Physician groups with more than 100 members were the first to be integrated into the Value-Based Payment Modifier (VBPM) program the Centers for Medicare and Medicaid Services (CMS) introduced in 2013. This year, 2015, those groups have begun receiving the bonuses and penalties associated with that program. Interestingly, though, only 14 of the 1,010 groups required to participate actually are receiving a bonus, and only 11 are seeing a negative adjustment.
“We performed well, but not enough for the bonus,” said Michael Kitchell, a neurologist with the McFarland Clinic in Ames, Iowa. “My sense of disappointment here is really significant. Why even bother?” Kitchell spoke with Kaiser Health News for an article about the VBPM.
What Is the VBPM, Again?
The VBPM program rewards providers who demonstrate high quality, low cost care as compared to their peers and penalizes those who provide low quality, high cost care. Increasingly more groups have been required to participate in the program: this year, all solo physicians and all-sized groups of physicians and other health professionals will be evaluated for 2017 payment bonuses or negative adjustments.
Besides the disappointment of not receiving a bonus—CMS admits that most providers and groups will fall within neutral tiering and receive neither bonuses nor penalties as was the case for 2015—other physicians don’t have the capability of reporting such complex quality metrics. “The participation rates, even though it’s mandated, are just really low,” said Dr. Alyna Chien, an assistant professor at Harvard Medical School. It’s “a level of analytics that just is not typically built into a doctor’s office,” she told Kaiser Health News.
How Are You Being Evaluated?
As well, some providers are confused about what is actually being evaluated. Quality is measured via the Physician Quality Reporting System (PQRS) but also outcomes measures calculated by CMS from submitted claims. Cost reporting is based on total per capita costs (plus Medicare Spending per Beneficiary) and per capita costs for beneficiaries with specific conditions. But CMS has acknowledged that “certain large single specialty groups—such as those limited to emergency medicine, diagnostic radiology, pathology, and anesthesiology—will not be attributed any beneficiaries under this attribution methodology.” In that case, those physicians will be given neutral tiering and will receive neither penalties or bonuses if they successfully participate in PQRS.
One tool to help physicians predict how their costs measure up for the program is the Quality and Resource Use Reports (QRURs) provided by CMS each year in late summer. However, that information is for the previous year’s dates of service, and by the time the information is provided, payments and penalties for the year in question are already decided, and the current year is more than half over.
The QRURs do provide the best possible predictor for future performance that CMS provides, however. CMS recently updated the How to Obtain a QRUR web page to more clearly explain how to access a QRUR on behalf of a group or physician solo practitioner.
Also, CMS plans to release mid-year QRURs later this month to physicians in groups of all sizes. Then, in the late summer of this year, CMS will provide the 2014 Annual QRURs to groups comprised of only non-physician eligible professionals, in addition to physicians in groups and to those who are solo practitioners.
What Should You Do?
- First, make sure you are participating in PQRS. If you are a solo practitioner, participate in one of the individual PQRS options. If you are part of a group, then register for the PQRS GPRO option and participate as a group, or make sure at least 50 percent of the physicians practicing under your tax ID number are participating as individuals. Not participating in PQRS for 2015 means an automatic 2 percent payment adjustment under the PQRS program PLUS an additional 2 percent (for solo practitioners or groups of 2-9) or 4 percent (for groups of 10 or more) payment adjustment.
- Then, go ahead and get copies of your 2013 QRURs, and when available, review your 2014 QRURs. Granted, the information is from a previous year, but at least you will have some idea of how you have performed in the past in order to anticipate this year’s cost analysis.
- Remember, most practices will fall into neutral tiering. While that may mean no bonus for the work you are providing, hopefully it will also mean no penalty for 2017.
- Finally, for more information, review the CMS document, What To Do In 2015 For The 2017 VM.
While the VBPM program, along with PQRS and EHR Meaningful Use, are going to be phased out after 2018—thanks to the Medicare Access and CHIP Reauthorization Act (MACRA) (HR 2) signed into law by President Obama just days ago—the new value-based formula known as the Merit-Based Incentive Payment System (MIPS), which also was created under MACRA, will continue to reward high quality, low cost care and penalize low quality, high cost care. So take steps today to report your data and begin participating.
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