Janis Oppelt

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com and ICD10Monitor.com; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.

The proposed 2017 update to the end-stage renal disease (ESRD) prospective payment system (PPS), which the Centers for Medicare & Medicaid Services (CMS) issued on June 24, 2016, contains revisions to policies and rates for renal dialysis services furnished to beneficiaries on or after January 1, 2017. The PPS includes all renal dialysis services furnished for outpatient maintenance dialysis, including drugs and biologicals (with the exception of oral-only ESRD drugs until 2025) and other renal dialysis items and services that were formerly separately payable under the previous payment methodologies.

Rates Mostly Increase

The proposed 2017 ESRD PPS base rate is $231.04—an increased base rate of $0.65 from the 2016 base rate. CMS projects that the updates for 2017 will increase the total payments to all ESRD facilities by 0.5 percent compared with 2016. For hospital-based ESRD facilities, CMS projects an increase in total payments of 0.7 percent, while for freestanding facilities, the projected increase in total payments will be 0.5 percent.

CMS also proposes to update the outlier services’ fixed dollar loss amounts for adult and pediatric patients and Medicare allowable payments (MAPs) for adult patients for 2017 using 2015 claims data.  By using the more current data, the fixed-dollar loss amount for pediatric beneficiaries would increase from $62.19 to $67.44 and the MAP amount would increase from $39.20 to $39.92, as compared to 2016 values.  For adult beneficiaries, the fixed-dollar loss amount would decrease from $86.97 to $83.00 and the MAP amount would decrease from $50.81 to $47.26. 

Three Years of Quality Measures

In all cases, payment incentives are made to dialysis facilities to improve the quality of care that they provide, and facilities that do not achieve a minimum total performance score (TPS) with respect to quality measures receive a reduction in their payment rates up to 2 percent under the ESRD PPS.

In the proposed 2017 rule, CMS addressed the quality measures for 2018–2020. For 2018, there would be eight clinical measures and three reporting measures encompassing anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, hospital readmissions, and mineral metabolism management.

CMS proposes two substantive changes to the hypercalcemia clinical measure to, as CMS explains, “ensure that the measure remains in alignment with the measure specifications endorsed by the National Quality Forum (NQF).”  These changes involve:

  • Updating the measure’s technical specifications for 2018 and future years to include plasma as an acceptable substrate in addition to serum calcium
  • Changing the denominator definition to include patient-months in the denominator even in the event that a facility reported no calcium values during the three-month study period.

In addition to most of the clinical measures and reporting measures listed above for 2018, the 2019 measures encompass more quality-of-life considerations, which the agency calls a natural “evolution” of the program. Instead of eight clinical measures, there would be seven and instead of three reporting measures there would be five with the following additions: safety, pain management, depression management, and hospital readmissions.

In 2019, a new ultrafiltration rate reporting measure also would be added, and the existing mineral metabolism reporting measure (calculated in part using claims data) would be replaced with a new serum phosphorus reporting measure. A facility’s TPS would be divided into the following:

  • 75 percent to the clinical measure domain
  • 15 percent to the safety measure domain
  • 10 percent to the reporting measure domain.  

In 2020, the total number of measures would increase to 15—eight clinical measures and seven reporting measures, including those above for 2019. Included in the eight clinical measures would be one identified as the standardized hospitalization ratio (SHR). The TPS would be broken down as follows:

  • 80 percent to the clinical measure domain
  • 10 percent to the safety measure domain.
  • 10 percent to the reporting measure domain

Other Proposals

In addition to the above QIP revisions, CMS addresses a wide variety of topics in proposed 2017 rule.

For example, it proposes to implement the provisions in the Trade Preferences Extension Act (TPEA) of 2015 provisions regarding the coverage and payment of renal dialysis services furnished by ESRD facilities to individuals with acute kidney injury (AKI). As directed by the TPEA, CMS will provide coverage and payment for renal dialysis services furnished on or after January 1, 2017.

It also proposes that drugs, biologicals, laboratory services, and supplies furnished to beneficiaries with AKI that are not considered to be renal dialysis services but that are that are related to the dialysis as a result of their AKI would be separately payable. 

Other topics covered include:

  • Home and self-dialysis training add-on payment adjustment
  • Payment for hemodialysis when more than three treatments are furnished per week
  • Changes to the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program, including information about a bid surety bond, state licensure, appeals process for a breach of contract action(s), and bid limits
  • The comprehensive ESRD care model.

A fact sheet on the above is available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-24.html.

Janis Oppelt is the editorial director for the publishing division of Panacea Healthcare Solutions, Inc.

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j oppeltHelping to improve patient quality of care and outcomes are two of the underlying goals of the proposed conditions of participation (COP) that the Centers for Medicare & Medicaid Services (CMS) issued more than six months ago (on November 3, 2015).

In the proposed rules, CMS discusses six new and revised standards for section 482.43—Discharge Planning—of the Code of Federal Regulations (CFR). Hospitals, long-term care hospitals (LTCHs), inpatient rehabilitation facilities, critical access hospitals (CAHs), and home health agencies (HHAs) must meet these requirements in order to participate in the Medicare and Medicaid programs.

In its rationale for the revisions, CMS observes that the current hospital discharge-planning process meets the needs of many inpatients released from the acute-care setting, but some discharges result in “less-than-optimal outcomes.” One problem, it says, is that although the current process requires hospitals to identify the inpatients needing discharge plans, it does not necessarily lead to an actual discharge plan. The lack of specificity in the current regulation results in a variety of implementation approaches in the acute-care hospital setting. As a result, successful transitions from acute-care hospitals also vary.

The changes proposed will bring the COP into closer alignment with current practice and reduce avoidable complications, adverse events, and readmissions, according to CMS. Revising the discharge-planning requirements was not, however, entirely the idea of CMS since it got a nudge from Congress, which passed the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) a year before CMS issued the proposed changes.

Provisions of the IMPACT Act

This legislation directed the Secretary of the Department of Health & Human Services to publish regulations to modify the COPs and interpretive guidance and require that quality and resource-use measures be considered during the discharge-planning process and to consider their goals of care and treatment preferences.  

The IMPACT Act defines quality measures as relating to at least the following domains: standardized patient assessments, including functional status, cognitive function, skin integrity, and medication reconciliation. It defines resource-use measures as including total estimated Medicare spending per individual, discharge to community, and measures to reflect all-condition risk-adjusted preventable hospital readmission rates.

The main objective of IMPACT, explains CMS, is to encourage patients and their families to become active participants in the planning of their transition to the post-acute-care setting or between settings by giving them access to information that will help them make informed decisions. It also explains, “Patients and their families that are well informed of their choices of high-quality PAC providers, including providers of community services and supports, may reduce their chances of being rehospitalized.”

Specific Changes

As stated above, the proposed changes to the discharge planning process affect section 482.43 of the CFR. Although the discussion by CMS in the Federal Register is chock full of details, a few of the key changes in the six areas revised are provided below.

Design: Hospital medical staff, nursing leader, and other pertinent healthcare professionals would be required to provide input in the development of the discharge planning process, which would be specified in writing and be reviewed and approved by the hospital’s governing body. Policies and procedures would be developed and reviewed periodically by the hospital’s governing body.

Applicability: The discharge planning process would apply to all inpatients and certain categories of outpatients, including those who are receiving observation services and undergoing surgery or other same-day procedures where anesthesia or moderate sedation is used. It also would apply to emergency department patients who have been identified by a practitioner as needing a discharge plan and any other category of outpatient as recommended by the medical staff and approved by the governing body.

Discharge planning process: Various hospital staff (such as registered nurses and social workers) would be required to begin identifying, within 24 hours after admission or registration, possible post-discharge goals, preferences, and needs of the patient and begin to develop a “tailored” discharge plan. Discharge planning would be complete before the patient leaves the hospital. In a new requirement, CMS indicates that the practitioner responsible for the patient’s care also would be involved in the ongoing process of establishing the patient’s goals of care and treatment preferences.

Discharge to home (includes residences and community agencies):  Detailed discharge instructions (including medications, follow-up appointments, important phone numbers etc.) must be included in the discharge plan and provided to the patient and/or caregiver, and hospital staff must review them using the “teach-back” method. In this method, the provider explains the instruction and the patient repeats its back to ensure his or her understanding.

In a new requirement, CMS says that written instructions may be provided on paper or electronically, whichever works for the patient and/or caregiver.

This section provides details about a variety of topics, including mandates to:

  • Reconcile medications, which, according to the American Medical Association, is the process of making sense of patient medications and resolving conflicts between different sources of information to minimize harm and maximize therapeutic effects
  • Send copies of the discharge instructions, pending test results, etc. to the hospital and practitioner responsible for follow-up care as well as the patient
  • Establish a post-discharge follow-up process, especially related to medication compliance.

Transfer to another healthcare facility: As now required, hospitals would continue to communicate necessary patient information when patients are transferred to another facility. CMS clarified its expectations, explaining the variety of methods that may be chosen to accomplish the requirement.

It also provided a minimum list of the detailed information that should accompany the patient. Although it does not intend to issue a specific form or format for transferring this information, it does encourage facilities to use certified health information technology.

Post-acute Care Services: The current regulation directs hospitals to provide a list of available Medicare-participating HHAs or skilled nursing facilities to patients for whom home health care or PAC services are indicated. They also would be required to inform patients who are enrolled in managed care organizations that they must verify their network participation and share information about participating providers. The list must be documented that it was presented to the patient, although the patient is free to choose who he or she wants.

The proposed rule was published in the November 3, 2015, Federal Register, which is available at http://federalregister.gov/a/2015-27840.

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Janis Oppelt is the editorial director for Panacea Healthcare Solutions.

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j oppelt

It’s no secret that the rising cost of prescription drugs—and patient access to them—is one of the healthcare industry’s hot topics right now. So hot is it for the Medicare program that the Department of Health & Human Services (HHS) held a special pharmaceutical forum in November to explore the issue.

Prescription drug spending in the United States was about $457 billion in 2015, or 16.7 percent of overall health spending, according to a report from the HHS Assistant Secretary for Planning and Evaluation (ASPE). In 2015, Medicare Part B spent $20 billion on outpatient drugs administered by physicians and hospital outpatient departments.

That is why the Centers for Medicare & Medicaid Program (CMS) issued a proposed rule on March 8 that outlines a two-phase approach for changing the current Medicare Part B payment model. Via the new model, CMS would test new ways to support physicians and other clinicians as they choose the drug that is right for their patients. The goal, CMS states, is to “drive the prescribing of the most effective drugs” and to test new payment approaches.

Generally, these drugs (such as cancer medications, injectables like antibiotics, or eye-care treatments) fall into the three categories below:

  • Drugs furnished incident to a physician’s service in the office or hospital outpatient settings
  • Drugs administered via a covered item of durable medical equipment
  • Other categories of drugs explicitly identified in the law.

Two Phases of Change

Generally, Medicare Part B pays physicians and hospital outpatient departments the average sales price (ASP) of a drug, plus a 6 percent add-on. CMS proposes changing the add-on payment to 2.5 percent plus a flat-fee payment of $16.80 per drug per day, which will, it says, cover the cost of any Medicare Part B drug. The flat fee would be updated at the start of each year by the percentage increase in the consumer price index for medical care for the most recent 12-month period. CMS proposes to launch this test in late 2016 (no earlier than 60 days after the rule is finalized).

In the second phase, CMS would implement value-based purchasing tools similar to those employed by commercial health plans, pharmacy benefit managers, hospitals, and other entities that manage health benefits and drug utilization. The proposed rule provides details of the following options.


Improving incentives for best clinical care. Physicians often can choose among several drugs to treat a patient, and the current Medicare Part B drug-payment methodology can penalize doctors for selecting lower-cost drugs, even when they are as good or better for patients based on the evidence.

  • Discounting or eliminating patient cost-sharing to improve beneficiaries’ access and appropriate use of effective drugs.
  • Sharing online clinicians’ best practices in prescribing or information on a clinician’s prescribing patterns relative to geographic and national trends and evidence-based clinical decision-support tools as a resource for providers and suppliers.
  • Basing prices on a drug’s clinical effectiveness for different indications. A medication might be used to treat one condition with high levels of success but an unrelated condition with less effectiveness or for a longer duration of time. The goal is to pay for what works for patients.
  • Setting a standard payment rate—a benchmark—for a group of therapeutically similar drug products.
  • Entering into voluntary, risk-sharing agreements with drug manufacturers to link patient outcomes with price adjustments.

Goals and Timelines

CMS will conduct a complete evaluation of the proposed model, which would run for five years. The agency’s goal is to have the incentive and value-based purchasing tests fully operational during the last three years to evaluate changes and collect sufficient data. 

The criteria for a successful model will be whether it reduces net Medicare spending, without limiting coverage or benefits, while maintaining or improving patient care.  CMS plans to implement a concurrent real-time claims-monitoring program to track utilization, spending, and prescribing patterns as well as changes in site of service delivery, mortality, hospital admissions, and several other high-level claims-based measures.

All providers and suppliers furnishing and billing for Part B drugs (all Part B drugs and biological) would be required to participate in the model, although not all would be part of each test, as described below. They would be placed in a control or study group based on Medicare Part B primary-care service areas. (The state of Maryland is excluded because hospital outpatient departments operate under an all-payer model.)

The proposed implementation dates currently look like this:

  • No earlier than 60 days after the final rule is released to the public CMS would begin to test the changes to Medicare Part B ASP payments for drugs by creating a control group and a study group.  One group would remain under the 6 percent add-on arrangement, and the second would receive 2.5 percent of the ASPs of a drug plus a flat $16.80 per drug per day payment.

106% Average Sales Price (ASP) (control)
102.5% ASP + $16.80 flat per day per drug payment

  • No earlier than January 2017 CMS would begin to test value-based purchasing arrangements by further dividing the ASP test and control groups as follows:
    • 106 percent ASP
    • 106 percent ASP with value-based purchasing tools
    • 102.5 percent ASP + $16.80
    • 102.5 percent ASP + $16.80 with value-based purchasing tools

The same set of value-based purchasing tools would be used in each of the two new study groups.

This proposed model would not affect drug coverage or any other benefits, and beneficiaries will still have complete freedom of choice of doctors, hospitals, and other providers and suppliers. 


Information Source

CMS is accepting comments on the proposed rule through May 9, 2016. It is available at  


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Janis Oppelt is the editorial director for Panacea Healthcare Solutions.

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Pharmaceutical innovation, patient access and affordability formed the foundation of a forum organized by the Department of Health & Human Services (HHS) on November 20, 2015. Participants of the “HHS Pharmaceutical Forum: Innovation, Access, Affordability and Better Health” included consumers, providers, employers, manufacturers, health insurance issuers, state and federal government representatives, and other key players, including representatives from the American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services (CMS).

The AHA reported that the group discussed the current challenges and possible opportunities to “improve patient access to affordable prescription drugs, develop innovative purchasing strategies, and incorporate value-based and outcomes-based models into purchasing programs in both the public and private sectors.”

Status Quo for Pharmaceuticals

“While the rest of the healthcare world moves toward value, prescription drug prices remain in a fee-for-service world,” stated Daniel Durham, executive vice president, Strategic Initiatives, AHIP, at the “Value-Based & Outcomes-Based Pharmaceutical Purchasing Programs” breakout session of the forum.

Even though Durham and the other four industry experts who were panelists of this session support the current movement toward value-based and outcomes-based programs, they believe that getting pharmaceuticals to that point will be a slow-moving train for a number of reasons.

For starters, pharmaceutical innovation takes time, costs money, and impacts the health of millions of patients and the bottom lines of companies and providers. As Durham and other panelists emphasized, pharmaceuticals must be affordable for everyone.

“We need to focus on sustainability,” said Durham. “The focus must be on private-sector, market-based solutions that drive value, so we’re paying for outcomes, not volume.”

He quoted a previous speaker who said, “In 20 years out, it will be outcomes equal revenue. Hopefully, we will get there a lot sooner.”

Defining Value

Under the standard value-based pricing agreements, payers and pharmaceutical companies link payment to the value achieved, rather than volume.Agreements dictate price (and/or coverage) relative to actual performance or outcomes.

However, panelist Bernard J. Tyson, chairman and chief executive officer for Kaiser Permanente, pointed out that the industry does not have a common definition of “value-based” yet. “Depending on who is promoting it, you may or may not agree with the definition,” he says.

Panelists agreed that “value” may have to be defined in different ways, which could be a monumental task. Kenneth C. Frazier, chairman of the board and chief executive officer, Merck & Co., believes that it varies by situation, saying, “To define value, we must think of it from the patient perspective—their individual lives—as well as the payer’s economic perspective.”

Dollars and Cents

Although pharmaceuticals may represent the most rapidly rising costs in government programs, they are “not the dominant driver of healthcare costs,” stated Frazier. In his opinion:

Medicines actually hold great promise for reducing future costs as we face growing rates of chronic disease and a rapidly growing aging population. Even the Congressional Budget Office has recognized that the increased use of medicines in Medicare will reduce costs.

However, getting to affordable is another story. Tyson addressed the economic perspective, citing the reality of negotiating for an affordable price in the current non-value-based world of pharmaceuticals. To his partner across the table who has set an exorbitant price for its product, he says, “I can bring 10.2 million members to this product, but I need a better price. I hear back that they would love to do that but they have this problem and that problem.” In his opinion:

There is something wrong with this picture. If the market would dictate that a pill is worth $1,000 and is truly market-based but someone can charge $10,000 for that pill, I don’t have a choice but to accept the $10,000. If I get the price down from $10,000 to $8,000, I’m still paying more than what the market would do if it was actually working on my behalf… That’s the starting point. It’s a fundamental flaw we need to address in the 21rd century.

Value-Based Experiments

Several years ago, Merck entered into a first-of-its-kind performance-based contract with the health insurer Cigna Corporation. Merck’s goal was to ensure that diabetic patients were controlling their blood-sugar levels by its products Januvia and Janumet. The drug manufacturer agreed to provide Cigna with an additional rebate if the company could show that it could get patients to their goals by taking their medicines on a regular basis.

As Frazier explained, “Instead of paying people for the amount of market share we get from that health plan, we incentivize companies like Cigna to make sure the patients got the benefits of the medicine. They got the outcome we wanted (getting patients to reach their goals), and we paid them for reaching those outcomes.”

Another panelist—Steve Miller, MD, senior vice president and chief medical officer, Express Scripts—provided another example. In 2016, his company intends to launch an indication-based formulary for certain medications. Currently, he said, the company is paying top dollar for every indication, including those where the patient outcomes are marginal.

The company’s goal is to ensure that payment for performance of a therapy aligns with the value that it delivers to each individual patient—an approach that makes therapy more affordable and accessible for all patients.

“A drug like Tarceva® (erlotinib) provides, on average, an additional five months of life for lung cancer patients compared to normal care. The same drug provides, on average, an additional 12 days of life for pancreatic cancer patients. Yet, we pay the same amount for the drug,” he reported. “We are going to change that.”

Wrapping It Up

Dr. Miller emphasized a point made by CMS acting administrator Andy Slavitt in his opening remarks. Specifically, there are no easy answers on how to move pharmaceuticals into the value-based world, but one thing is clear: A sustainable system is needed. As Dr. Miller stated:

We need to talk more about value-based and outcomes-based systems and must adopt new payment systems that continue to award manufacturers but also make patient access and affordability available.

The question remains: What can pharmaceutical manufacturers, government agencies, healthcare payers, and patients do to make for a better future? All of the components of the system must work together for things to change.

All panelists agreed that more experiments to achieve this are needed.

The above panel discussion, along with other forum breakout sessions, can be found at https://www.youtube.com/watch?v=vjUkhIzJtkc&index=7&list=PLrl7E8KABz1G1mxcJg6MxcVzXndRT-7CL

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Janis Oppelt is the editorial director for Panacea Healthcare Solutions.

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The healthcare industry is still aflutter regarding the passage of legislation on April 16 that permanently repealed the sustainable growth rate (SGR) formula used to determine Medicare Physician Fee Schedule (MPFS) payment, thus averting a 21-percent cut set for April 1 and implementing a 0.5-percent rate update from 2015 to 2019. The legislation, called the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also includes two new value-based payment (VBP) programs that are expected to consolidate and expand several incentive programs currently in place.

Through MACRA, Congress directed the Secretary of the Department of Health & Human Services (HHS) to develop and implement, by Jan. 1, 2019, the Merit-Based Incentive Payment System (MIPS) and to “sunset” the following programs:

Physician Quality Reporting System (PQRS); 

Electronic health record (EHR) incentive program; and

Physician value-based modifier (VBM) program

Eligible professionals (EPs) may participate voluntarily in MIPS or choose to participate in an “alternative payment model” (APM). In this second option, participating providers would “bear financial risk for monetary losses…that are in excess of a nominal amount.” A 5-percent annual lump bonus would be attached to the PFS payments for physicians involved in an APM as long as they also report quality measures and use certified EHR technology. 

In the legislation, Congress noted that the HHS Secretary may use inpatient hospital quality measures but not hospital outpatient department measures in the list of MIPS measures. The only exception to using outpatient measures would be in the case of items and services furnished by emergency physicians, radiologists, and anesthesiologists.  

Congress Gets Serious

In an April 15 blog post, Lisa Bielamowicz, MD, The Advisory Board Company’s chief medical officer, wrote that MACRA “broadens the scope and elevates the importance of quality measurement.” She also wrote:

“By increasing the percentage of fee-for-service revenue tied to quality, Congress is placing additional emphasis on quality measurement. …It is also broadening the definition of quality, adding resource use and clinical improvement measures to the typical list of quality measures. The new payment system heightens the burden on providers to track, report, and improve quality performance. Providers need to ensure they are on track to building dynamic capabilities for monitoring and analyzing quality performance.”

As Bielamowicz mentions, the legislation requires that HHS use the following four performance categories to determine an EP’s overall quality “score:” 

  • Quality measures from the existing programs and qualified clinical data registries will be used, and new ones will be developed through notice-and-comment rulemaking. Congress has noted that global outcome measures and population-based measures also may be used for this category.
  • Resource-use measures from the current VBM program will be used and possibly refined based on public input identifying specific clinical criteria and characteristics so that patients may be classified into care episode groups and patient condition groups. The goal of these classifications is to distinguish the relationship with, and responsibility of, a physician treating a patient at the time of furnishing an item or service.
  • Clinical practice or care delivery improvement activities that are likely to result in improved outcomes. Examples include expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, and participation in an alternative payment model. HHS will establish these in collaboration with professionals, including those in small practices and rural health professional shortage areas.
  • Meaningful use willinclude current EHR requirements, demonstrated by use of a certified system. 

Between Now and Then

Until otherwise notified by the Centers for Medicare & Medicaid Services (CMS), it will be business as usual for the current quality programs through the end of 2018. Unfortunately, it’s conceivable that some physicians are thinking “why bother?” since several of the incentive programs are being consolidated in a few years.

That’s an easy question to answer, according to Judy Burleson, the American College of Radiology’s senior advisor of quality metrics, who said that “the incentive payment for reporting PQRS quality measures ended in 2014; penalties associated with not participating satisfactorily in the program begin in 2015, based on 2013 reporting. And the amount of those penalties will increase between 2015 and 2018 to a substantial level. Payment for this performance period will occur in 2016, and a penalty will be applied for those who did not report in 2014.” 

Burleson explained that potential penalties stemming from PQRS participation include the PQRS reporting penalty as well as the VBP modifier penalty that uses PQRS quality measure performance rates – and, she noted, “this percentage will keep climbing each year.” 

For example, a physician who did not report PQRS successfully in 2014 will receive a 1.5-percent PQRS penalty in 2016, and any physician group that does not fully report PQRS will automatically receive a 2-percent VBM penalty in 2016 (for groups of 10 or more physicians). Also, a physician group of 10 or more that is successful at PQRS may receive up to a 2-percent VBM penalty in 2016 based on lower performance rates on PQRS measures. For 2015 and subsequent years, the PQRS payment adjustment will be -2-percent and the VBM payment adjustment will increase to up to -4-percent for groups of all sizes and solo practitioners (TBD for 2018). 

Another 1-percent deduction will be made to payments for EPs who have not demonstrated meaningful use; penalties increase by 1 percent each year until 2019, when they will plateau at 5 percent. Although it’s too late for non-participants to avoid the 2015 or 2016 penalties, they can avoid penalties in 2017 by beginning participation next year. Radiologists also may use a “specialty code exemption” for up to five years.

To avoid negative payment adjustments, physicians must be convinced to report quality measures during the next several years. MACRA makes it clear that Congress expects HHS to expand and improve current quality measures under the new MIPS program. It seems obvious that there’s no time like the present to begin the transition. 

About the Author

Janis is the editorial director of Panacea’s® publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com, ICD10Monitor.com, and VBPmonitor.com; coordinating the compliance question of the week; and contributing to the annual book update process. She has 20 years of experience in topics related to Medicare regulations and compliance. 

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Monday, 16 March 2015 15:09

More Value-Based Payments on the Way

Better Health, Better Care and Lower Costs: New Private-Public Sector Task Force Pledges accelerate the pace of delivery system transformation

An impressive group of non-government leaders have formed a new consortium called the Health Care Transformation Task Force (HCTTF). According to its website, those who join “commit to putting 75% of their businesses in value-based arrangements by 2020.” Members of the HCTTF include six of the nation’s top 15 health systems and four of the top 25 health insurers. 

The task force, which includes patients, payers, providers and purchasers, announced its goals two days after Department of Health & Human Services (HHS) Secretary Sylvia Burwell announced the federal agency’s goals. (See story on page 1.) This new partnership, states HCTTF’s website, will “work to clear the way for a sweeping change of the U.S. health care system.”  

As a news release states, “Together, the two announcements send a clear signal that the public and private sector are aligning around a new trajectory for health care payments that moves away from fee-for-service and into alternative payment models.”

The HCTTF website confirms that it seeks to provide a “critical mass of business, operational and policy expertise from the private sector that, when combined with the efforts of the Centers for Medicare & Medicaid Services and other public and private sector stakeholders, can accelerate the pace of delivery system transformation.”

A key goal established by the group relates to issuing policy recommendations, and its first recommendations relate to improving commercial, Medicare and Medicaid accountable care organizations (ACOs). Other top priorities that will be addressed include developing a common bundled payment framework and improving care for high-cost patients.

Information Source: To learn more, visit www.hcttf.org.

About the Author

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com and ICD10Monitor.com; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.

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