Improving health is our policy
Makes changes to the feedback program to provide reports to individual physician regarding their resource utilization rates. Requires development of episode grouper software to aggregate clinically related claims and report to physicians on their resource use by episode.
CMS continues to provide feedback reports to physicians. For more information, visit CMS’s Medicare FFS Physician Feedback Program website.
On July 8, 2013, CMS released its CY14 Medicare Physician Fee Schedule (MPFS) proposed regulation, which delineates proposed payment changes to physician payments, in addition to effectuating ACA-authorized requirements consistent with these statutory provisions of the law. Comments on the underlying proposed regulation are due by September 6. A CMS press release is available here.
On November 27, 2013, CMS issued the CY14 Medicare Physician Fee Schedule (MPFS) final rule, in which it decided not to finalize proposed cuts to potentially misvalued codes with higher reimbursement rates than in the hospital outpatient setting. The rule did make some RVU changes that cut some specialties, however, and added a separate payment for non-face-to-face chronic care management services. Comments on the rule are due by January 27.
On Mar. 6 CMS released guidance on the Physician Quality Reporting System (PQRS) 2013 Reporting Year and 2015 Payment Adjustment for Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals (CAHs).
Mar. 20 marked the last day for groups to submit quality data through the GPRO Web Interface.
On Mar. 23, CMS hosted Virtual Office Hours as part of its ‘Getting Started with Quality Measures’ for the 2015 PQRS series.
On Apr. 9, 2015 CMS announced that groups can now register to participate in the 2015 Physician Quality Reporting System (PQRS) Group Reporting Option (GPRO) via the Physician Value – Physician Quality Reporting System (PV-PQRS) Registration System. PQRS GPRO is an option available to groups with 2 or more eligible professionals (EPs).
On Apr. 17, as part of a proposed rule updating FY 2016 Medicare payment policies and rates for inpatient stays at general acute care and LTCHs (IPPS/LTCH), CMS proposed “four clinical episode-based payment measures for inclusion in the Hospital IQR Program beginning with the FY 2018 payment determination: Kidney/Urinary Tract Infection Clinical Episode-Based Payment measure, the Cellulitis Clinical Episode-Based Payment measure, the Gastrointestinal Hemorrhage Clinical Episode-Based Payment measure, and the Lumbar Spine Fusion/Refusion Clinical Episode-Based Payment measure.”
On Sep. 9, 2015, CMS made available the 2014 Annual Quality and Resource Use Reports (QRURs) to every group practice and solo practitioner (details).
On Feb. 12, 2016, CMS extended the deadline for comment on episode groups developed under this provision for the purposes of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation.
SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM.
(a) IN GENERAL.—Section 1848(n) of the Social Security Act
(42 U.S.C. 1395w–4(n)) is amended—
(1) in paragraph (1)—
(A) in subparagraph (A)—
(i) by striking ‘‘GENERAL.—The Secretary’’ and
inserting ‘‘GENERAL.— ‘‘(i) ESTABLISHMENT.—The Secretary’’;
(ii) in clause (i), as added by clause (i), by striking
‘‘the ‘Program’)’’ and all that follows through the period
at the end of the second sentence and inserting ‘‘the
‘Program’).’’; and
(iii) by adding at the end the following new clauses:
‘‘(ii) REPORTS ON RESOURCES.—The Secretary shall
use claims data under this title (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 to individuals under this title.
‘‘(iii) INCLUSION OF CERTAIN INFORMATION.—If
determined appropriate by the Secretary, the Secretary
may include information on the quality of care furnished
to individuals under this title by the physician
(or group of physicians) in such reports.’’; and
(B) in subparagraph (B), by striking ‘‘subparagraph
(A)’’ and inserting ‘‘subparagraph (A)(ii)’’;
(2) in paragraph (4)—
(A) in the heading, by inserting ‘‘INITIAL’’ after ‘‘FOCUS’’;
and
(B) in the matter preceding subparagraph (A), by
inserting ‘‘initial’’ after ‘‘focus the’’;
(3) in paragraph (6), by adding at the end the following
new sentence: ‘‘For adjustments for reports on utilization under
paragraph (9), see subparagraph (D) of such paragraph.’’; and
(4) by adding at the end the following new paragraphs:
‘‘(9) REPORTS ON UTILIZATION.—
‘‘(A) DEVELOPMENT OF EPISODE GROUPER.—
‘‘(i) IN GENERAL.—The Secretary shall develop an
episode grouper that combines separate but clinically
related items and services into an episode of care for
an individual, as appropriate.
‘‘(ii) TIMELINE FOR DEVELOPMENT.—The episode
grouper described in subparagraph (A) shall be developed
by not later than January 1, 2012.
‘‘(iii) PUBLIC AVAILABILITY.—The Secretary shall
make the details of the episode grouper described in
subparagraph (A) available to the public.
‘‘(iv) ENDORSEMENT.—The Secretary shall seek
endorsement of the episode grouper described in
subparagraph (A) by the entity with a contract under
section 1890(a).
‘‘(B) REPORTS ON UTILIZATION.—Effective beginning
with 2012, the Secretary shall provide reports to physicians
that compare, as determined appropriate by the Secretary,
patterns of resource use of the individual physician to
such patterns of other physicians.
‘‘(C) ANALYSIS OF DATA.—The Secretary shall, for purposes
of preparing reports under this paragraph, establish
methodologies as appropriate, such as to—
‘‘(i) attribute episodes of care, in whole or in part,
to physicians;
‘‘(ii) identify appropriate physicians for purposes
of comparison under subparagraph (B); and
‘‘(iii) aggregate episodes of care attributed to a
physician under clause (i) into a composite measure
per individual.
‘‘(D) DATA ADJUSTMENT.—In preparing reports under
this paragraph, the Secretary shall make appropriate
adjustments, including adjustments—
‘‘(i) to account for differences in socioeconomic and
demographic characteristics, ethnicity, and health
status of individuals (such as to recognize that less
healthy individuals may require more intensive interventions);
and
‘‘(ii) to eliminate the effect of geographic adjustments
in payment rates (as described in subsection
(e)).
‘‘(E) PUBLIC AVAILABILITY OF METHODOLOGY.—The Secretary
shall make available to the public—
‘‘(i) the methodologies established under subparagraph
(C);
‘‘(ii) information regarding any adjustments made
to data under subparagraph (D); and
‘‘(iii) aggregate reports with respect to physicians.
‘‘(F) DEFINITION OF PHYSICIAN.—In this paragraph:
‘‘(i) IN GENERAL.—The term ‘physician’ has the
meaning given that term in section 1861(r)(1).
‘‘(ii) TREATMENT OF GROUPS.—Such term includes,
as the Secretary determines appropriate, a group of
physicians.
‘‘(G) LIMITATIONS ON REVIEW.—There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the establishment of the methodology
under subparagraph (C), including the determination
of an episode of care under such methodology.
‘‘(10) COORDINATION WITH OTHER VALUE-BASED PURCHASING
REFORMS.—The Secretary shall coordinate the Program with
the value-based payment modifier established under subsection
(p) and, as the Secretary determines appropriate, other similar
provisions of this title.’’.
(b) CONFORMING AMENDMENT.—Section 1890(b) of the Social
Security Act (42 U.S.C. 1395aaa(b)) is amended by adding at the
end the following new paragraph:
‘‘(6) REVIEW AND ENDORSEMENT OF EPISODE GROUPER UNDER
THE PHYSICIAN FEEDBACK PROGRAM.—The entity shall provide
for the review and, as appropriate, the endorsement of the
episode grouper developed by the Secretary under section
1848(n)(9)(A). Such review shall be conducted on an expedited
basis.’’.
(202) 309-0796
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