Physician Groups that demonstrate high quality care receive increases to their Medicare Payments

By Sean Cavanaugh, Deputy Administrator & Director, Center for Medicare & Patrick Conway, MD, Deputy Administrator for Innovation and Quality & CMS Chief Medical Officer

This week, CMS posted results from the implementation of the first year of the Value-based Payment Modifier (Value Modifier) : http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2015-Value-Modifier-Results.pdf. Part of the Affordable Care Act, the Value Modifier rewards physicians and groups of physicians who provide high quality and cost effective care, while encouraging improvement for those who do not report quality measures or who don’t meet the mark. Based on their 2013 performance on quality and cost measures, nearly 7,000 physicians in 14 group practices across the country are receiving an increase in their Medicare payments in 2015.

Those group practices receiving increases fall into two categories:

  1. Groups that were determined to be providing high quality care and having average costs compared to national benchmarks. This comprises the majority of those receiving increases.
  2. Groups that were determined to be low cost and met the average quality performance compared to national benchmarks.

While groups that exceeded the program’s benchmarks in quality and cost efficiency receive an increase in physician payments under the Medicare Physician Fee Schedule, those who do not perform well or failed to meet quality reporting requirements are seeing a decrease to their Medicare payments in 2015. Most physician groups nationwide met the quality reporting requirements and their Medicare payments remain unchanged.

Physician groups getting an upward 2015 Value Modifier adjustment had, on average, lower (better) hospital readmissions rates—14.3 per 100 admissions—than the corresponding benchmark of 16.4 per 100 admissions. These groups also had on average lower hospital admissions rates for acute and chronic ambulatory care sensitive conditions.

Today’s news comes on the heels of Secretary Burwell’s recent announcement that HHS is setting measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care they give to patients. The Value Modifier is just one of many programs currently underway geared toward providing better care, spending healthcare dollars more wisely, and having healthier people and communities through the Affordable Care Act. To achieve these aims, we are focused on three key areas: (1) improving the way providers are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly to providers, consumers, and others to support better decisions while maintaining privacy.

The Value Modifier is being phased in gradually. In 2015, the Value Modifier is being applied to groups with 100 or more eligible professionals. In 2015, these groups were also given the option of electing “quality-tiering,” which was voluntary for the first year of the Value Modifier. Quality-tiering determines the type of payment adjustment (upward, downward or neutral) and the amount of the adjustment based on performance on quality and cost measures. Those who did not elect quality-tiering are not subject to upward or downward adjustments in 2015 based on their performance. Physician groups and physicians can find information about their quality and cost performance in their Quality Resource and Use Reports that were made available last fall. Information on how to access the reports can be found here.

Beginning in 2016, quality-tiering will automatically apply to all groups subject to the Value Modifier, which includes groups with at least 10 or more eligible professionals. In 2017, the Value Modifier will apply to all groups and to solo practitioners who are physicians. Although the Value Modifier currently only applies to physician payments, beginning in 2018, CMS will begin applying it to non-physician eligible professionals as well.

When it comes to improving the way providers are paid, we want to reward value and high-quality care, rather than volume. The Value Modifier reinforces our emphasis on quality, value and shared accountability, and recognizes and rewards those physician groups and physicians who meet those goals.

Successful ICD-10 Testing Shows Industry Ready to Take Next Step to Modernize Health Care

By Marilyn Tavenner, Administrator, Centers for Medicare and Medicaid Services

I am delighted to announce that CMS has recently successfully completed the first week of end-to-end testing of new ICD-10 coding.

The International Classification of Diseases, or ICD, is used to standardize codes for medical conditions and procedures. While most countries already use the 10th revision of these codes (or ICD-10), the United States has yet to adopt this convention. Since ICD-10 codes are more specific than ICD-9, doctors can capture much more information, meaning they can better understand important details about the patient’s health than with ICD-9-CM.

Approximately 660 providers and billing companies submitted nearly 15,000 test claims. This successful week of testing continues to put us on course for successful implementation of this important initiative that better reflects modern practice of medicine by Oct. 1, 2015.

Health care professionals use codes from the International Classification of Diseases—or ICD—to record their patients’ health conditions and document inpatient hospital procedures.

The U.S. is the last major industrialized nation to make the switch to ICD-10. The structure of ICD-9, which is more than 35 years old, limits the number of new codes that can be created, and many ICD-9 categories are full. ICD-10 provides room for code expansion, so providers can use codes more specific to patient diagnoses. [Fact sheet on ICD-10]

To promote the health care community’s smooth transition from ICD-9 to ICD-10, CMS is conducting a comprehensive program of testing. Because ICD codes are required on medical bills, we want health care providers to be confident they can submit Medicare claims and get paid as the nation switches to ICD-10.

To that end, Medicare recently tested ICD-10 claims processing with a variety of stakeholders including health care providers, billing agencies, and equipment suppliers. Overall, participants in the January 26 to February 3 testing were able to successfully submit ICD-10 claims and have them processed through our billing systems. To the extent that some claims were rejected, most didn’t meet the mark because of errors unrelated to ICD-9 or ICD-10.

Testing allows us to identify areas of improvement, and we will work with outside entities and stakeholders to improve those very small deficiencies identified. And we will continue to do testing, especially in those areas we identify as needing improvement.

We’ve also identified one point that’s caused some confusion in the health care community and beyond. So, we are communicating far and wide that everyone must use:

  • ICD-9 for services provided before the October 1 deadline
  • ICD-10 for services provided on or after October 1

That means ICD-10 can be used only for test purposes before October 1. And, only ICD-10 can be used for doctor’s visits and other services that happen on or after October 1. ICD-9 cannot be used to bill for services provided on or after October 1. This rule applies no matter when the claim is submitted, so claims submitted after October 1, 2015, for services provided before that date must use ICD-9 codes.

These rules and others around adopting ICD-10 apply to all health care providers, not just those who accept Medicare or Medicaid. So, like CMS, health insurance plans across the country are engaging in robust testing programs with doctors, hospitals, and other health care providers and suppliers. No major issues have emerged in the course of testing.

As the ICD-10 deadline draws near, I especially encourage medical practices and hospitals that bill Medicare to take advantage of testing opportunities. Beyond testing, CMS has undertaken an unprecedented level of outreach, training, and education to prepare the health care community for ICD-10. Our website cms.gov/ICD-10, offers many resources, including the Road to 10 tool, designed especially for small medical practices.

CMS is ready for ICD-10. And, thanks to our many partners—spanning providers, health plans, coders, clearinghouses, professional associations and vendor groups—the health care community at large will be ready for ICD-10 on October 1.

I appreciate the tremendous efforts and achievements of health professionals as we work together to realize the benefits of ICD-10 and other advances toward the ultimate goal of improving the quality and affordability of health care for all Americans.

###

What Consumers Need to Know about Corrected Form 1095-As

Last year, millions of Americans used advance payments of tax credits to help lower the cost of their monthly health insurance premiums. Now that tax season is here, individuals and families enrolled in a health plan through the Marketplaces will need to provide some basic information about their health insurance when they file their tax returns.

If you signed up for coverage through the Marketplace last year, you should have received a statement in the mail in February from the Marketplace called a Form 1095-A. This statement includes important information you need in order to complete and file your tax return. One piece of information included in your 1095-A is the premium amount for the “second lowest cost Silver plan” in your area. This premium amount represents the benchmark plan we use to determine the amount of premium tax credit you were eligible to receive.

Your 1095-A form should have arrived in your mailbox in February. Most consumers can also download a copy of their 1095-A through their HealthCare.gov account. We have been urging consumers to check the information on their forms – such as the number of people in your household – for accuracy. People who find errors on their form can contact the Marketplace Call Center at 1-800-318-2596 to find out how to request a corrected form.

About 20 percent of the tax filers who had Federally-facilitated Marketplace coverage in 2014 and used tax credits to lower their premium costs – about 800,000 (< 1% of total tax filers) – will soon receive an updated Form 1095-A because the original version they were issued listed an incorrect benchmark plan premium amount. Based upon preliminary estimates, we understand that approximately 90-95% of these tax filers haven’t filed their tax return yet. We are advising them to wait until the first week of March when they receive their new form or go online for correct information before filing. For those who have filed their taxes — approximately 50,000 (< 0.05% of total tax filers) – the Treasury Department will provide additional information soon.

It’s important to note that this issue does not affect the majority of Marketplace consumers and only affects people who signed up through one of the 37 states using HealthCare.gov. About 80 percent of Marketplace consumers who received a 1095-A from the federal Marketplace do not have affected forms and should go ahead and file their annual tax return. Additionally, this issue does not mean that consumers received the incorrect amount of tax credit throughout the year. It’s also important to note that this does not affect the vast majority of tax filers who will just need to check a box on their tax return to indicate that they had health coverage in 2014 either through their employer, Medicare, Medicaid, veterans care, or other qualified health coverage programs. 

Our priority is to make sure people with affected forms are alerted to the issue and are made aware of the steps they need to take. If your form was affected, you will receive a phone call from the Marketplace by early March, in addition to letters and emails with additional information about the status of your form.

Marketplace consumers concerned about the status of their 1095-A forms should take the following actions:

  1. You can find out if you are affected by logging in to your account at HealthCare.gov. You will see a notice message that will let you know if your form was or was not affected.  A majority of tax filers with Marketplace coverage through HealthCare.gov that received a 1095-A– about 80 percent – will find that their form was not affected by this issue and will be able to file their taxes with their current form.
  2. Wait to file if your form was affected. It’s best to wait to file your tax return until you receive your corrected 1095-A Form from the Marketplaces.  New forms are being sent from the Marketplace beginning in early March. When your corrected form is ready, we’ll also send a message to your Marketplace account on HealthCare.gov.
  3. If you need to file now, use our tool. If you can’t wait, and want to find the correct amount of the second lowest cost Silver plan that applied to your household in 2014, you have 2 options: 1) You can use this tool to find that amount, or 2) You can call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) and they can help.

As soon as we discovered the error, we immediately began examining who was affected, how to communicate about the error, and how to make the corrections process as simple as possible for consumers. We are committed to making sure that consumers who need corrected forms are contacted with updates and will receive new forms quickly. We are focused on making sure that every Marketplace consumer understands how taxes and health care intersect and if they need to get a corrected form, the steps they need to take.

Consumers with questions or who want to learn more are encouraged to visit www.healthcare.gov/taxes.  Representatives at the Marketplace Call Center are also standing by to answer consumer questions. The call center is open 24/7 at 1-800-318-2596.

Continuing to improve patient safety in hospitals

By Patrick Conway, Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer

Recently, a Department of Health and Human Services report showed that an estimated 50,000 fewer patients died in hospitals and approximately $12 billion in health care costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013.

This progress toward a safer health care system occurred during a period of concerted attention by hospitals throughout the country to reduce adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients, an initiative growing out of the Affordable Care Act, is a nation-wide public-private collaboration that began in April 2011 with two main goals: reduce preventable hospital-acquired conditions by 40 percent and 30-day readmissions by 20 percent.

Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results. Nationally, we are improving patient safety, resulting in 1.3 million adverse events and infections avoided in hospitals since 2010. This translates to a 17 percent decline in hospital-acquired conditions over the three-year period.

We are committed to making even greater progress keeping people as safe and healthy as possible. That is why we are launching a second round of Hospital Engagement Network contracts to continue reducing preventable hospital-acquired conditions and readmissions.

The Hospital Engagement Network funding will be available to award contracts to national, regional or state hospital associations, large health care organizations that hold corporate ownership and operational control of a group of hospitals that consist of at least 25 hospitals, or national affinity organizations that will support hospitals in the efforts to reduce preventable hospital acquired conditions and readmissions.

The Partnership for Patients and the Hospital Engagement Networks are one part of an overall effort to deliver better care, spend dollars more wisely, and improve health through the Affordable Care Act. Initiatives like the Partnership for Patients, Accountable Care Organizations, Quality Improvement Organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8 percent between January 2012 and December 2013 – translating into 150,000 fewer readmissions – in addition to quality improvements mentioned above.

And last month, HHS announced a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.

More information about the Hospital Engagement Network solicitation may be found at FedBizOpps.gov.

CMS encourages competition from all qualified entities that will help continue to build on the successes we have made so far.

Additional Information

 

 

CMS intends to modify requirements for Meaningful Use

By Patrick Conway, MD

Today, we at the Centers for Medicare & Medicaid Services (CMS) are pleased to announce our intent to engage in rulemaking to update the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs beginning in 2015. These intended changes would help to reduce the reporting burden on providers, while supporting the long term goals of the program.

Since the first year of the EHR Incentive Programs in 2011, the United States has seen unprecedented growth in the adoption and meaningful use of EHRs. To date, more than 400,000 eligible providers have joined the ranks of hospitals and professionals that have adopted or are meaningfully using EHRs. This means that millions of patients across the nation are benefiting from the potential of better coordinated care among professionals, more accurate prescribing, and improved communication.

The new rule, expected this spring, would be intended to be responsive to provider concerns about software implementation, information exchange readiness, and other related concerns in 2015. It would also be intended to propose changes reflective of developments in the industry and progress toward program goals achieved since the program began in 2011.

We are considering proposals to:

  • Realign hospital EHR reporting periods to the calendar year to allow eligible hospitals more time to incorporate 2014 Edition software into their workflows and to better align with other CMS quality programs.
  • Modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.
  • Shorten the EHR reporting period in 2015 to 90 days to accommodate these changes.

To clarify, we are working on multiple tracks right now to realign the program to reflect the progress toward program goals and be responsive to stakeholder input. Today’s announcement that we intend to pursue the changes to meaningful use beginning in 2015 through rulemaking, is separate from the forthcoming Stage 3 proposed rule that is expected to be released by early March. CMS intends to limit the scope of the Stage 3 proposed rule to the requirements and criteria for meaningful use in 2017 and subsequent years. 

These changes reflect the Department of Health and Human Services’ commitment to creating a health information technology infrastructure that elevates patient-centered care, improves health outcomes and supports the providers who care for patients. We continuously strive to work in partnership with providers to improve affordability, access, and quality.

For more information about the EHR Incentive Programs, please visit HTTP://www.cms.gov/EHRIncentivePrograms.

###

Moving forward on primary care transformation

By Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and Chief Medical Officer 

Today, we at the Centers for Medicare & Medicaid Services (CMS) are excited to announce the promising findings from two large-scale tests of advanced primary care: the Comprehensive Primary Care (CPC) initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration. The CPC initiative, in its first year, decreased hospital admissions by 2% and emergency department visits by 3%, contributing to the reduction of expenditures nearly enough to offset care management fees paid by CMS. The MAPCP Demonstration generated an estimated $4.2 million in savings through the use of advanced primary care initiatives.

These two programs are part of broader efforts to deliver better care, spend dollars more wisely, and have healthier people and communities.

Comprehensive Primary Care initiative

With authority from the Affordable Care Act, the CPC initiative is a unique multi-payer partnership between Medicare, Medicaid private health care payers, and primary care practices in four states (Arkansas, Colorado, New Jersey and Oregon) and three regions (New York’s Capital District and Hudson Valley, Ohio and Kentucky’s Cincinnati-Dayton region, and Oklahoma’s Greater Tulsa region). This initiative includes providing care management for those at greatest risk; improving health care access; tracking patient experience; coordinating care with hospitals and specialists; and using health information technology to support population health. Practices receive non-visit based care management fees from the participating payers, and the opportunity to share in savings.

In the first year, 492 practices participated, serving about 345,000 Medicare beneficiaries and more than 2.5 million patients overall. Results from this first year suggest that CPC has generated nearly enough savings in Medicare health care expenditures to offset care management fees paid by CMS.

  • The primary sources of the savings were reduced rates of hospital admissions and emergency department visits.
  • The bulk of the savings was generated by patients in the highest-risk quartile, but favorable results were also seen in other patients.
  • Over 90 percent of practices successfully met all first-year transformation requirements.
  • The expenditure impact estimates differ across the seven regions.
  • Additional time and data are needed to assess impact on care quality.

Results should be interpreted cautiously as effects are emerging earlier than anticipated, and additional research is needed to assess how the initiative affects cost and quality of care, beyond the first year. Because the effects of the CPC program are likely to be larger in subsequent years, these early results are consistent with the possibility that the model will eventually break-even or generate savings.

Multi-payer Advanced Primary Care Practice Demonstration

The MAPCP Demonstration is multi-payer initiative in which Medicare is participating with Medicaid and private health care payers in eight advanced primary care initiatives in Maine, Michigan, Minnesota, New York, North Carolina, Pennsylvania, Rhode Island, and Vermont. Unlike CPC, the states convene the participants and administer the initiatives rather than CMS. Under this demonstration, participating practices and other auxiliary supports (e.g., community health teams) receive monthly care management fees from the participating payers and additional support (e.g., data feedback, learning collaboratives, practice coaching).

More than 3,800 providers, 700 practices, and 400,000 Medicare beneficiaries participated in the first year. During the first year, the demonstration produced an estimated $4.2 million in savings. Also, the rate of growth in Medicare FFS health care expenditures was reduced in Vermont and Michigan, driven largely by reduced growth in inpatient expenditures. There is less evidence that the state initiatives were able to reduce hospitalization, readmission and emergency department visit rates. Additional findings in this evaluation period include:

  • The MAPCP payments provided needed support to help practices transform the way they deliver and coordinate care, including use of nurse care managers or care coordinators, restructuring of staff, improvements in patient flow, adoption of health information technology, and more frequent staff meetings.
  • Medicare was able to integrate seamlessly with the structure and organization of the eight state initiatives. Medicare’s participation sent a strong signal about the importance of primary care and the potential of these programs, helping to affirm payer and provider commitments.
  • Although collecting and using data was a recurring challenge, health information systems facilitated the transformation process.

These first-year results illustrate the potential for steady improvements in the participating practices’ advanced primary care capabilities. CMS anticipates continued improvements as the participating practices deepen and refine their methods of delivering advanced primary care so that patients can continue to receive improved quality and coordination of care.

Additional

 

 

ACOs Moving Ahead

By Sean Cavanaugh, Deputy Administrator and Director, Center for Medicare

Today, we at CMS are excited to announce that 89 new Accountable Care Organizations (ACOs) will be joining the Medicare Shared Savings Program (Shared Savings Program). With today’s announcement, we will have a total of 405 ACOs participating in the Shared Savings Program next year, serving more than 7.2 million beneficiaries. When combined with the Innovation Center’s 19 Pioneer ACOs, we will have a total of 424 ACOs serving over 7.8 million beneficiaries.    

ACOs are one part of this Administration’s vision for improving the coordination and integration of care received by Medicare beneficiaries. ACOs are groups of doctors, hospitals, and other health care providers that work together to give Medicare beneficiaries in Original Medicare (fee-for-service) high quality, coordinated care. ACOs can share in any savings they generate for Medicare, if they meet specified quality targets.

Since ACOs first began participating in the program in early 2012, thousands of health care providers have signed on to participate in the program, working together to provide better care to Medicare’s seniors and people with disabilities. In 2014 alone, existing Shared Savings Program ACOs added almost 17,000 healthcare providers, and the 89 new ACOs will bring approximately 23,000 additional physicians and other providers into the ACO program starting January 1. The growth of this program for providing health care has been continued and consistent since its inception, and we are encouraged by that interest.

We are starting to see promising results. This fall, we released the early findings from the ACOs who started the program in 2012. Shared Savings Program ACOs improved on 30 of the 33 quality measures in the first 2 years, including patients’ ratings of clinicians’ communication, beneficiaries’ rating of their doctors, and screening for high blood pressure. They also outperformed group practices reporting quality on 17 out of 22 measures. We are also seeing promising results on cost savings with combined total program savings of $417 million for the Shared Savings Program and the Pioneer ACO Model.

While we are encouraged by what we have seen so far, we also understand there are opportunities to improve the program to make it stronger. Earlier this month, we published a proposed rule to update the guidelines for the program. We are looking forward to receiving comments from ACOs, beneficiaries, and their advocates, providers, and other stakeholders interested in seeing the ACOs succeed long-term.

ACOs are also just one way that CMS is working to reduce the rate of growth in Medicare spending while improving care. Medicare spending per beneficiary was essentially flat in nominal dollars in fiscal year 2014, and from 2010 to 2014, Medicare spending per beneficiary grew at a rate that was 2 percentage points per year less than growth in GDP per capita. While the recent slow cost growth has multiple causes, our reforms in the Medicare and Medicaid programs are meaningful contributors to these gains and are improving quality as well. Preliminary data for 2013, for example, indicates improvements in patient safety resulted in 50,000 fewer deaths, 1.3 million fewer patient harms, and $12 billion in avoided health care spending. Recent research implies that many of these reforms may be generating savings in the private sector as well.

Ultimately, today’s announcement is about delivering better care, spending dollars more wisely, and having healthier people and communities. ACOs drive progress in the way care is provided by improving the coordination and integration of health care, and improving the health of patients with a priority placed on prevention and wellness. We look forward to continuing this partnership with doctors, hospitals, and other health care providers in increasing value and care coordination across the health system.

For a list of the 89 new ACOs announced today, visit: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News.html ?

 ###

Follow

Get every new post delivered to your Inbox.

Join 463 other followers

%d bloggers like this: