Value-Based Payment Modifier - American Society of Anesthesiologists (ASA)

The Value-Based Modifier Program (VM) is a budget neutral payment modifier based on relative quality and cost of care. Medicare adjusts physician payments using quality data from the Physician Quality Reporting System (PQRS) and cost data from Medicare claims for fee-for-service patients. This is a pay for value (i.e., quality relative to cost) program — higher value gets higher pay; lower value gets lower pay.

Who will be subject to the VM?

In CY 2018, Medicare will apply the value modifier to physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs) in groups with 2+ EPs and those who are solo practitioners, as identified by their Tax Identification Number (TIN). For a detailed timeline of VM implementation, please visit the CMS Value-Based Payment Modifier Timeline page.

How is the VM calculated?

The VM is calculated for a group (identified by their TIN) using a quality composite score and a cost composite score. The quality composite scores are derived from six quality domain scores; each domain score is based on performance scores for PQRS measures reported, using its associated domain. Quality-tiering will determine if group performance is statistically better, the same, or worse than the national mean, based on standard deviation calculations.

How does PQRS participation impact my VM?

The VM relies on PQRS participation for the purpose of determining quality performance. In 2018, the quality score under the VM will be based on 2016 PQRS reporting, as well as CMS-calculated outcomes measures related to hospital readmissions and hospital admissions for certain chronic and acute conditions.

  • Groups of 10 or more EPs who successfully meet 2016 PQRS reporting requirements will receive an upward, neutral, or downward payment adjustment ranging from -4 percent to +4x, where x is a budget-neutral payment adjustment factor to be determined by CMS. Groups who have not successfully met PQRS requirements in 2016 will receive an automatic 4 percent VM penalty in 2018. 
  • Groups of 2-9 EPs and physician solo practitioners who successfully meet 2016 PQRS reporting requirements will receive an upward, neutral, or downward payment adjustments ranging from -2 percent to +2x, where x is a budget-neutral payment adjustment factor to be determined by CMS. Those who have not successfully met PQRS requirements in 2016 will receive an automatic 2 percent VM penalty in 2018. 
  • Groups consisting exclusively of non-physician EPs and solo practitioners who are PAs, NPs, CNSs or CRNAs who successfully meet 2016 PQRS reporting requirements will receive an upward payment adjustment of 2x, where x is a budget-neutral payment adjustment factor to be determined by CMS, or a neutral payment adjustment. Because 2016 is the first performance year that these types of providers will be counted toward the VM, downward adjustments will not apply to these groups when they successfully participate in PQRS in 2016. Those who have not successfully met PQRS requirements in 2016 will receive an automatic 2 percent VM penalty in 2018. 

What is quality-tiering?

The quality-tiering methodology is used to determine whether a group or solo practitioner in Category 1 (see the next question) will receive an upward, neutral, or downward payment adjustment under the VM in 2018, based on 2016 reporting. Groups and solo practitioners that provide high-quality, low-cost care to Medicare beneficiaries can earn an upward adjustment, while groups and solo physician practitioners that provide low-quality, high-cost care may receive a downward adjustment. Note: Groups and solo practitioners will be eligible for an additional +1.0x if average beneficiary risk scores is in the top 25 percent of all beneficiary risk scores.

For the 2018 payment year, the following quality-tiering methodology will be considered in determining the VM payment adjustment for those in Category 1. An * in the charts below indicate an upward VM payment adjustment factor. VM is a budget neutral program so the positive adjustments are based on the practices who were penalized for not participating in or not satisfactorily meeting criteria for PQRS and those who received a negative VM.

Physicians, Pas, NPs, CNSs and CRNAs in groups of 10+ EPs:

Cost/Quality

Low Quality

Average Quality

High Quality

Low Cost

0.0%

+2.0%*

+4.0%*

Average Cost

-2.0%

0.0%

+2.0%*

High Cost

-4.0%

-2.0%

0.0%

 

Physicians, PAs, NPs, CNSs and CRNAs in groups of 2-9 EPs and solo practitioners 

Cost/Quality

Low Quality

Average Quality

High Quality

Low Cost

0.0%

+1.0%*

+2.0%*

Average Cost

-1.0%

0.0%

+1.0%*

High Cost

-2.0%

-1.0%

0.0%


PAs, NPs, CNSs and CRNAs in groups consisting exclusively of non-physician 
EPs and PAs, NPs, CNSs and CRNAs who are solo practitioners

 

Cost/Quality

Low Quality

Average Quality

High Quality

Low Cost

0.0%

+1.0%*

+2.0%*

Average Cost

0.0%

0.0%

+1.0%*

High Cost

0.0%

0.0%

0.0%


How are VM payment adjustments determined? 

Groups and solo practitioners will be designated under one of the following two categories for the purposes of determining payment adjustments under the VM in 2018. 

  • Category 1: Includes all solo practitioners who satisfactorily report PQRS quality measures as individuals and those in group practices that meet the criteria via GPRO for the purpose of avoiding the 2018 PQRS payment adjustment during the 2016 reporting year.
    • Groups that do not self-nominate through GPRO under PQRS but have at least 50 percent of EPs who meet the criteria for satisfactory reporting for PQRS as individuals will be included. 
    • Groups and EPs participating in a Medicare Shared Saving Program (MSSP) ACO that successfully reports quality measures data will be part of Category 1
  • Category 2: Includes all groups and solo practitioners that do not fall under Category 1 and are subject to an automatic 2018 VM penalty. 
    • Groups and EPs participating in an MSSP-ACO that does not successfully report quality measures data will be part of Category 2. 

For Category 1 TINs, CMS uses the Quality and Cost Composite Scores to determine whether TINs receive an upward, neutral, or downward payment adjustment and the magnitude of the adjustment through quality-tiering. To be considered either a high or a low performer in quality, a TIN’s Quality and Cost Composite Score must be at least one standard deviation above or below the mean quality composite score for the peer group and must be statistically significantly different from the mean quality composite score for the peer group. 

If the TIN’s Quality or Cost Composite Score is within one standard deviation of the mean composite score for the peer group or is not statistically significantly different, then the TIN’s performance is designated as average.

Where can groups (identified by their Tax Identification Number or "TIN") find their 2016 VM and Quality and Cost Composite Scores? 

The quality and cost data used to calculate the 2018 Value Modifier will be contained in the 2016 Annual Quality and Resource Use Reports (QRURs). The Annual QRURs show how payments to physicians in the TIN will be affected by the Value Modifier in 2018, including any upward, neutral, or downward payment adjustment. Educational documents on the QRURs are available on the QRUR website.

Who should I contact for VM questions?

For questions regarding the VM Program, please contact the Physician Value Help Desk:
Monday – Friday: 8 a.m. – 8 p.m. EST
Phone: 1 (888) 734-6433, press option 3; (TTY 1-888-734-6563)

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For information on PQRS reporting options and regulatory information, please contact the ASA Department of Quality and Regulatory Affairs at (202) 289-2222 or qra@asahq.org

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