Update on the Medicare Value-Based Payment Modifier and Electronic Health Record Incentive Program Requirements
SVS Quality and Performance Measures Committee Provides Information on National Changes
How will the Medicare Physician Fee Schedule (PFS) Physician Feedback Program/Value-based Payment Modifier Program impact the Society for Vascular Surgery’s membership over the next three years? The SVS Quality and Performance Measures Committee has outlined key components and changes.
What is the Medicare Value-Based Payment Modifier?
The Value-Based Payment Modifier provides for differential payment to a physician or a group of physicians under the PFS based upon the quality of care furnished compared to the cost of care during a performance period. The Value Modifier is an adjustment made on a per claim basis to payments for items and services under the PFS and is applied at the Taxpayer Identification Number (TIN) level to physicians [and beginning in 2018, to non-physician eligible providers (EPs)] billing under the TIN. The Value Modifier is currently separate from the payment adjustment and incentives under the Physician Quality Reporting System (PQRS). However, CMS is aligning the Value Modifier Program’s quality measurement component with the reporting requirements under the Physician Quality Reporting System (PQRS).
What is the timeline for implementation?
Under the provisions of the Affordable Care Act, CMS began applying a Value Modifier under the Medicare PFS in 2015. The modifier is based on performance in 2013 for groups of 100 or more eligible professionals.
Beginning Jan. 1, 2016, the Value Modifier has been applied to payments for physicians in Tax Identification Number (TIN) with 10 or more eligible professionals, provided that at least one physician submitted a Medicare claim during 2014 under the TIN. In 2015 and 2016, CMS did not apply the Value Modifier to TINs in which one or more physicians in the TIN participated in the Medicare Shared Savings Program, the Pioneer Accountable Care Organization (ACO) Model or the Comprehensive Primary Care (CPC) initiative during the relevant performance period.
As of Jan. 1, 2017, the Value Modifier will be applied to physician payments for every physician, including physician solo practitioners and physicians in groups with two or more eligible professionals based on data reported in 2015. CMS provides specific policies through rulemaking regarding application of the Value Modifier to TINs participating in Medicare Shared Savings Program ACOs, Pioneer ACOs, the CPC initiative, and other similar initiatives.
What quality and cost measures are used in the Value Modifier?
All providers must be enrolled in a qualified PQRS program. In addition, the quality measurement component of the Value Modifier includes three outcome measures that CMS calculates from Fee for Service (FFS) Medicare claims including two composite measures of hospital admissions for ambulatory care-sensitive conditions (one for acute conditions and one for chronic conditions) and one measure of 30-day all-cause hospital readmissions. For the cost measure components, CMS includes the performance of six cost measures: total per capita costs for all attributed beneficiaries measure, total per capita costs for beneficiaries with four specific conditions (diabetes, coronary artery disease, chronic obstructive pulmonary disease, heart failure), and Medicare Spending per Beneficiary (MSPB).
What is the anticipated payment adjustment for Calendar Year 2016?
The Value Modifier being applied in CY 2016 is based on the CY 2014 performance period. To be eligible for payment adjustments under the Value Modifier quality-tiering methodology and to avoid an automatic negative 2 percent Value Modifier payment adjustment in CY 2016, Eligible Professionals in groups with 10 or more EPs MUST have participated in the PQRS and satisfied reporting requirements as a group or as individuals in CY 2014.
Physician groups could have either participated in the PQRS Group Practice Reporting Option (GPRO) or the EPs in the group participated in the PQRS as individuals in CY 2014 with at least 50 percent of the EPs in the group having met the satisfactory reporting criteria as individuals (or in lieu of satisfactory reporting, satisfactorily participated in a Qualified Clinical Data Registry). Quality-tiering is mandatory for groups subject to the Value Modifier in CY 2016. Groups with 100 or more Eligible Professionals are subject to upward, neutral, or downward adjustment under quality-tiering, and groups with between 10 to 99 EPs are subject to only upward or neutral adjustment under quality-tiering in 2016.
CY 2017 Payment Adjustment - Physician Solo Practitioners and Physicians in Groups of 2 or more Eligible Professionals
CY 2015 was the performance period for the Value Modifier that will be applied in CY 2017. In order to be eligible for upward, downward, or neutral payment adjustments under the Value Modifier quality-tiering methodology and to avoid an automatic negative two percent (“-2.0%”) (for physician groups with between 2 to 9 EPs and physician solo practitioners) or negative four percent ("-4.0%") (for physician groups with 10 or more EPs) Value Modifier payment adjustment in CY 2017, EPs in groups and solo practitioners MUST have participated in the PQRS and satisfy reporting requirements as a group or as individuals in CY 2015. Physician groups may have participated in the PQRS GPRO in CY 2015 or the EPs in the group may have participated in the PQRS as individuals in CY 2015 with at least 50% of the EPs in the group meeting the satisfactory reporting criteria as individuals (or in lieu of satisfactory reporting, satisfactorily participate in a Qualified Clinical Data Registry)
CY 2018 Payment Adjustment - Physicians and Non-Physicians Who Are Solo Practitioners or in Groups of 2 or More Eligible Professionals.
In CY 2018, Medicare will apply the Value Modifier to all physicians and non-physicians who are solo practitioners or in groups of 2 or more EPs. CMS finalized that the 2018 Value Modifier will be applied to all physician and non-physician EP solo practitioners and those in groups in 2018 as it was in 2017.
Where can TINs find their 2016 Value Modifier and their Quality and Cost Composite Scores?
Authorized representatives of TINs can access the 2014 Annual Quality and Resource Use Reports at https://portal.cms.gov.
How can physicians earn incentives based on performance and avoid automatic downward payment adjustments under the Value-Based Payment Modifier in the future?
Option 1: Participate in the PQRS as a Group Practice by selecting one of the GPRO reporting mechanisms:
- Qualified PQRS Registry
- Electronic Health Record (EHR)
- Web Interface (for groups with 25 or more EPs only)
- Consumer Assessment of Health Providers and Systems (CAHPS) for PQRS Survey via a CMS-certified Survey Vendor
Option 2: Participate in the PQRS as Individuals via one of the following four reporting mechanisms:
- Medicare Part B Claims
- Qualified PQRS Registry
- Electronic Health Record (EHR)
- Qualified Clinical Data Registry
Vascular specialists must be aware of the current status of the Medicare Value-based Payment Modifier and upcoming changes that could impact reimbursement. For most vascular specialists, participation in a qualified PQRS and understanding the nuances of the Medicare performance-based payments will be increasingly important.
