TMF HEALTH QUALITY INSTITUTE For no-cost consult- ing on Medicare’s quality reporting programs, turn to the TMF Quality Innovation Network Quality Improve- ment Organization, an offshoot of the TMF Health Quality Institute. Under con- tract with Medicare, TMF has created several educational networks you can join:
kFOR HELP WITH PQRS, QRURs, AND VALUE- BASED PAYMENT, JOIN THE VALUE-BASED IMPROVE- MENT AND OUTCOMES NETWORK:
www.tmfqin .org/Networks /Value-Based- Improvement-and- Outcomes.
kFOR HELP WITH HEALTH INFORMATION TECHNOLOGY, JOIN THE MEANINGFUL USE NETWORK:
www.tmfqin.org/ Networks/Meaning ful-Use.
kOR CONTACT: Christine Allen at
chris.allen@hcqis .org or (866) 439- 8863.
are “relatively straightforward and simple because the primary outcome we’re look- ing for is something we are already doing,” such as avoiding systemic antibiotics for pa- tients who don’t need them. “At this early stage, the PQRS program hasn’t fundamen- tally changed the way I do things. But it has fundamentally changed the way in which I think about documenting so the care I pro- vide can be demonstrated as being quality.” Having the flexibility to pick measures
also allows Dr. Ragain to develop a plan to boost disease screening and immunization rates. “In studies where you ask doctors if they believe in giving Pneumovax, 99 per- cent say yes, but only 20 percent or less are getting it. It’s about systems, and like any- thing, if you set up a system to deliver that care, it works better than if you depend on individual memory. Now we’ll drive those rates high, and that will change care.” Especially with the new quality and re-
source use reports (QRURs) Medicare re- leased, “knowing how we fare compared to the average range and benchmark is a good thing. And it’s really the first time we actu- ally had that kind of clinical data feedback.” The feedback reports provide informa-
tion on physicians’ cost and quality perfor- mance in 2013 and how they compare with their peers. Dr. Ragain says the analysis, though tricky to interpret, got his group thinking about how to coordinate specialty and primary care so patients who primarily visit the ophthalmology clinic, for example, don’t miss their vaccinations. Because the QRURs also preview the
performance scores Medicare uses to cal- culate the VBM, Dr. Ragain also could see his group face a potential penalty this year and make adjustments in time to avoid it.
WHY IS 2015 SO IMPORTANT?
This year, Medicare did away with the fi- nancial incentives previously offered to get physicians to participate in its various quality reporting programs. Now it’s purely a penalty-based system for those who do not comply. Also, with the VBM now in play, quality data reported in 2015 will af- fect Medicare payments for all physicians by 2017, and any penalties incurred are ap- plied in addition to those for PQRS nonre-
30 TEXAS MEDICINE April 2015
porting and failing to meet EHR meaningful use criteria. Those penalties alone add up to as much as 9 percent of pay in 2017. Earlier this year, the Department of
Health and Human Services — for “the first time in the history of the Medicare program,” according to a statement (tma
.tips/1zXX0au) — also set a goal of hav- ing 85 percent of all traditional Medicare payments tied to quality by 2016, whether through the physician VBM, alternative models like ACOs, patient-centered medi- cal homes, or bundled payments. “They told us this was coming,” Dr. Wal-
ters said. The move was already envisioned in the Deficit Reduction Act of 2005, “and if that was 2005, you can bet it was discussed in 2002 or 2003, if not before. It’s the train that’s hitting us now, but that train has been building up speed for some time, and the speed is going to rapidly increase.”
HOW DOES THE VALUE-BASED PAYMENT MODIFIER WORK?
Created by ACA, the VBM determines pay- ments by comparing a quality index value
— based on selected PQRS measures — with a cost index value — based on total physi- cian and hospital costs for that patient, ex- plains Donna Kinney, director of research and data analysis in TMA’s Division of Medical Economics. The modifier rewards or penalizes physicians whose scores are significantly different from average. The result is cuts to all Medicare fees for phy- sicians whose patients incur higher-than- average Medicare costs if quality scores are low; payment increases to physicians when measured quality is high and Medicare cost is low; and no adjustments for physicians whose care falls within the average.
WHAT ARE THE PENALTIES? WHEN DO THEY TAKE EFFECT?
The intersection of these federal quality reporting programs and their associated penalties could add up to a significant hit to physicians’ Medicare income for those who have not successfully participated as far back as 2013. That’s because the penal-
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