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Value-Based Payment for Physicians in Medicare: Small Step or Giant Leap?Value-Based Payment for Physicians in Medicare

Andrew M. Ryan, PhD; and Matthew J. Press, MD, MSc
[+] Article, Author, and Disclosure Information

From Weill Cornell Medical College, New York, New York.

Financial Support: Dr. Ryan is supported by a grant from the Agency for Healthcare Research and Quality (K01 HS018546-01). Dr. Press is supported in part by funds provided to him as a Nanette Laitman Clinical Scholar in Public Health at Weill Cornell Medical College.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1715.

Requests for Single Reprints: Andrew M. Ryan, PhD, Department of Public Health, Weill Cornell Medical College, 402 East 67th Street, Room LA-215, New York, NY 10021; e-mail, amr2015@med.cornell.edu.

Author Contributions: Conception and design: A.M. Ryan, M.J. Press.

Analysis and interpretation of the data: A.M. Ryan.

Drafting of the article: A.M. Ryan.

Critical revision of the article for important intellectual content: A.M. Ryan, M.J. Press.

Final approval of the article: A.M. Ryan.

Ann Intern Med. 2014;160(8):565-566. doi:10.7326/M13-1715
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The Physician Value-Based Payment Modifier (PVBPM) is the first national value-based purchasing program for physicians in fee-for-service Medicare. The concept of shifting from volume- to value-based payment embodied by the PVBPM is a radical change for the Medicare program. The authors discuss the implementation challenges associated with this reform and what they mean for the future of the PVBPM.

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Value Based Payment - Unintended Consequences
Posted on May 3, 2014
Jonathan M. Schwartz, M.D.
The Grosse Pointe Medical Group
Conflict of Interest: None Declared
The authors rightly are concerned about the risk of unintended consequences in a value based payment environment that include rewards for achieving certain clinical outcomes or performing certain processes intended to improve the quality of care in a patient population. The risk of financial penalties for not achieving these milestones may create a more insidious and pernicious effect on care and outcomes than envisioned by either the authors or CMMS.

The risk of financial penalties will create a subtle but certain incentive for physician practices to discharge, block access, or otherwise disclaim responsibility for difficult to manage patients or those patients whom they perceive as marginally or frankly noncompliant. It is these patients who will be perceived by physicians as contributing to the denominator of performance measures but not the numerator. This may further disenfranchise and fracture the care of those patients with chronic illness who are most at risk for complications and poor (and expensive) outcomes.

Policy makers should seriously consider this risk before imposing a punitive payment regime.
Posted on June 24, 2014
Michelle Kline Koltov, MPH
American College pf Physicians
Conflict of Interest: None Declared
The authors raise some interesting and good points regarding the impact of value based payment (VBP) program. There are, however, a few areas and policies referenced throughout the article that I think would benefit from some clarification and explanation.
The value based payment program was included in the Affordable Care Act (ACA) as a way to transition the payment system to reward value of care, rather than volume. CMS implements this program through the annual Medicare Physician Fee Schedule rule making process. In implementing the program, CMS aligned the reporting for the value based payment program with the physician quality and reporting system (PQRS) in an effort to reduce the reporting burden on physicians and their practices. PQRS, unlike the VBP, is a pay for reporting program that uses a combination of incentive payments and payment adjustments that has applied to all eligible professionals (EPs) since 2006. In addition, the VBP was established in the ACA and the first year of the program, which was in 2013 (payment adjustment in 2015), only applied to groups of 100 or more eligible professionals. Another important aspect of the VBP program is the two year delay between performance year (ie requirement to PQRS report) and the year when the value based payment modifier is applied. For example, a group of 10 or more EPs must report PQRS in 2014, to avoid the 2016 value based payment penalties.
The authors mention various “current proposals” from CMS, however many of the proposals referenced in the article were finalized in the 2014 Medicare Physician Fee Schedule during November 2013. In November 2013, CMS finalized that the value based payment program would apply to groups of 10 or more eligible professionals in 2014. In addition, as required by the ACA, the program must apply to all physicians by 2017. CMS will include their proposals for the 2015 VBP program in the 2015 proposed Medicare Physician Fee Schedule, which is usually published in July.
Quality-tiering, referred to as “value-tiering” in the article, is the methodology used by CMS to determine how the value modifier is applied to group practices. Under quality-tiering, CMS calculates quality and cost scores for group practices and compares these scores to a national benchmark to determine if a group is high, low, or average performing. This is then used to determine the value modifier amount (positive, negative, or neutral adjustment) that will be applied to physician payments. The authors note that large groups can choose to participate in the quality-tiering. However, this was only optional for 2013 and groups of 100 or more had to make this election by October 15, 2013. Furthermore, CMS changed this policy for the 2014 program and made quality-tiering mandatory for all practices with 10 or more EPs. CMS finalized that groups of 10-99 EPs will be held harmless from downward adjustment under quality-tiering during their first year. Hopefully CMS will continue this policy as the VBP program is expanded and applied to smaller practices. As the authors noted, many of these practices will be reporting PQRS for the first time and this policy allows the groups to gain reporting experience before being at risk for a downward adjustment. It also allows CMS to gain experience in analyzing and improving the accuracy of the VBP program before applying a penalty to a larger group of practices.
Lastly, the authors note that PQRS performance has yet to be publically reported. However, the CMS Physician Compare website posts the names of EPs that satisfactorily submit quality data to various CMS programs, including the PQRS program. Large group practices that submit measures through the group practice reporting option (GPRO) web interface are publicly reported and are included on the clinical quality of care performance section of the group practice's page. Currently, this includes the Diabetes Mellitus (DM) and Coronary Artery Disease (CAD) PQRS GPRO measures. CMS plans to expand the publication of other measures in future years. In addition, CMS posts the names of EPs who report the PQRS cardiovascular prevention measures group.
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