Practice evolution timeline
Chet Seward, Senior Director, Health Care Policy
Key dates to remember
It is challenging to keep track of the myriad issues and deadlines associated with the continually changing health care system. Here is a list of major topics and milestones that are color-coded to help you organize the pieces of your practice’s evolution. Green pieces represent payment reform. Purple signify delivery system redesign, while blue are for transparency and accountability issues. Yellow pieces represent administrative simplification.
Thanks to the flawed Medicare sustainable growth rate (SGR) formula, a 27.4% reduction in physician payments is scheduled to take place March 1. Unless Congress acts to avert it, thousands of Colorado physician practices and the patients they serve will be affected.
Value-based payment modifier
Medicare will soon begin to apply a value modifier to physician payment rates under the Medicare physician fee schedule based upon the quality and cost of care delivered. This process will begin with specific physicians and physician groups in 2015 and expand to all physicians by 2017. Physician performance during 2013 will be used to calculate the modifier for 2015 physician fees. The value-based modifier builds on the Physician Feedback Program, created in 2008, that provides confidential feedback reports to physicians about the resource use and quality of care they provide to their Medicare patients. (Source: Centers for Medicare & Medicaid Services)
Physician Quality Reporting System
The Physician Quality Reporting System (PQRS, formerly PQRI) is a voluntary reporting program established in 2007 by the Centers for Medicare & Medicaid Services. The program creates a financial incentive for eligible professionals to report data on certain quality measures for Medicare Part B services. Beginning in 2015, those eligible physicians who do not satisfactorily submit PQRS data will have their Medicare payment rates reduced by 1.5%. Physicians must satisfactorily report PQRS data during the 2013 reporting period (Jan. 1 - Dec. 31, 2013) in order to avoid the 2015 penalty. (Source: Centers for Medicare & Medicaid Services)
All Payer Claims Database
The All Payer Claims Database (APCD) is a secure database that will be the comprehensive source for claims data from all public and private payers in Colorado. It was created via legislation in 2010 and is administered by the Center for Improving Value in Health Care (CIVHC). The APCD will provide valuable data on Colorado health care costs and utilization to highlight gaps and spot opportunities for improvement. Claims data from 12 carriers and Medicaid will begin to flow in February 2012. The first set of aggregate reports (Tier 1) on the incidence and variation of targeted medical conditions, state and regional cost patterns, and utilization of services will be available in the fall of 2012. Tier 2 reports will be out in July 2013 and will allow for comparisons of providers on things like cost of procedures and quality of care provided by different provider. Tier 3 reports are expected in 2014 and will feature enhanced analytics to spotlight individual provider level data, episode groups and model the effects of alternative payment strategies. (Source: Center for Improving Value in Health Care, CIVHC).
The E-prescribing (e-Rx) program began in 2009 and provides incentives for eligible professionals who are successful electronic prescribers. Physicians do not need to participate in PQRS to participate in the e-RX Incentive Program. The reporting period for the 2012 e-Rx incentive payment is Jan. 1, 2012 - Dec. 31, 2012, and physicians can choose one of three e-Rx reporting options, including claims-based, registry-based and electronic health record (EHR)-based systems.
For 2009 and 2010, e-Rx incentives were 2% of a provider’s total estimated allowed Medicare charges for covered professional services during the reporting period (one calendar year). Incentive amounts for e-Rx have been reduced to 1% in 2011 and 2012 and will decrease to 0.5% in 2013. Physicians may be subject to a 1.5% payment adjustment (penalty) in 2013 unless they successfully report 10 unique e-Rx events before June 30, 2012. Those who successfully achieve the 2012 e-Rx incentive will also be considered a successful ePrescriber for purposes of avoiding the 2% payment adjustment in 2014. (Source: Centers for Medicare & Medicaid Services)
Meaningful use of EHRs
Physicians who implement and “meaningfully use” a certified electronic health record (EHR) are eligible to receive incentive payments from the government through the 2009 HITECH Act. Physicians can receive up to $18,000 in 2011 or 2012 and up to a total of $44,000 through 2015 if they continue to qualify. (Source: American Medical Association, Centers for Medicare & Medicaid Services)
Medicaid Accountable Care Collaborative
The Colorado Medicaid Accountable Care Collaborative (ACC) is a central part of the state’s strategy to reform the Medicaid system from one that pays for a high volume of services to one that rewards value-driven health outcomes. Colorado Medicaid caseloads have increased by 72% since 2008 to over 650,000 patients. More than 100,000 of them are currently enrolled in the ACC, which relies on Regional Care Collaborative Organizations to support providers in seven different regions across the state. The ACC uses both fee-for-service and other payment methods to drive care system transformation. The state expects to net 7% savings in the current fiscal year on this program and, if all goes as planned, stepwise expansion of the ACC to other Medicaid patients not in other managed care options will begin on July 1, 2012. (Source: Colorado Department of Health Care Policy and Financing)
ACOs, bundled payments and other payment reforms
The passage of the Affordable Care Act accelerated a number of payment reform programs already underway, in addition to creating a few new initiatives. Federal programs launched in 2012 include the Medicare Shared Savings Program (ACO), the Pioneer ACO program, the Advance Payment ACO Model, the Bundled Payment for Care Improvement program and the Comprehensive Primary Care Initiative. Private payers are also stepping up payment reform activities, including pilots in three Colorado communities that are using the Prometheus episode of care model to use a gain-sharing approach to reducing potentially avoidable complications. CIVHC has developed a plan for payment and delivery system reform in Colorado that includes a 2015 midway milepost where fee-for-service is no longer predominant. Their 2018 goal is to have a high penetration of global payments and highly integrated health systems across the state. (Source: CIVHC)
ICD-10 & Version 5010 Standards
These two transitions will require significant system and business changes throughout the health care industry. Everyone covered by the HIPAA, not just those who submit Medicare claims, must transition to ICD-10 by Oct. 1, 2013. Claims that do not use ICD-10 diagnosis and inpatient procedure codes cannot be processed after that date. Version 5010 HIPAA electronic transaction standards are intended to improve standardization for administrative and clinical data compared with the current Version 4010/4010A standards. It is not possible to create or transmit electronic claims using ICD-10 codes without transitioning to Version 5010 HIPAA transaction standards. (Source: Centers for Medicare & Medicaid Services).
Posted in: Colorado Medicine | Practice Evolution