CMS will be tiering the two composites – quality of care and cost of care – based on the group’s standardized performance as compared to national benchmarks. High-cost/ low-quality providers will have a downward adjustment of minus 1% – the same downward adjustment as non-PQRS reporters (see table). High-quality/low-cost, high-quality/average-cost, or average-quality/low-cost providers will have an upward adjustment. As this is a budget-neutral program, until CMS knows how much money is in the pot from those who are not reporting or received downward adjustments, Medicare will not be able to calculate how much money will be distributed for those receiving an upward adjustment.
Groups are eligible for an additional 1% if reporting clinical data for quality measures for an average beneficiary risk score is in the top 25% of all beneficiary risk scores. So, those groups who perform at high levels and have a complex patient population would receive an additional 1% to their value modifier.
I have my QRUR, but how do I read it?
On the performance highlight page of the QRUR, the first box indicates the number of Medicare fee-for-service patients that you treated and, on average, the number of physicians that treated each Medicare patient for whom claims were submitted. On this highlight page, CMS also shows performance on PQRS measures and claim-based quality measures compared with other PQRS participants nationwide regardless of specialty.
Quality of care
The claims-based quality measures section also gives information on the quality of care received by beneficiaries, regardless of who provided the care. This information is provided to give a preview of the measures and the performance rates that physicians will see if they select the PQRS administrative claims reporting option for 2013.
Costs of care
Medicare recognizes that not all of these measures assess care provided by certain specialists. Therefore, CMS risk adjusts and standardizes payments for all cost measures based on a physician’s patient characteristics (age, gender, Medicaid eligibility, history of medical conditions, and end-stage renal disease). Based on these characteristics, CMS risk adjusts the total annual per capita costs up or down for all of a physician’s Medicare patients.
Though counterintuitive, if a physician’s cost were adjusted upward, this means that on average, a physician treated beneficiaries who were less complex than the average Medicare fee-for-service beneficiary. And if a physician’s cost were adjusted downward, this means that on average, the patients a physician treated were more complex than the average Medicare fee-for-services beneficiary.
CMS categorizes Medicare fee-for-service patients according to the degree of a physician’s involvement with each patient. "Directed" patients are considered those patients for whom a physician billed 35% or more of their office or other evaluation and management (E&M) visits, which would be most characteristic of a primary care provider. The patients whose care a physician "influenced" are those for whom a physician billed fewer than 35% of their office or other E&M visits, but for 20% or more of all cost. This might be more characteristic of a specialist such as a gastroenterologist. The "contributed" category includes the rest of the beneficiaries and those would be less than 35% of office and E&M visits and less than 20% of cost billed by the physician.
The report indicates the number of patients and individual physician share of costs billed by medical professionals. The benchmarks for the cost measures are those in your specialty. The total per capita costs are all risk adjusted and price standardized to ensure fair comparison.
CMS recognizes that Medicare fee-for-service patients may have seen multiple physicians. A patient can be attributed to multiple physicians, each in the appropriate care category. Because of the 35% rule for directing, up to two physicians can "direct" care and up to five physicians can "influence" care, but multiple physicians can "contribute" to care.
The report will indicate the results for the Medicare patient whose care you directed, the average for Medicare patients whose care was directed by physicians in your specialty in the nine states, and then the amount by which your Medicare patients costs were higher or lower than average.
CMS will also show you the number of other physicians who submitted claims for your patients. Many physicians may be unaware of how many physicians their fee-for-service patients are seeing. The reports indicate where your patient’s Medicare costs fall relative to other physicians in your specialty. The same analysis is repeated for "influenced" and "contributed," and would be shown in your report if you had patients who were attributed to you in those categories.
