Part 2: Why PQRS and VBM is Important to Your Practice this Year

valuemodifierThe Value-Based Modifier Program (VBMP or VBM) was created to establish differential payment to physicians based on the quality of care provided to Medicare beneficiaries. Costs are measured during a specific time period and based on provider participation in the Physician Quality Reporting System (PQRS) program.

Participation in the VBM in 2015 will result in either bonus payments, no adjustments or negative payment adjustments in 2017.

The 2015 Value-based Modifier Program (VBM) will apply to:

  • Group Practices (GPs) with two or more EPs (eligible professionals)
  • Physicians who are solo practitioners

For Payment Adjustment year 2018, based on performance year of 2016, the VBM will apply to:

  • Groups that consist only of non-physician EPs (for example, groups with only nurse practitioners or physician assistants)
  • Non-physician EPs who are members of group practices that include physicians
  • Non-physician EPs who are solo practitioners

Categories of VBM Participants

CMS will use two categories to determine CY 2017 VBM payments based on participation in the PQRS program in 2015.

Category 1 includes:

  • Groups that meet the criteria for satisfactory reporting of PQRS quality measures via the GPRO (through use of web-interface, EHR or registry reporting)
  • Groups that do not register to participate in the PQRS as a group but have at least 50 percent of the group’s EPs either meet the criteria for satisfactory reporting of PQRS as individuals (using claims, EHR or registry reporting) or in lieu of satisfactory reporting, satisfactorily participate in a PQRS-qualified clinical data registry.
  • Solo practitioners that meet the criteria for satisfactory reporting of PQRS quality measures as individuals (through use of claims, registry, or EHR reporting) or in lieu of satisfactory reporting, satisfactorily participate in a PQRS-qualified data registry.

Category 2 includes:

  • Groups and solo EPs that fail to satisfactorily report or participate under PQRS.

Payments and Penalties by Category-Approach

Category 1

  • Apply the quality-tiering methodology for all groups with 10 or more EPs making them subject to upward, neutral or downward adjustments derived under the quality-tiering methodology
  • Groups with 2 to 9 EPs and solo practitioners would be subject only to upward or neutral adjustments derived under the quality-tiering methodology

Category 2

  • Apply a -4.0 percent VBM to groups with 10 or more EPs
  • Apply a -2.0 percent VBM to groups with 2 to 9 EPs and solo practitioners

Outcome Measures

In addition to their PQRS measures, EPs must report three outcome measures. The three outcome measures for 2015 are the same measures as 2014.

  • All Cause Readmission
  • Composite of Acute Prevention Quality Indicators (bacterial pneumonia, urinary tract infection,dehydration)
  • Composite of Chronic Prevention Quality Indicators (COPD, heart failure, diabetes)

Cost Measures

The three cost measures for 2015 are the same measures as in 2014.

  • Total per capita costs measure (annual payment risk-adjusted Part A & Part B costs)
  • Total per capita costs for beneficiaries with four chronic conditions: COPD, Heart Failure,
    Coronary Artery Disease and Diabetes
  • Medicare Spending per Beneficiary measure (MSPB), which includes Part A and B costs during the 3 days before and 30 days after an inpatient hospitalization. The measure attributes the hospitalization to the group of physicians providing the plurality of Part B services during the

Registration for VBM

There is no formal registration for the VBM program except for group practices who report PQRS through the GPRO options Web Interface, Qualified Registry, and EHR reporting. For 2014 performance, those GPs had to register as a GPRO for PQRS by September 30, 2014.

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