $18k ($12k, $8k, $4k, $2k)

2012 1% Incentive $18k ($12k, $8k, $4k, $2k)

20130.5% Incentive

1.5% Reduction

$15k ($12k, $8k, $4k)

2014No Incentive

2% Reduction

$12k ($8k, $4k)

2015 N/A 1% Reduction

2016 N/A 2% Reduction

2017 N/A 3% Reduction

Demonstration Projects

• CMS currently pays for quality through a series of Demonstration Projects

• Several Demonstrations are mandated through Congressional Legislation

• Must be budget neutral

VBP Demonstrations and

Pilots

• Physician Group Practice Demonstration

• Medicare Care Management Performance

Demonstration

• Medicare Medical Home Demonstration

• Medicare Healthcare Quality

• Gainsharing Demonstrations

• Accountable Care Episode (ACE)

Demonstration

Demonstration Purpose

• Test the development and implementation

of Medicare policy changes prior to

legislation enacting such changes on a

national basis

– Whether it works…

– What refinements…

• Generally look at payment, new benefit,

new organization of care delivery

Acute Care Episode (ACE)

Demonstration

Problems with Current System

• Increased number of services not

necessarily correlated with better care

• Conflicting provider incentives

– Hospitals paid per discharge

– Physicians paid per service

Global Payment

• Fee-for-service

• Part A and Part B

• Services related to acute care

episode only

• Cardiovascular and/or orthopedic

procedures

Sites Selected

• Hillcrest Medical Center – Tulsa

• Baptist Health System – San Antonio

• Oklahoma Heart Hospital – Oklahoma City

• Lovelace Health System – Albuquerque

• Exempla Saint Joseph Hospital – Denver

• Two are cardiovascular only

• One is orthopedic only

• Two are both cardiovascular and orthopedic

Determination of Payment Rates

• Based on competitive bids from sites

• Compared to regular average Medicare payments to the hospitals and physicians

• Evaluated based upon the size of the discount

• Subject to annual IPPS updates

Benefits for Providers

• Potentially increased patient volume

– Value-Based Care Center

• Increased coordination leading to

increased efficiency

• Flexibility of managing global payments

• Option to engage in gainsharing

Gainsharing Demonstrations

• Authority

– Deficit Reduction Act (DRA) Section 5007

– Medicare Modernization Act (MMA) Section 646

– In the absence of statutory authority, gainsharing is restricted by law

• Purpose

– To allow hospitals to provide gainsharing payments designed to improve quality and efficiency of care to physicians

• Timing

– 3-year projects

• Target

– Hospitals and physicians

• Compensation

– Hospitals may share savings with physicians

Hospital and Physician

Alignment of Incentives

• Medicare pays hospitals prospectively for bundles

of services using DRGs

• Physicians generally paid per service

• How to align incentives to improve quality and

efficiency?

• Encourage physician-hospital collaboration by

permitting hospitals to share internal savings

Gainsharing Payments

• Incentive system must be uniform across

physicians, can be reviewed and audited.

• Payments must be linked to quality and

efficiency

• Gainsharing must be a transparent

• Must represent share of internal hospital

savings and be tied to quality improvement

• Limited to 25% of physician fees for care of

patients affected by quality improvement

activity

Demo Comparison

Design Feature DRA Section 5007 MMA Section 646

Size 2 hospitals

Beth Israel, NY

CAMC, WV

Physician groups and up to 13

affiliated hospitals in limited

number of geographic areas.

NJ 12 and WV 1

Scope of Evaluation Inpatient episodes and post-

discharge window (e.g., 30

days)

Inpatient episodes including

pre- and post-hospital care

over duration of demonstration

Eligible

Organizations

PPS hospitals, excludes CAHs Physician groups and affiliated

hospitals, integrated delivery

systems

Efficiency in the Quality Context

Efficiency Is One of the Institute of

Medicine's Key Dimensions of Quality

1. Safety

2. Effectiveness

3. Patient-Centeredness

4. Timeliness

5. Efficiency: absence of waste, overuse,

misuse, and errors

6. Equity

• Institute of Medicine: Crossing the Quality Chasm:

A New Health System for the 21st Century, March, 2001.

Physician Resource Use Reports

Pilot

Statutory Authority

Medicare Improvement for Patients and Providers Act of 2008, Section 131(c)

The Secretary shall establish a Physician Feedback Program under which the Secretary shall use claims data (and may use other data) to provide confidential reports to physicians (and, as determined appropriate by the Secretary, to groups of 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.

Physician Resource Use Measurement

Goals

Construct resource use measures that are meaningful, actionable, and fair

Provide confidential reports of resource use to individual/groups of physicians

Compare actual use to expected resource use

Link resource use to measures of quality and patient experiences of care

Statutory Authority

MIPPA Section 131(c)

MIPPA Options:

Resource use can be measured on an episode or

per capita basis, or both

Resource use can be measured with claims or

through other data sources

Focus can be on selected physicians by: specialty,

conditions treated, geography, high cost outliers,

minimum # of cases

CMS can make adjustments to resource use

measures to render them comparable across

physicians

Resource use measures can apply to individual

physicians or physician groups

Prepare claims data, including

Standardize unit prices

Group claims into episodes of care;

Sum costs of all claims in an episode

Risk-adjust the cost of each episode

Attribute each episode and associated episode cost

to one or more physicians

Calculate physician’s average cost for all

attributed episodes

Compare physician’s average cost to peer group

benchmark (including drill downs)

Produce, test, and distribute RURs

1

2

3

4

5

6

7

Creating Resource Use Reports

Value-Based Purchasing and

Hospital-Acquired Conditions

• The Hospital-Acquired Conditions provision

is a step toward Medicare VBP for hospitals

• Strong public support for CMS to pay less for

conditions that are acquired during a hospital

stay

• Considerable national press coverage of

HAC has prompted dialogue of how to

further eliminate healthcare-associated

infections and conditions

Statutory Authority:

DRA Section 5001(c)

Beginning October 1, 2007, hospitals were required to submit data on their claims for payment indicating whether diagnoses were present on admission (POA)

Beginning October 1, 2008, CMS cannot assign a case to a higher DRG based on the occurrence of one of the selected conditions, if that condition was acquired during the hospitalization

This provision does not apply to Critical Access Hospitals, Rehabilitation Hospitals, Psychiatric Hospitals, or any other facility not paid under the Medicare Hospital IPPS

Statutory Selection Criteria

CMS must select conditions that

are

1. High cost, high volume, or both

2. Assigned to a higher paying

DRG when present as a

secondary diagnosis

3. Reasonably preventable

through the application of

evidence-based guidelines

Present on Admission

Present on admission (POA) is defined as present at the time the order for inpatient admission occurs– Conditions that develop during an outpatient encounter,

including emergency department, observation, or outpatient surgery, are considered POA

POA indicator is assigned to – Principal diagnosis

– Secondary diagnoses

– External cause of injury codes (Medicare requires reporting only if E-code is reported as an additional diagnosis)

POA Indicator Reporting Options

Code Reason for Code

Y Diagnosis was present at time of inpatient admission.

N Diagnosis was not present at time of inpatient admission.

U Documentation insufficient to determine if condition was

present at the time of inpatient admission.

W Clinically undetermined. Provider unable to clinically

determine whether the condition was present at the time

of inpatient admission.

1 Unreported/Not used. Exempt from POA reporting. This code

is equivalent code of a blank on the UB-04; however, it was

determined that blanks are undesirable when submitting this

data via the 4010A.

― A joint effort between the healthcare

provider and the coder is essential to

achieve complete and accurate

documentation, code assignment, and

reporting of diagnoses and procedures.‖

Selected HACs for

Implementation

1. Foreign object retained after surgery

2. Air embolism

3. Blood incompatibility

4. Pressure ulcers– Stages III & IV

5. Falls– Fracture

– Dislocation

– Intracranial injury

– Crushing injury

– Burn

– Electric shock

Selected HACs for

Implementation

6. Manifestations of poor glycemic control

– Hypoglycemic coma

– Diabetic ketoacidosis

– Nonketotic hyperosmolar coma

– Secondary diabetes with ketoacidosis

– Secondary diabetes with hyperosmolarity

7. Catheter-associated urinary tract infection

8. Vascular catheter-associated infection

9. Deep vein thrombosis (DVT)/pulmonary embolism

(PE)

– Total knee replacement

– Hip replacement

Selected HACs for

Implementation

10. Surgical site infection

– Mediastinitis after coronary artery bypass graft (CABG)

– Certain orthopedic procedures

• Spine

• Neck

• Shoulder

• Elbow

– Bariatric surgery for obesity

• Laprascopic gastric bypass

• Gastroenterostomy

• Laparoscopic gastric restrictive surgery

Candidate HACs

• Fiscal Year 2009 Inpatient Prospective

Payment System (IPPS) final rule

http://edocket.access.gpo.gov/2008/pdf/E8-

17914.pdf (page 39)

Candidate HACs

1. Surgical site infection following device

procedures

2. Failure to rescue

3. Death or disability associated with drugs,

devices, or biologics

4. Dehydration

5. Malnutrition

Candidate HACs

6. Water-borne pathogens

7. Surgical site infections following

procedures – orthopedic and other

8. Ventilator-associated pneumonia

9. Clostridium difficile-associated disease

Proposed 2010 IPPS Rule

http://federalregister.gov/OFRUpload/OFR

Data/2009-10458_PI.pdf

Guidelines for Preventing HACs

• Where are guidelines developed– Professional organizations, Task Forces,

Government agencies, academic institutions

• What are they– Recommendations for interventions based

scientific evidence or expert opinion

• Who develops and uses them– Scientists, clinicians

– Policy makers, consumers

Future Considerations

• Risk adjustment– Individual and population level

• Rates of HACs for VBP– Appropriate for some HACs

• Uses of POA information– Public reporting

• Adoption of ICD-10– Example: 125 codes capturing size, depth, and location of

pressure ulcer

• Expansion of the IPPS HAC payment provision to other settings– Discussion in the IRF, OPPS/ASC, SNF, LTCH

regulations

Never Events

• Wrong surgery performed on a patient

• Surgery performed on wrong body part

• Surgery performed on the wrong patient

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223

Resources Available

Physician Quality Reporting Initiative:https://www.cms.hhs.gov/pqri

CMS Quality Initiatives – General Information:http://www.cms.hhs.gov/QualityInitiativesGenInfo/

12/9/08 Issues Paper: Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services

http://www.cms.hhs.gov/center/physician.asp

Hospital Quality Reporting:www.hospitalcompare.hhs.gov

Demonstrations:http://www.cms.hhs.gov/DemoProjectsEvalRpts/

pqri_inquiry@cms.hhs.gov

Resources

• E-Prescribing Incentive Program Website:

http://www.cms.hhs.gov/PQRI/03_EPrescribingIncentiveProgram.asp#TopOfPage

• Medicare’s Practical Guide to the E-Prescribing Incentive Program:

http://www.cms.hhs.gov/partnerships/downloads/11399.pdf

• E-Prescribing General Information:

http://www.cms.hhs.gov/eprescribing/

• SureScripts’ E-Rx Hub includes list of vendors who meet E-Prescribing qualifications:

http://www.surescripts.com/get-connected.aspx?ptype=physician

• Clinician’s Guide to Electronic Prescribing– http://ehealthinitiative.org/eRx/clinicians.mspx

• National E-prescribing Conference CME– http://www.massmed.org >e-prescribing CME information

THANK YOU!

Questions?

Barbara.Connors@cms.hhs.gov