What to Expect from the Value Modifier in 2017
The Centers for Medicare & Medicaid Services (CMS) has implemented value-based programs to measure quality and cost of care provided to Medicare patients. The Value Modifier (VM) is a value-based payment adjustment mechanism that CMS has been phasing in since 2015, which means the rules change every year. Here is how the VM might apply to your practice in 2017, and beyond.
How the Value Modifier Works
As with all value-based programs, the VM rewards healthcare professionals who provide quality care cost-effectively, and penalizes those who don’t. The VM quality measurement component is aligned with the Physician Quality Reporting System (PQRS), and adjustments are applied to the Taxpayer Identification Number (TIN) of eligible physicians and physician groups on a per claim basis for healthcare services paid under the Medicare Physician Fee Schedule (PFS).
In 2015, VM adjustments applied to physicians in groups of 100 or more eligible professionals, based on 2013 performance. To avoid an automatic negative 1 percent VM payment adjustment, these providers had to either self-nominate for a PQRS Group Practice Reporting Option (GPRO) and report at least one measure via the GPRO web interface or a registry, or elect the CMS-calculated administrative claims option as a group in 2013. Providers who elected to have their VM calculated using the quality-tiering methodology were subject to upward, neutral or downward payment adjustments.
Note: “Eligible professionals” includes physicians, practitioners, physical and occupational therapists, qualified speech-language pathologists and qualified audiologists.
In 2016, VM adjustments applied to physicians in groups of 10 or more eligible professionals, based on 2014 performance. Providers who participated in the PQRS and satisfied reporting requirements were eligible for upward, downward, or neutral payment adjustments under the VM quality-teiring methodology and avoided an automatic negative 2 percent payment adjustment.
In 2017, the final phase-in year, VM adjustments will apply to solo practitioners and physicians in groups of two or more eligible professionals, based on 2015 performance. These providers had to have participated in the PQRS and satisfied reporting requirements in 2015 to be eligible for upward, downward, or neutral payment adjustments and avoid an automatic negative 2 percent (for physician groups of two to nine) or negative 4 percent (for physician groups with 10 or more) in 2017.
VM adjustments for physicians participating in the Medicare Shared Savings program will be based on the participating Accountable Care Organization’s (ACO) quality data and average cost.
The 2017 VM will be waived for physician groups if at least one eligible professional who billed for Medicare PFS items and services under the TIN during 2015 participated in the Pioneer ACO Model or the Comprehensive Primary Care Plus (CPC+) initiative, and none participated in a Shared Savings Program ACO in 2015.
What Lies Ahead
In 2018, VM adjustments will also apply to physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who are solo practitioners or in groups of two or more, based on 2016 performance.
The VM sunsets Dec. 31, 2018, and will be replaced with the Merit-based Incentive Payment System (MIPS).
CMS 2015 QRUR and 2017 Value Modifier website