QRUR & VBPM More Essential Acronyms to Learn
By Lynn Berry, PT, CPC
The Value-based Purchasing (VBP) initiative, part of the Affordable Care Act of 2010, requires differential Medicare payments for physicians or physician groups based on the quality of care they furnish, as compared to the cost of that care. The driving concept behind VBP is that health care buyers, including consumers and third-party payers, should hold providers responsible for both the quality and the cost of care. To implement this concept, CMS will apply a yet-to-be-determined, value-based payment modifier (VBPM) to physician services billed under the Medicare Physician Fee Schedule (MPFS). By 2017, the VBPM will be applied to claims for most or all physicians who submit claims under the MPFS (see the accompanying information, “Value-based Payment Modifier Timeline”).
The QRURs are designed to:
- Make physicians aware of their resource use and total cost per beneficiary;
- Put forth the idea of being paid for both quality of care and the amount of resources expended;
- Inspire care coordination across various specialties; and
- Help work out the bugs with physician feedback before the program is initiated and your payments are affected.
In March 2012, CMS distributed 23,730 QRURs to physicians in Iowa, Kansas, Missouri, and Nebraska. The QRURs were derived from 2010 Physician Quality Reporting System (PQRS) claims data and claims-based reports for any physician in the above four states that billed at least one claim through the MPFS. They did not include PQRS measures reported electronically or through registries. The reports were confidential and for use only by the individual physicians, at that time. They were removed from the website July 13, 2012 and will be replaced by new reports containing 2011 data in the fall of 2012 for nine states (California, Iowa, Illinois, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin).
What QRURs Tell You
QRURs inform providers where they stand compared to other providers of the same specialty regarding quality measures reporting and the cost of care. CMS designated 28 quality measures and 13 sub-measures (41 total, including preventive care, cancer, diabetes, and heart conditions) to determine whether the beneficiary received the indicated treatment during 2010 for primary care and preventive services. The National Quality Forum (NQF) is working on additional measures for chronic diseases (asthma and chronic pulmonary disease) and other conditions (pneumonia and hip and knee replacements).
The QRURs separately identify services that the physician:
- Directed (the physician billed for 35 percent or more of all of the patient’s outpatient evaluation and management (E/M) visits;
- Influenced (the physician billed fewer than 35 percent of the patient’s outpatient E/M visits, but accounted for 20 percent or more of the professional cost of care); and
- Contributed to the (physician billed for less than 35 percent of the patient’s outpatient E/M visits and accounted for less than 20 percent of the patient’s total professional cost of care).
For each category, the actual Medicare costs of care were assigned per beneficiary, and were risk-adjusted by medical history and patient demographics. Percentages were provided for higher or lower cost per care, per physician, compared with peers and whether their quality of care was better than, equal to, or worse than average for the particular quality measures.
CMS provides the template used for the QRURs on its website.
CMS distributed the QRURs to a few states first, allowing these physicians to look at the overall quality of care received by patients they cared for using the PQRS measures noted, even though the physician might not have provided the measures him- or herself. It also allowed physicians to compare the number of PQRS measures they reported versus their peers, and provided them with an overview of the true total cost of care for each of their patients.
The QRURs also provided a way to analyze individual physician involvement with each of the patients treated. This type of data has not been previously available. It is hoped that physicians will use this data to think about the way they practice, and how they can coordinate resources with other physicians and hospitals to reduce overall costs. They can look at the reports and see where they excel in providing efficient care, and where they can make improvements in quality and/or cost by using resources better.
QRURs Foretell Value-based Reimbursement
A practice that currently is not using PQRS might want to consider which measures are applicable to their practice, and implement their use to show the quality of care they are actually providing as individuals. Remember: In 2015 there will be a payment penalty from CMS for not reporting quality measures.
The new proposed rule for the 2013 MPFS (CMS-1590-P) notes that participation in PQRS will affect the way in which the VBPM is applied.
For physician groups with 25 or more eligible professionals that have met satisfactory reporting criteria for PQRS, the value-based payment modifier would not affect payments (it would be set at 0.0 percent)—unless they choose an option to earn an upward payment adjustment for high performance, “high quality and low cost.” This option would, however, place the group at risk for a payment adjustment for poor performance, “low quality and high cost,” with a maximum downward payment adjustment of -1.0 percent, initially.
For those physicians that have not met PQRS reporting criteria, or do not participate in PQRS, their value-based payment modifier would be set at -1.0 percent, in addition to the -1.5 percent for non-participation in PQRS. CMS is seeking comment on whether this should apply to physicians in solo practice or groups with less than 25 eligible providers.
Over time, other measures will be included in the QRURs, such as Healthcare Effectiveness Data and Information Set (HEDIS) measures, Medicare EHR Incentive Program measures, and patient satisfaction scores. Another area in development is an “episode grouper” to include episode-based costs, including clinical-related data to apply to an episode of care (a specific period of time from the onset to conclusion of care). An example of this would be a hip or knee replacement surgery that includes all related services and costs for that episode (inpatient and/or outpatient surgery, physician visits, home health, rehabilitation, skilled nursing facility (SNF), etc.).
See the MPFS proposed rule of 2013 at: www.ofr.gov/OFRUpload/OFRData/2012-16814_PI.pdf
As new programs replace the existing fee-for-service (FFS) payment model, providers will need to pay more attention to the various demonstration projects and initiatives being started. It will take a lot of time and effort, but comments on the new models from current providers will aid Medicare in making provider-friendly choices in the future as they modify their system designs.
If your practice is in one of the four states, and you have received a report and wish to comment, you can email CMS at CMS_Medicare_Physician_Feedback_Program@mathematica-mpr.com, or participate by asking questions and providing feedback at any upcoming conference calls yet to be announced. CMS is enlisting your feedback now as they work to improve the process.
If your practice is not in the states where QRURs have been distributed, go to the CMS website to learn what is in store for you when your geographic area is accessed, and to ask questions or comment on ways to make the process more valuable. For more information, go to www.cms.gov/physicianfeedbackprogram.
You may also comment on the regulations for the VBPM found in the proposed rule at www.regulations.gov.
Learn the new acronyms. Join the discussion. Be a part of the process early in the game!
Lynn Berry, PT, CPC, had over 35 years of clinical and management experience before beginning a new career as a coder and auditor. She later became a provider representative for a Medicare carrier. She now has her own consulting firm, LSB HealthCare Consultants, LLC, furnishing consulting and education to diverse provider types. She is also a senior coder and auditor for The Coding Network and a pilot tester for CMS web-based training courses. She has held several offices in her local AAPC chapter and continues as one of the directors of the St. Louis West chapter.