We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.
—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser
No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.
CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.
The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.
Menu of Metrics
In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.
“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.
PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.
The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.
CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.