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Background

What?

The Physician Feedback/Value-Based Payment Modifier Program provides comparative performance information to physicians and medical practice groups, as part of Medicare’s efforts to improve the quality and efficiency of medical care.  By providing meaningful and actionable information to physicians so they can improve the care they deliver, CMS is moving toward physician reimbursement that rewards value rather than volume.

The Program (which is specific to Fee-For-Service Medicare—not Medicare Advantage) contains two primary components:

•The Physician Quality and Resource Use Reports (QRURs)

•Development and implementation of a Value-based Payment Modifier (VM)

Why?

This program supports the transformation of Medicare from a passive payer to an active purchaser of higher quality, more efficient health care through the value-based purchasing (VBP) initiative.  Physician feedback reporting was initiated under Section 131 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and was expanded by section 3003 of the Affordable Care Act of 2010. The Affordable Care Act directed CMS to provide information to physicians and group practices about the resources used and quality of care provided to their Medicare Fee-For-Service patients, including quantification and comparisons of patterns of resource use/cost among physicians and medical practice groups. Most resource use and quality information in the QRURs is displayed as relative comparisons of performance among similar physicians or groups.  Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS).  Both cost and quality data are to be included in calculating the VM for physicians. By 2017, the VM is to be applied to all physicians who bill Medicare for services provided under the physician fee schedule.

Timeline for the Physician Feedback/Value-Based Payment Modifier Program

2012

December

In December 2012, we provided large group practices that, in 2011, participated in the Physician Quality Reporting System (PQRS) web-interface Group Reporting Option (GPRO) a group QRUR.

Beginning in December 2012, we provided physician-focused (rather than group-focused) QRURs to physicians practicing within a group of twenty-five or more eligible professionals in nine states.  The nine states were California, Illinois, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin.

2013

July-October

Group practices of 100 or more eligible professionals were to register and participate in PQRS as a group in order to avoid a -1 % payment adjustment (in 2015) under the value modifier. Of note, the VM payment adjustment is separate from the PQRS payment adjustment and payment adjustments from other Medicare sponsored programs.

September

In September 2013, we provided all groups nationwide in which 25 or more eligible professionals submitted claims under a single tax identification number (TIN) a QRUR based on calendar year 2012 data. For more information on the 2012 QRUR, please see the 2012 QRUR (disseminated in 2013) web page on the CMS Physician Feedback/Value-based Payment Modifier Website.

December

In December 2013, we provided Individual Eligible Professional (IEP) PQRS Performance Reports to all group practices with 25 or more EPs for which at least one EP reported PQRS measures as an individual in 2012 and was found to be PQRS incentive-eligible. The IEP PQRS Performance Reports provide a summary of the Individual EPs’ performance on PQRS measures reported in 2012. For more information on the IEP PQRS Performance Report, please see the Individual Eligible Professional PQRS Performance Report Template on the Physician Feedback/Value-based Payment Modifier website.

2014

April-September

All group practices with 10 or more EPs should register and participate in PQRS in order to avoid the negative 2% payment adjustment under the value modifier in 2016. We will compute the 2016 value modifier payment adjustment for groups that register based on their performance in calendar year 2014.  Groups that choose not to register and therefore to not participate in PQRS as a group may still avoid the negative 2% payment adjustment under the value modifier in 2016 if 50 percent or more of the individual eligible practitioners in their groups successfully avoid the PQRS penalty by reporting as individuals through PQRS.

Late Summer

For all group practices and solo practitioners, CMS will make available QRURs based on data from calendar year 2013.  For group practices with 100 or more EPs that elect quality tiering, the QRURs will show the group practice’s value-based payment adjustment for Medicare Physician Fee Schedule reimbursements in 2015.

2015

January

We will apply the VM to all payments for physicians in groups of 100 or more EPs.

Spring-Summer

Group practices of the designated size should register and participate in PQRS in order to avoid the negative payment adjustment under the value modifier in 2017. We will compute the 2017 value modifier payment adjustment for groups that register based on their performance in calendar year 2015.  

Summer

For all group practices and solo practitioners, CMS will make available QRURs based on data from calendar year 2014, showing the value-based payment adjustment for Medicare Physician Fee Schedule reimbursements in 2016 as appropriate.  

2016

January

We will apply the VM to all payments for physicians in groups of 10 or more EPs based on performance in 2014.

Summer

For all group practices and solo practitioners, CMS will make available QRURs based on data from calendar year 2015, showing the value-based payment adjustment for Medicare Physician Fee Schedule reimbursements in 2017 as appropriate.  

2017

January

We will apply the VM to all payments for physicians, including solo practitioners, based on performance in 2015.

Summer

For all group practices and solo practitioners, CMS will make available QRURs based on data from calendar year 2016, showing the value-based payment adjustment for Medicare Physician Fee Schedule reimbursements in 2018 as appropriate.  

What Should Physicians in Group Practices of 10 or more EPs  Do in 2014?

  • Decide how to participate in PQRS in 2014.  Groups of 10 or more eligible professionals have two ways to participate in PQRS in order to avoid the VM negative payment adjustment in 2016:  group reporting or individual reporting.
    • Group Reporting – Register by September 30, 2014
    • Individual Reporting – No registration necessary
      • If a group practice does not seek to report quality measures as a group, CMS will calculate a group quality score if at least 50 percent of the EPs within the group report measures individually and successfully avoid the 2016 PQRS payment adjustment.
      • Individual EPs may report on measures available to individual EPs via the following reporting mechanisms:
        • Claims
        • CMS Qualified Registries
        • EHR
        • Qualified Clinical Data Registries (new for CY 2014)
      • The group practice does NOT have to register for this option. 
      • For more information on the reporting mechanisms available for Individual EPs in 2014, please visit the Physician Quality Reporting System Website.
  • Decide which PQRS measures to report and understand the measure specifications.
  • Review quality measure benchmarks.
      • For more information on the benchmarks to be used in the 2013 QRURs as well as in the calculation of the 2015 VM based on 2013 performance, please see the PY 2013 Prior Year Benchmark document on the Value Modifier page  of the CMS Physician Feedback/Value Based Payment Modifier website.
      • The quality benchmarks shown in the PY 2013 Prior Year Benchmark document are means and standard deviations for Physician Quality Reporting System (PQRS) quality indicators, ambulatory care sensitive condition measures, and the all-cause readmissions measure that will be applied for the 2016 VM. We base the benchmarks on performance on these measures from the year prior to the performance year (2013 performance for the 2014 QRURs) for all solo practices and groups nationwide. We will assess a group’s performance on quality based on the benchmarks, and the document provides an opportunity for groups to look at these benchmarks to see how their performance on each of the quality measures fare in comparison to the national mean performance.
  • Obtain your 2013 QRUR – available late summer of 2014 at https://portal.cms.gov.
      • In addition to quality and cost data, the 2013 QRUR will contain information about the beneficiaries attributed to the group, their resource use (costs) and specific chronic diseases.

For more information on what physicians in groups of 10 or more EPs need to do in 2014, please see the MLN Connects™ video presentation on The CMS Value-Based Payment Modifier: What Medicare Eligible Professionals Need to Know in 2014 and the Action for Groups with 10 or More Eligible Professionals to take In Order To Avoid the Automatic CY 2016 Value-Based Payment Modifier Downward Payment Adjustment [PDF, 148KB] document.