Navigating Value Based Care
By Amy Lynn Sorrel Texas Medicine December 2015

TMA-TMF Collaboration Helps Physicians Navigate the Medicare Value-Based Care Maze

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Quality Feature — December 2015

Tex Med. 2015;111(12):41-44.

By Amy Lynn Sorrel
Associate Editor

Clark W. Brazil, MD, thought he was doing everything right to keep up with the Medicare value-based care requirements that increasingly base payments on the quality and cost of the care provided. 

Knowing certain financial penalties were imminent if he didn't participate, the Wichita Falls vascular surgeon signed up two years ago with a Texas Medical Association-endorsed registry to start reporting on the requisite quality measures under the Physician Quality Reporting System (PQRS). He also adopted an electronic health record (EHR) system to qualify him for the meaningful use program. 

"I thought I had things pretty well covered," Dr. Brazil said. In spite of his efforts, however, "I was left holding the bag." 

The confusing web of rules still hit Dr. Brazil with a 2-percent payment penalty this year. He didn't know the measures he reported under PQRS did not automatically carry over to satisfy separate reporting requirements under Stage 2 of Medicare's EHR meaningful use program.

It wasn't until TMA referred Dr. Brazil to TMF Health Quality Institute that he was able to sort through the mess. "I knew from [Medicare] letters that I was having problems, but I could not figure out what they wanted. [TMA and TMF] were outstanding, and I wouldn't have known without them." 

TMA is collaborating with TMF to connect even more Texas physicians to free educational and technical resources the Medicare-contracted statewide quality improvement organization and network offers to better position doctors for the rapid transition to value-based payment. 

One of TMF's top jobs is to help physicians, hospitals, and other entities improve quality right at home with hands-on assistance to improve clinical processes and health care outcomes. TMF also focuses on federal quality reporting obligations that will affect all physician payments by 2017. As part of Medicare's overall goals to reduce costs and improve quality, new TMF projects launched in April also focus on improving behavioral health screening and immunization rates — areas that also can help physicians meet their federal reporting requirements, improve patients' health, and increase practice payments.

Because Medicare funds the TMF contract to further national quality improvement efforts, physicians can take advantage of services that could otherwise add up to $10,000 at no cost. Now physicians can browse TMF's menu of services online in a one-stop shop via TMA's TMF Networks Resource Center

With steep penalties in full swing and a new payment paradigm on the horizon with the elimination of the Medicare Sustainable Growth Rate (SGR) formula, TMF is a valuable and trusted partner to guide physicians through the maze before they get lost in it, says Clifford K. Moy, MD. The Frisco psychiatrist and former speaker of the TMA House of Delegates is TMF medical director for behavioral health. 

In the next few years, "value-based care will be the major payment mechanism implemented in Medicare and in the commercial space," he said. With TMF's help, "physicians have the opportunity now to learn about it, prepare for that transition, and think about what it means to your practice."

When it comes to population health — another important component of value-based care — Dr. Moy says preventive services like behavioral health screenings and immunizations also will figure prominently into reducing health care costs and improving outcomes and, as a result, determining physician payments. 

Trusted Partner

Under its latest Medicare contract, TMF went from being the statewide quality improvement organization for Texas since 1984 to what the Centers for Medicare & Medicaid Services (CMS) now calls a broader quality innovation network/quality improvement organization for a multistate region that includes Texas, Arkansas, Missouri, Oklahoma, and Puerto Rico. Having partnered with TMF in the past on some of the quality improvement tools and public health programs TMA offers, the association strongly supported TMF's bid last year to remain the statewide quality improvement organization for Texas.

When it comes to value-based improvement projects, Medicare requires TMF to help physicians successfully report under the PQRS, meaningful use, and value-based payment modifier programs. The latter adjusts physician payments based on the quality data they report to PQRS and on Medicare cost data, all from two years prior. Payments to large practices face adjustments this year based on 2013 quality and cost data. The 2015 data will determine payments for all physicians in 2017 and so on. (See "Your Guide to Medicare Value-Based Care," April Texas Medicine, pages 26-34.) 

TMF officials say participation in these programs now also helps physicians prepare and set expectations for what's to come in 2019, when CMS implements the new Merit-Based Incentive Payment System (MIPS). Congress created MIPS when it eliminated SGR in April under the 2015 Medicare Access and CHIP Reauthorization Act (MACRA). Under the new payment paradigm, Medicare's three main quality reporting programs — PQRS, meaningful use, and the value modifier — remain in effect through 2018. Starting in 2019, MIPS will combine them into a single value-based program that continues to assess physician performance and payment based on quality, utilization, clinical practice improvement activities, and EHR use. (See "R.I.P. SGR," June 2014 Texas Medicine, pages 26-37.) 

TMF provides most of its services through online "learning and action networks," organized not only to educate and provide technical assistance to physicians on specific topics but also to connect physicians with other practices that are working on similar issues. Physicians can dial into free, web-based learning sessions on PQRS or meaningful use, for example, and ask questions. TMF has hosted virtual demonstrations with EHR vendors and has offered a series of webinars that break down performance improvement into easy steps practices can follow and use to set goals. 

The organization also helps practices stay up to date with Medicare's constantly changing quality reporting requirements. Once CMS finalizes regulations governing MACRA implementation, TMF will offer additional services to help physicians participate in MIPS.   

TMA Council on Health Care Quality Chair Gregory M. Fuller, MD, says physicians' reporting obligations become more important now that the financial incentives for participating in federal quality programs have shifted entirely to penalties.  

"Doctors see these programs and the first thing they say is, 'I'm frustrated, and I'm not going to do it,'" the Keller family physician said. While those frustrations are indeed real, Dr. Fuller also cautions: "If they don't do it, they have to realize how much it could potentially cost their practice."

Valuable Tools

A new payment adjustment calculator TMF offers now "takes that unknown and makes it predictable," says Tracy Swoboda, TMF project director for value-based payment initiatives. (See "Medicare Payment Adjustment Calculator.")

Via an Excel worksheet, physicians enter an estimate of their expected Medicare Part B allowable charges for the reporting year, and the tool automatically calculates the penalties associated with opting out of the PQRS, meaningful use, and value-based modifier programs. Access the calculator in TMA's TMF Networks Resource Center.  

TMF also offers guidance in interpreting complex quality feedback reports Medicare began releasing to all doctors to give them a window into their performance and help them act on it. PQRS Feedback Reports provide information on physicians' quality performance. The Quality and Resource Use Reports (QRURs) provide detailed information on physicians' quality and cost performance and how they compare with their peers. PQRS and QRUR scores feed directly into how Medicare now calculates payment penalties under the value-based modifier — and eventually will determine financial bonuses and penalties under MIPS. (See "Technical Assistance Required," July 2015 Texas Medicine, pages 59-62.)

Over the past few years, TMF consultants have helped hundreds of practices implement clinical improvements and successfully report to PQRS, including transitioning practices like Dr. Brazil's to reporting quality information electronically. Ms. Swoboda says TMF's goal is to reach many more practices — 75 percent of an estimated 76,000 PQRS reporters in its multistate region — and help them incorporate performance improvement into their practices. 

Half of Texas physicians participated in PQRS in 2013, the last year the program offered incentives, according to the latest Medicare numbers. 

"Unfortunately, these programs are not going away. [PQRS] sunsets and just rolls into another layer of penalties and incentives [under MIPS], and patients are becoming educated and looking for practices ahead of the curve," Ms. Swoboda said, referring to Medicare's public quality rating website, Physician Compare. TMF's services, on the other hand, are a low-risk path "for doctors to dip their toe in the water and make an estimation now, because private payers will follow suit." 

For Dr. Brazil, TMF consultants "helped me understand what I need" to avoid future penalties. He met the Stage 1 meaningful use requirements "no problem, but Stage 2 goes to a whole new level. And it's worthless to go through the federal websites to find out what you need." 

With TMF's assistance, Dr. Brazil learned he can stay with the TMA-endorsed PQRSwizard registry to continue meeting the program's quality reporting requirements. But he'll likely have to switch to a different EHR system to simultaneously satisfy meaningful use mandates. 

The organization also helps practices stay up to date with the roughly 300 constantly changing quality measures they can choose from when reporting. Or on the other hand, for example, TMF helped Dr. Brazil figure out how to satisfy the federal requirements with a limited measure menu for his specialty.

Preventive Measures 

Medicare also charges TMF with enlisting physician practices to increase screening of depression and alcohol use disorders in primary care settings and to raise adult immunization rates through improved tracking, documentation, and reporting. 

"We know that approximately 30 percent of the cost of caring for patients can be associated with behavioral health conditions. Maybe not direct costs, but certainly behavioral health impacts other illnesses, acute and chronic. And without the ability to manage those conditions, we are not going to see better outcomes," Dr. Moy said. "In terms of understanding the total cost of care, behavioral health is a significant area that has been underemphasized over the past few decades. But with these screenings, physicians have the potential to get better patient outcomes, better payment, and bonuses down the line under Medicare's quality programs," for improving care.

Medicare's goals include: 

  • Screening 75 percent of Medicare beneficiaries receiving care at primary care practices for depression and alcohol use disorder;
  • Reducing 30-day readmission rates for patients discharged from inpatient psychiatric facilities; and
  • Increasing follow-up care with a behavioral health specialist. 

In addition to TMF's educational webinars and online peer networks, primary care physicians get access to technical assistance incorporating evidence-based screening tools and electronic documentation systems to ensure they screen patients annually. The latter brings the added benefit of allowing physicians to get paid for behavioral health services. Medicare has a series of billing codes that allow physicians to bill for depression and alcohol use screenings as part of an annual checkup.  

Both behavioral health screenings and immunizations are also key quality measures physicians can report to comply with Medicare's value-based care programs. Too, physicians can bill for providing immunizations for certain vaccine-preventable diseases. 

Medicare aims to achieve national immunization rates of 90 percent for pneumonia, 70 percent for influenza, and 30 percent for herpes zoster by 2020. TMF's immunization network gives physicians access to: 

  • Data-sharing and analysis help; 
  • Ways to improve immunization assessment, referral, documentation, and electronic reporting to state registries; and
  • Strategies to increase patient engagement. 

Ms. Swoboda acknowledges that even with TMF's help, clinical transformation requires time and effort on physicians' part. But without targeted guidance and education, physicians face "unlimited hours and challenges and a high risk of not being successful with reporting and improvement."

Dr. Brazil is not holding his breath for the federal government to simplify its value-based care programs any time soon. But at least with TMA and TMF's help, "it wasn't enough to save me this time. But I'm more prepared for next time."  

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Medicare Payment Adjustment Calculator

TMF offers a calculator that takes the unknown out of Medicare's penalty-based quality initiatives. Simply enter an estimate of your expected Medicare Part B allowable charges for the reporting year, and the tool automatically calculates the penalties associated with opting out of the Physician Quality Reporting System, meaningful use of electronic health records, and value-based modifier programs.

Access the calculator in TMA's TMF Networks Resource Center.

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Last Updated On

May 13, 2016

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