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Terrence Kay

Terrence Kay. Acting Director Hospital and Ambulatory Policy Group Center for Medicare Management, CMS. Medicare Regulatory Update. Physician payment including the annual update Physician Quality Reporting Initiative (PQRI) Ambulatory Surgical Center Payments for CY 2008

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Terrence Kay

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  1. Terrence Kay Acting Director Hospital and Ambulatory Policy Group Center for Medicare Management, CMS

  2. Medicare Regulatory Update • Physician payment including the annual update • Physician Quality Reporting Initiative (PQRI) • Ambulatory Surgical Center Payments for CY 2008 • Outpatient Hospital payments for CY 2008 • Inpatient Hospital payments for FY 2008 • Other

  3. Medicare Physician Fee Schedule • Components of the fee schedule • Process for revising policies/payments • Sustainable Growth Rate (SGR) • 2008 Physician Fee Schedule Issues

  4. Components of the Fee Schedule • In 2007, estimated to pay over $60 billion to over 900,000 physicians and other health care professionals • Each of the over 7,500 services paid under the MPFS is divided into 3 components: • physician work • practice expenses • malpractice insurance • Relative value units (RVUs) must be established for each of the 3 components. • The law requires that changes in RVUs must be done in a budget neutral manner.

  5. Sustainable Growth Rate (SGR) • The SGR is an annual growth rate that applies to physicians’ services paid by Medicare • It is intended to control growth in aggregate Medicare expenditures for physicians' services. • The SGR formula is based on four factors: • Estimated change in fees for physicians’ services • Estimated change in average number of Medicare fee-for-service beneficiaries • Estimated projected growth in real GDP per capita • Estimated change in expenditures due to changes in law and regulation • When actual expenditures exceed target expenditures, the PAF can reduce the physician update. This is what has happened in the last several years. (Alternatively, when the target exceeds actual expenditures, the PAF will increase the update.)

  6. SGR and the Physician Update • Since 2002, there have been negative physician updates. • Since 2003, Congress has averted physician fee cuts • CY 2003: Consolidated Appropriations Resolution of 2003 (CAR) = allowed CMS to calculate a 1.6 percent increase • CY 2004 and 2005: Medicare Modernization Act of 2003 (MMA) = set a minimum 1.5 percent increase each year • Deficit Reduction Act of 2005 (DRA) = set the 2006 conversion factor the same as 2005 • Tax Relief and Health Care Act of 2006 (TRHCA) = set the 2007 conversion factor the same as 2006

  7. SGR and Physician Update Issues • The SGR is cumulative. • TRHCA required the negative update to be re-couped in 2007. This results in an estimated physician update of minus 9.9 percent for 2008. • Fundamental changes to the SGR formula or the calculation of the physician update require legislation

  8. Projected Physician Fee Schedule Updates Under Current Law

  9. Issues for CY 2008 NPRM • CMS annually updates the physician fee schedule through proposed and final rules published in the Federal Register. • The final rule must be published by November 1 and changes are effective January 1 of the following year. • The 2008 proposed rule was released on July 2, 2007. Comments accepted until August 31. • Major issues included are: • Update to the GPCIs, and discussion of revisions to certain localities • Year two of phase-in of new practice expense methodology • Completion of third five year review of work RVUs • Discussion/implementation requirements of Tax Relief and Health Care Act of 2006. Includes establishment of quality reporting measures and the Implementation of Physician Assistance and Quality Initiative Fund for 2008. • Self-referral rules

  10. Additional PFS NPRM Issues • The physician fee schedule rule is often used as a vehicle for other related issues.

  11. Centers for Medicare & Medicaid Services 2007 Physician Quality Reporting Initiative (PQRI)

  12. Overview • Value-Based Purchasing and the PQRI • PQRI Introduction: Information about PQRI • PQRI Reporting: Understanding the Measures • PQRI Support: Educational Tools and Resources

  13. Value-Based Purchasing and PQRI • Value-based purchasing is a key mechanism for transforming Medicare from a passive payer to an active purchaser. • Current Medicare Physician Fee Schedule is based on quantity and resources consumed, NOT quality or value of services. • Value = Quality / Cost • Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care.

  14. Quality and PQRI • PQRI reporting will focus attention on quality of care. • Foundation is evidence-based measures developed by professionals. • Reporting data for quality measurement is rewarded with financial incentive. • Measurement enables improvements in care. • Reporting is the first step toward pay for performance.

  15. PQRI Introduction: • Tax Relief and Healthcare Act (TRHCA) Division B, Title I, Section 101 provides statutory authority for PQRI and defines: • Eligible professionals • Quality measures • Form and manner of reporting • Determination of satisfactory reporting • Bonus payment calculation • Validation • Appeals

  16. Physicians MD/DO Podiatrist Optometrist Oral Surgeon Dentist Chiropractor Therapists Physical Therapist Occupational Therapist Qualified Speech-Language Pathologist Practitioners Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Nutrition Professional Registered Dietician PQRI Introduction: Eligible Professionals

  17. PQRI Introduction: The Quality Measures • Final list of 74 quality measure statements, descriptions, and detailed specifications now posted at: www.cms.hhs.gov/PQRI.

  18. PQRI Introduction: The Bonus Payment • Professionals that report successfully are eligible for a 1.5 percent bonus payment, subject to a cap. • Potential bonus payment is calculated using total allowed charges for covered professional services furnished during the reporting period and paid under the Physician Fee Schedule. • A cap on the bonus may apply.

  19. PQRI Introduction: Key Information • Reporting period: Dates of Service between July 1, 2007 through December 31, 2007 • No need to register: just begin reporting. • Must be an enrolled Medicare provider (but need not have signed a Medicare participation agreement). • Need to use individual National Provider Identifier (NPI).

  20. PQRI Introduction: The Tools • Gather information and educational materials from the PQRI website (www.cms.hhs.gov/pqri).

  21. PQRI Reporting: Data Submission • The individual NPI of the participating professional must be properly used on the claim. • Multiple Eligible Professionals with their NPIs may be reported on the same claim with each quality data code line item corresponding to the services rendered by the professional for that encounter. • All claims must reach the NCH file by February 29, 2008 to be included in the bonus calculation.

  22. Ambulatory Surgical Centers • HHS released a final rule on July 16, 2007 that will implement a revised payment system for Ambulatory Surgical Centers (ASCs). • The rule outlines the final policies for the revised ASC payment system to be implemented January 1, 2008. • Proposed ASC payments for 2008 are included in the proposed rule for Outpatient Hospital PPS.

  23. ASC background • There are currently about 4,600 ASCs enrolled in Medicare. • Total Medicare expenditures for CY 2006 Medicare payments to ASCs are estimated at about $2.5 billion.

  24. Current ASC payment system • The current “ASC list” of approved procedures for which Medicare pays participating ASCs a facility fee consists of more than 2,500 surgical procedures.  • Each procedure on the current ASC list is assigned to one of nine prospectively determined ASC payment rates, ranging from $333 to $1339.  • ASC rates were last rebased in March 1990 using cost, charge, and utilization data from a 1986 survey of ASC costs.

  25. New ASC Payment System • The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires CMS to revise the ASC payment system no later than January 1, 2008. • The new ASC system is based on the Outpatient Hospital Ambulatory Payment Groups (APCs).

  26. ASC New Payment System • The statute requires a zero percent ASC update through CY 2009. • As required by the MMA, the revised ASC payment system is budget neutral.

  27. Proposals for Outpatient Hospital PPS and ASCs • Annual proposals released on July 16 • Published in the Federal Register--August 2 • Proposes a 3.3% annual update for OPPS • Proposes expanding bundling of payments for OPPS • Proposes ASC payments at 65% of the OPPS rate

  28. Inpatient Hospital PPS • Final rule announced August 1 and effective on October 1, 2007.

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