In an effort to begin moving away from traditional fee-for-service payment models and toward pay-for-performance, the Centers for Medicare and Medicaid Services (CMS) is aligning the Physician Quality Reporting System (PQRS) with a value-based payment modifier (VBPM) for physicians. The program would link a quality analysis of a set of measures with a payment modifier. The underlying concept is that Medicare should reimburse for value, not simply for quantity of services provided.
The VBPM, introduced under Section 131 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 and expanded under Section 3003 of the Affordable Care Act, is continuing to grow and change, making the sustained advocacy efforts of SHM critical. By 2017, the VBPM will be applied to all physicians.
CMS uses quality measures from the PQRS to assess the performance of physicians. Within PQRS, physicians have the option to report on measures that are relevant to their practice and patient population. There are multiple reporting methodologies, including registries, claims, and the group practice reporting option (GPRO), each with a slightly different set of expectations and requirements. Performance on these measures is compared against a national benchmark for all physicians who report the measure.
Cost measures, universally applied to all physicians, look at the total resource expenditures for a physician’s attributed Medicare beneficiaries. These measures include: total per capita costs and costs for specific conditions, including diabetes, COPD, coronary artery disease and heart failure. Performance in these measures is compared within specialty designation.
Physician feedback reports (Quality and Resource Use Reports, QRURs) use quality data from the PQRS and claims data from Medicare fee-for-service patients to illustrate the costs and quality of services provided to patients. As these reports are refined, they will form the feedback element of the payment modifier.
Learn more about quality measures and PQRS.
The payment modifier is an adjustment to payments on the Medicare fee schedule that will be derived from the comparative quality data from the PQRS and the physician feedback reports. Similar to hospital value-based purchasing, the VBPM will withhold a percentage of the Medicare fee-for-service payments based on results from the performance year two years prior to the payment adjustment year.
Performance year for 2016 VBPM for physicians in groups with more than 10 EPs.
Payment Adjustment applied to groups of 100 or more EPS. Performance year for 2017 VBPM for all physicians.
Payment Adjustment applied to groups of 10 or more EPs. Performance year for 2018 VBPM.
Payment Adjustment applied to all physicians. Performance year for 2019 VBPM.
2018 and Beyond
Program continues. Penalties can be increased by CMS.
Getting Ready for Physician Value-Based Purchasing
Patrick Torcson, MD, MMM, SFHM
View the presentation from SHM's Annual Meeting 2013