Will the Medicare Physician Value-Based Payment Modifier Affect Your Anesthesia Group?

If you are an anesthesiologist practicing in a group of 100 or more eligible professionals (EPs) and submitting claims to Medicare under a single taxpayer number, you may be subject to the Value Based Payment Modifier (VBPM) in 2015.  By 2017, all physicians participating in Fee-for-Service Medicare will be affected by the VBPM.  This Alert is intended to help anesthesiologists familiarize themselves with the VBPM.

The VBPM program, as provided for in the Affordable Care Act, is designed to connect the cost and quality of medical services in order to pay for “value” rather than the quantity of care.  It combines quality measures under the Physician Quality Reporting System (PQRS) with cost measures and a payment adjustment.

The VBPM and PQRS are related but independent.  Readers are reminded that EPs who do not participate in PQRS in 2013 are subject to a -1.5% payment adjustment in 2015.  Non-participation in 2014 and subsequent years will produce an annual -2.0% adjustment beginning in 2016.

Groups With 100 or More EPs

To avoid a negative one percent (-1%) VBPM payment adjustment in 2015—on top of the -1.5% adjustment for failure to participate in PQRS—anesthesiologists in a single-taxpayer number group that includes at least 100 physicians and nurse anesthetists and/or anesthesiologist assistants should make sure that their group registers and participates in the PQRS as a group.  The exceptions are groups participating in the Medicare Shared Savings Program ACOs, Pioneer ACOs or the CMS Comprehensive Primary Care Initiative, which are not covered by the VBPM for 2015 or 2016.  Other 100+ EP groups have until October 15, 2013 to tell CMS which of the following three PQRS reporting options they have selected for calendar year 2013:

1. “Group Practice Reporting Option” (GPRO) web interface
2. GPRO registries
3. Administrative claims, calculated by CMS by analyzing billing claims.  (Groups  that have physicians who want to continue reporting PQRS measures individually will need to elect the administrative claims reporting option in order to avoid the -1% adjustment; simply reporting PQRS measures claim by claim is no longer adequate.)

Representatives of group practices who have not yet registered should select their reporting mechanism through the Physician Value-PQRS Registration System (PV-PQRS) at https://portal.cms.gov using a valid Individuals Authorized Access to the CMS Computer Services (IACS) account.

Groups that self-nominate for either GPRO option must in addition report at least one GPRO quality measure in order to avoid the -1% penalty in 2015.  Electing to have one’s claims analyzed by CMS means that CMS will automatically abstract data showing, in virtually all cases, that no quality metric available under this option applied to the anesthesiology group and that there should therefore be no penalty.  The administrative claims option measures focus on preventive and chronic disease care.  Thus the CMS-calculated administrative claims reporting option requires no effort beyond signing up.  Large groups with 100-plus EPs can avoid both the -1% VBPM adjustment and the -1.5% PQRS payment adjustment in 2015 through this option.

Large groups that are subject to the VBPM will have an opportunity to elect a Quality Tiering option to calculate the 2015 value modifier for their group, based on quality and cost performance in 2013.  In most cases the result of electing quality tiering would be a neutral value modifier, with no impact on payment.  High quality and low costs could result in a positive value modifier and an upward adjustment of up to 2% in 2015 payments. Conversely, if quality was low and costs were high, the result could be negative payment adjustments of 1%.  Quality tiering does not appear to apply to anesthesiology or to any non-primary care specialties yet and it is not a recommended option for most of our readers.  It will be the subject of a future Alert at the appropriate time.

Smaller Groups and Individuals

Just as for groups of 100 or more EPs, for smaller groups and individuals, too, signing up for the CMS-calculated administrative claims reporting  option will avoid a negative payment adjustment in 2015 that would be imposed for not participating in PQRS.  This may provide insurance to providers who might otherwise not successfully participate in PQRS this year. Remember, though, that reporting a single measure will suffice to avoid the 2015 PRQS -1.5% adjustment. 

In 2013, neither individuals nor groups of fewer than 100 EPs are subject to the VBPM.  The proposed 2014 Medicare fee schedule for physician services, published on July 19, 2013, would expand implementation of the VBPM to groups of 10 or more EPs and would require mandatory participation in quality-tiering.  This proposal has drawn strong opposition from provider associations, not least because of the lack of reliable outcome or cost measures that apply to many specialties and because “Many physicians are unaware of the program’s existence, and many more continue to struggle with understanding the criteria and methodologies used by the program, which is still in its infancy.” (MGMA Comment Letter to CMS Administrator Marilyn Tavenner, September 6, 2013.)

The release by CMS—scheduled for today, September 16—of Quality and Resource Use Reports (QRURs), or physician feedback reports, is intended to provide information that will serve as the basis for the VBPM payment adjustments for larger groups starting in 2015, based on 2013 performance.  The QRURs will be available to all groups with 25 or more EPs through the PV-PQRS.  Although these smaller groups will not be eligible for quality-tiering and the opportunity to earn an upward adjustment until 2016 at the earliest,  CMS encourages all groups to: “When you receive a confidential QRUR, review it and help us improve future reports by offering input and suggestions.”

CMS will hold a National Provider Call on September 24, 2013 from 3:00 PM - 4:30 PM Eastern Time to provide an overview of the QRUR and how to interpret and use the data in the report.  Register for the call (“Program Year 2012 Quality and Resource Use Reports—Mapping a Route to Success for the 2015 Value-Based Payment Modifier”) here.

Don’t expect your QRUR to be error-free.  The type of program CMS is attempting through the VBPM is extremely complex and will take longer than a couple of years to begin functioning at all reasonably.  We expect that the final 2014 Fee Schedule rule, due out in November, will be less far-reaching than the proposed rule and will not apply the VBPM to groups of 10 EPs.  Regardless, the VBPM is an important development in Medicare’s transition from volume- to value-based purchasing and the ramifications of that change for all physicians and other EPs.  As we learn more, we will continue to provide our readers with the information.