What is the Value–Based Payment Modifier (Value Modifier)?
Section 3007 of the Affordable Care Act mandated that, by 2015, the Centers for Medicare & Medicaid Services (CMS) begin applying a value modifier under the Medicare Physician Fee Schedule. Both cost and quality data are to be included in calculating payments for physicians.
- Physicians in groups of 100 or more eligible professionals who submit claims to Medicare under a single tax identification number will be subject to the value modifier in 2015, based on their performance in calendar year 2013.
- All physicians, regardless of practice size, who participate in Fee–For–Service Medicare, are subject to the value modifier in 2017 based on calendar year 2015 data.
How Does the Value Modifier Work?
The value modifier and the Physician Quality Reporting System (PQRS) are aligned. All physicians who participate in the value modifier will be evaluated on quality measures submitted through PQRS. The value modifier functions in both directions by rewarding high–performing physicians with increased payments and by punishing low–performing physicians with decreased payments.Physicians who do not participate in PQRS and do not report at least one measure will receive a downward payment adjust of –1.0%.
The 2015 and 2016 value modifier does not apply to groups that are Accountable Care Organizations (ACO) or ACO participants.
How Do I Participate?
From December 1, 2012–January 31, 2013, groups can self–nominate to participate in the 2013 PQRS web–interface group reporting option (GPRO) or a registry. From July 1, 2013– mid October 2013, CMS will continue the self–nomination/registration process for groups of 100 or more eligible professionals so that you can notify CMS of the three potential methods of group reporting (i.e. GPRO web interface, registry and administrative claims) you will use for 2013 to avoid a negative 1% payment adjustment under the value modifier.If physicians within a medical practice group need or prefer to participate in PQRS as individuals, in order for the group to avoid a negative 1% payment adjustment under the value modifier, an authorized group representative will need to commit the group, as a whole, (via a CMS–hosted registration process) to having CMS calculate a quality score from administrative (claims–based) quality measures.
What is the Quality Tiering Option?
Under the value modifier, physicians who elect a quality tiering calculation can receive upward, no, or downward payment adjustments based on quality and cost composites. It is important to note that a group practice with 100 or more eligible professionals may avoid a 2015 value modifier downward payment adjustment by self–nominating for the PQRS as a group and satisfactorily reporting at least one measure. Alternatively, physicians can also elect not to receive a quality tiering calculation and, therefore, will not receive a payment adjustment (0.0%).
Quality tiering will determine if group performance is statistically better, the same, or worse than the national mean. Quality tiering could result in a positive or negative 2015 payment adjustment for a relatively small number of groups with cost and quality performance indicators that vary substantially from the mean. The majority of groups would have no adjustment as a result of choosing quality tiering—only the outliers.