how medicare data impacts your practice...• cms finalized its 2016 proposal to adopt the...
TRANSCRIPT
Thomas Walke, PhD
Marjorie Kanof, MD
Health Policy Alternatives, Inc.
How Medicare Data Impacts Your
Practice
November 6, 2015
Questions for Today
• What information is out there that can be useful to examining Medicare payment issues related to the podiatry specialty?
• What information is available on podiatrists that provide services to Medicare beneficiaries?
• What are some of the initial data needs with respect to alternative payment models?
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Public Use Data Files on Medicare Physician
Payment, Utilization, and Quality
• Data from the Physician Fee Schedule (PFS) Proposed and Final Rules
• Data from the PFS Contractor Files
• Medicare Physician Data File: Medicare Provider Utilization and Payment Data: Physicians and Other Supplier Public Use File
• Physician Compare Data
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DATA FROM THE PROPOSED
AND FINAL PFS RULES
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PFS Proposed and Final Rule: Key Data Files
• Addendum B Relative Value Units
• CY 2014 Utilization Data – Specialty, HCPCs, Modifier, Facility, Allowed Charges,
Services (discounted, undiscounted)
• Practice Expense (PE) Input Files – Direct PE input data
– Indirect Practice Cost Indices
– Physician Time
• Other assorted files – Codes subject to various PFS adjustments (e.g., Multiple
Procedure Payment Reduction)
– HCPCS Defined as Misvalued for Target
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PFS Proposed and Final Rule Data: Addendum B
Relative Value Units and Related Information
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PFS Proposed and Final Rule Data:
Medicare Utilization File
• 2014 latest
• Requires analysis
using Excel or
Statistical Software
Allows one to examine
for a specialty:
• the utilization by code
• how usage of code
compares with other
specialties
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PFS Proposed and Final Rule Data:
Practice Expense Input Files
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Example for 11721 (Debride nail 6 or more)
DATA FROM THE PFS
CONTRACTOR FILES
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PFS Contractor Files: Summary
• Medicare rate calculation files that CMS provides to contractors for use in processing claims
• Relative Value File (updated quarterly)
– RVUs for more than 10,000 physician services
– Fee schedule status indicator
– Payment adjustment indicators
• Geographic Practice Cost Indices file
– Details GPCIs for 89 total PFS localities used to adjust payments based on geographic area.
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PFS Contractor File: National RVU File
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Application of PFS Data: Medicare
Snapshot of Podiatry Specialty, 2016
HCPCS Description
2014
Volume of
Services
(millions)
Estimated 2016
Total Medicare
Allowed
Charges, All
Settings
(millions)
% of
Estimated
Total
Medicare
Allowed
Charges
% Change in 2016
Estimated Medicare
Pay Compared with
2015
11721
Debride nail 6 or
more
7.3 $329.3 17% 2.1%
99213
Office/outpatient
visit est
4.3 $316.6 16% 1.0%
99203
Office/outpatient
visit new
1.1 $123.4 6% 0.5%
11056
Trim skin lesions 2
to 4
1.9 $112.9 6% 1.1%
99212
Office/outpatient
visit est
2.2 $95.1 5% 0.5%
11750 Removal of nail bed
0.2 $27.7 1% -30.8%
All other codes
14.4 $980.3 49% 0.8%
Total
31.5 $1,985.34 100.0% 0.4%
Source: HPA analysis of 2016 Medicare Physician Fee Schedule Proposed Rule 12
DATA FROM THE PFS MEDICARE
PHYSICIAN DATA FILE
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• Referred to “officially” as the Medicare Provider Utilization and Payment Data: Physicians and Other Supplier Public Use File
• First released on April 9, 2014 contains never-before-seen data on Medicare Part B fee-for-service payments to physician and other health care providers in 2012
• What does it include? – Provider information for more than 950,000 providers who
participate in Medicare (e.g., names, credentials, gender, provider type.. )
– Service information by Healthcare Common Procedure Coding System (HCPCS) (e.g., number of services provided, number of Medicare beneficiaries served, and service setting)
– Payment information on $90 billion paid out to Medicare beneficiaries in 2013 (e.g., includes average Medicare payment after deductible and coinsurance)
Medicare Physician Data File: Background
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Source: http://graphics.wsj.com/medicare-billing/#/name=&special=Podiatry&city=&state=, accessed October 15, 2015.
• Data available in raw
form on the CMS
website
• Other sites, such as
the Wall Street
Journal have search
engines that make it
easier to lookup
particular providers
and drill down for
more detail.
Medicare Physician Data File: Podiatry
Example
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Medicare Physician Data File: Podiatry
Example (Con’t)
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Medicare Physician Data File:Podiatry Example
(Con’t)
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Medicare Physician Data File: Potential Uses
and Concerns
Potential Uses of Physician Data File
• Greater program
transparency
• Source of information for
consumers and providers
• Use of data by state,
commercial payers and
federal audit agencies,
investigative journalists.
Potential Concerns about Use of Data
• Data can be misleading!
Multiple providers are
allowed to bill using the same
NPI (e.g., group practices)
• Does not include data on
services performed on 10 or
fewer beneficiaries
• Extremely large dataset and
difficult to manipulate without
statistical software
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QUALITY DATA FROM
PHYSICIAN COMPARE
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Physician Compare: Podiatry
Example
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Physician Compare: Limited Quality Information
Posted (for now)
Individual EPs have a green check on their profile page:
• Satisfactorily report under PQRS
• Successfully participate in Electronic Prescribing (eRx) Incentive program;
• Participate in EHR Incentive program; or
• Report as part of the 2013 PQRS Cardiovascular Prevention measures group in support of Million Hearts®.
Group Practices have a green check on their profile page:
• Satisfactorily report under the Group Practice Reporting Option (GPRO); or
• Successfully participate in the eRx Incentive program.
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Physician Compare: Benchmarking and Star
Ratings
• CMS finalized its 2016 proposal to adopt the Achievable Benchmark of Care (ABCTM) methodology
• CMS plans to use the benchmark to “systematically assign stars for the Physician Compare 5-star rating”
• CMS provides additional details in the final rule about how the methodology would work.
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DATA NEEDS FOR ADVANCED
PAYMENT MODELS
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Advanced Payment Models: Data
Needs • More granular data – patient-based data
• Broader Perspective (what settings are affected) – All Part A and B Services
– Hospital
– Physician
– LTC
– DME
– Part B Drugs
• Provider Control
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Part A and Part B Payment for Surgical Procedure
(30 days pre/90 days post-admission)
65%
18%
18%
3%
5% 12%
1%
Admission
Re-admission
Other Physicians
Surgeon
Hospital OPD
Post-Acute Care
DME
Concluding Observations
• Abundance of payment and utilization data available for Medicare policy analysis
• Limited quality data available and posted
• Be aware of information being reported on you from the Physician Data file or on Physician Compare
• Continue to examine the feasibility of advanced payment models/bundling
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While I can explain the meaning of life, I don’t dare try to
explain how the Medicare system works.
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Time for your questions?