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PQRS Incentives, Penalties and the Coming Value Based Payment Modifier

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The following is a guest post by Barry Haitoff, CEO of Medical Management Corporation of America.
Barry Haitoff
Much of the focus of healthcare has been on meaningful use and the EHR incentive money. Considering we just reached $19 billion of payouts, it’s definitely a topic worthy of attention. However, a topic which hasn’t gotten nearly as much attention, but is nearly or possibly more important than meaningful use is PQRS and the Value Based Payment Modifier.

Before I dig into some of the details and timelines for PQRS and the Value Based Payment Modifier, it’s really important to note that both of these programs are really just a preview of what’s happening with Medicare reimbursement. These programs are the core of the shift towards paying physicians differentially based on the quality and cost of the care they provide and away from the traditional fee for service model. We’ve seen similar value based payment arrangements with the advent of ACOs, CINs and other clinical networks establishing innovative payment models with payers. Understanding where these programs are going will give you a preview of what’s happening with healthcare reimbursement.

PQRS
When it comes to PQRS, much like meaningful use, there is both a PQRS incentive and PQRS penalty (carrot and stick if you prefer). 2014 is the final year to receive the PQRS incentive money (0.5% of Medicare Part B claims) and participants must submit 12 months of 2013 CQM data by February 28, 2014 if reporting by claims data, March 21, 2014 if reporting by GPRO web interface, and March 31, 2014 if reporting by registry data. (Note: The 2013 MU reporting deadline was moved to March 31, 2014, but the PQRS deadlines have not changed.). However, more important is that providers who don’t report PQRS 2013 data will be penalized 1.5% in 2015. Those who don’t participate in PQRS in 2014 will be penalized 2% in 2016.

Value Based Payment Modifier
While most people have heard about PQRS and are hopefully participating to avoid the penalties, many people haven’t heard about the Value Based Payment Modifier that is built on the PQRS foundation. While you could look at the Value Based Payment Modifier final rule, this Value-Based Payment Modifier summary is a much better overview of the program.

Essentially, the Affordable Care Act (ACA) required that CMS implement a value based payment modifier that would apply to Medicare fee for service payments. This program will start with physicians in groups of 100 or more eligible professionals under the same TIN beginning January 1, 2015, and apply to all physicians and groups by January 1, 2017. CMS also recently announced that this applies to both par and non-par Medicare providers with 100 or more eligible professionals.

Here’s a look at how this new Value Modifier will work for groups of physicians with 100 or more eligible professionals and will likely be a preview of what’s to come for all Medicare physicians:
CMS Value Modifier

While the program starts with relatively small 1% adjustments, this quote from CMS also provides a clear indication of where they want to take this program:

We also anticipate that we would propose to increase the amount of payment at risk for the Value Modifier as we gain additional experience with the methodologies used to assess the quality of care, and the cost of care, furnished by physicians and groups of physicians.

What should you do to be prepared for this new Value Based Payment Modifier?
1. Participate in the PQRS program since it’s the foundation of what’s to come.
2. Keep an eye on changes to the PQRS and Value Based Modifier programs. They are changing regularly and it’s worth knowing what’s changing with these programs.
3. Work with your professional organization to provide feedback on these programs. No doubt they’re keeping an eye on them and providing feedback as part of the government rule making process. Make sure your voice is heard.

CMS looks at this new value based modifier as a budget neutral program. That means that there are going to be winners and losers. By understanding how these programs work, you can better assess if you want to work to avoid the payment adjustments or if you’re ok taking them on.

Like it or not, PQRS is the start of the movement towards quality based reimbursement and likely a small preview of coming attractions. Of course, if the SGR Fix gets funded by congress, then PQRS, Meaningful Use and the Value Based Modifier will be sunset at the end of 2017 and rolled into a new Merit-Based Incentive Payment System (MIPS) that will start in 2018. More on MIPS in the future, but I think we can safely say that MIPS will be an amalgamation of all these incentive programs.

Medical Management Corporation of America, a leading provider of medical billing services, is a proud sponsor of EMR and HIPAA.

February 20, 2014 I Written By

Keeping the “Health” in “Heathcare”

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‘Tis the season for family gatherings, holiday parties, and a plethora of professional networking events – all of which give me ample opportunity to perfect my “elevator speech”, introducing my business. It seems like each time I discuss what I do for a living, the question that follows is, “So, how do you feel about Obamacare?”

I understand that the Affordable Care Act, AKA Obamacare, is a significant slice of the polarizing pie our nation is currently attempting to consume and digest. And I appreciate that now, for the first time in my career, more people than not take an interest in what I have to say about being “a healthcare data consultant.” In years past, eyes would glaze over as I explained the enormous potential of predictive analytics in wellness and disease management programs, or the power of unstructured data mining for clinical notes data. Mentioning the health insurance plans I worked with brought inquiries into individual versus group rates, and complaints about the latest round of premium increases. It’s been refreshing to experience keen interest and pointed questions as I talk, rather than have each person gulp the last sip of wine and excuse themselves to run for more as soon as they figured out I have nothing to do with how much out-of-pocket expense they’re incurring after each doctor visit.

But as much as I enjoy the sudden interest in healthcare policy and data management, there isn’t enough wine in the world to make me debate the politics of healthcare reform with my 6’5″ uncles, my friends, or my social media connections. I am not a lawyer or political pundit. I am not qualified to comment on the merits of the ACA legislation. I am not an economist. I am not qualified to comment on the fiscal impact of Obamacare. I am a technologist. I am qualified to comment on the translation of ACA’s many provisions into the infrastructure and applications supporting our healthcare system. I am also a healthcare system consumer. I AM qualified to comment on what I believe this historic legislation means to my health, the health of my family, and the health of future generations.

This is what ACA healthcare reform and its many facets – Health Information Exchange (HIE), Electronic Health Records (EHR), Electronic Medical Records (EMR), Meaningful Use (MU) – mean to me: more, better, faster healthcare data capture and communication between all the stakeholders involved in my health and wellness:

- More health data: Meaningful Use-certified EMR applications require that particular medical service activities and clinical data elements are captured and stored discretely, electronically, and made available for retrieval upon patient demand.

- Better health data: The majority of medical procedures, products, services, events, and outcomes are codified in order to meet regulatory standards. It may take longer for your provider to enter the information about a patient encounter into an EMR system than it did to scribble notes on a chart; however, because those detailed discrete data elements are now tied to compensation and incentives, there is a higher likelihood that more specific details will be captured individually per encounter, generating a more complete picture of a patient’s medical history than a manual review of their paper charts. No handwriting recognition required.

- Faster access to critical health data: With EHR applications and HIEs, providers can instantly access patient medical records from provider/facility sources and multiple insurance carriers. The difference between electronic transmission speeds and manual chart retrieval could be the difference between life and death.

How could a higher volume of increasingly accurate, integrated, and immediately available healthcare data result in adverse health outcomes?

To me, healthcare isn’t about politics. It is health care. It’s about me, caring for my health, and the health of my loved ones. I believe that technological advances can and will empower healthcare stakeholders of all ilks – provider, health insurance plan, pharmaceutical industry, patients – to increase the speed of condition diagnosis and treatment, and to assist in establishing and maintaining healthy habits for improved health over a lifetime.

This season, put the “health” back in “healthcare”.

December 11, 2012 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Republican Candidates Healthcare Stances

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Dr. James Coffin, VP of Healthcare and Life Sciences at Dell, has a post up on the Dell Healthcare Community site that looks at the stances of the various Republican candidates for the US Presidential nomination. It’s an interesting read if you haven’t been following the republican candidates very much.

What the article doesn’t address is these candidates stance on the HITECH Act. The key here is to realize that the HITECH act isn’t part of the Affordable Care Act which every GOP candidate is saying they will repeal if they become President. So, where does that really leave the HITECH Act should a republican president be elected?

The problem is that no one really knows. Those who argue that the HITECH Act is safe often lean on the ideas that EMR and EHR has always had bipartisan support. Many often mention that the push for adoption of EHR software was started by a republican president, George W. Bush. I actually agree that both sides of the aisle want to have widespread adoption of EHR. We could certainly argue the benefits or detriments of EHR adoption, but for a relatively uninformed senate, house and president when it comes to EHR, they’re going to easily grab on to the idea that technology can improve healthcare. We may agree or disagree with this point, but I think we’d be hard pressed to find a senator that thinks we shouldn’t have EHR technology in healthcare.

The problem with the above discussion has to do with the way that EHR is being paid for. Again, this isn’t about whether the idea of paying doctors to use EHR software is right or wrong, good or bad. This is more about the political stance of the republicans and how they want government to spend money. It seems very clear to me that Republicans are going to keep sitting on their no spending/cut spending soap box. If a republican becomes President, we’re likely to see widespread cuts. Could HITECH money be a casualty of those cuts? Absolutely. Will they be a casualty? Can anyone predict what Washington will really do?

Should doctors and practices then be afraid of going after the EHR stimulus money? Well, I’ve been advising doctors and practices for the last couple years to not implement an EHR in order to get the government hand out. Those that are doing EHR for “free” government money are going to be disappointed. Not only because the money could be cut, but because sooner or later that money will be gone. So, if you’ve followed my advice, then the loss of the EHR stimulus money will be unfortunate but not too terrible.

On the other hand, those people who only did EHR because the government was waving the carrot and the stick are likely going to be quite disappointed. Particularly if the practice focused on the governments EHR requirements instead of their own individual practice needs when it comes to an EHR. Sadly, I believe there are many clinics in this boat.

I’m sure there are other Washington DC insider workings that are in play as well. Hopefully many of you will share some of what you know in the comments.

Personally, I’m still fairly confident that the EHR stimulus money will play itself out. I’ll be a little surprised if indeed it does get cut. I think republicans will have larger fish to fry. However, there’s certainly that possibility, so doctors should take this into account when they’re selecting and implementing an EHR.

September 9, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.