CMS Announces 2016 Value Based Payment Modifier (VBPM) Results and Upward Payment Adjustment Factor

On March 7, CMS published the results from the implementation of the 2016 Value Modifier (based on 2014 reporting) and the adjustment factor that will be applied to physician groups subject to upward payment adjustments under the Value Modifier in 2016.

The upward payment adjustment factor in 2016 is +15.92 percent. The Value Modifier adjustment factor is determined after the close of the reporting period (2014) and is based on the estimated aggregate amount of downward payment adjustments.

There are 13,813 physician group practices with ten or more eligible professionals that were subject to the 2016 Value Modifier based on 2014 performance.  Physicians in 5,418 groups failed to meet minimum reporting requirements of having more than fifty percent of the group eligible professionals report for PQRS, and will see -2 percent decrease in their Medicare payments in 2016. This is in addition to a PQRS penalty adjustment.

8,395 groups met the criteria to avoid the 2016 VBPM adjustment based on PQRS reporting and their 2016 Value Modifier was calculated using the quality-tiering methodology.  Of those groups, physicians in 128 groups exceeded the benchmarks in quality and cost and will receive an increase in their payments under the Medicare Physician Fee Schedule. 59 physician groups will see a decrease of either -1 or -2 percent in their Medicare payments in 2016 based on their 2014 performance. Medicare payments for 8,208 physician groups will remain unchanged because they either had average cost and quality scores in 2014 performance or there was insufficient data to calculate the groups’ Value Modifier.

Physician groups and physician solo practitioners can find information about their quality and cost performance in their 2014 Annual Quality Resource and Use Reports (QRURs) that were made available last fall. For groups that are receiving an upward or downward payment adjustment under the 2016 Value Modifier, the Medicare Administrative Contractors (MACs) will begin paying claims based on the updated payment amounts after March 14, 2016, and the groups will start seeing the adjustments on their claims in the next six weeks. CMS will reprocess any CY 2016 claims with dates of service that were prior to this date.  In addition, if a groups Value Modifier changes as a result of a pending informal review, CMS will retroactively update their payment adjustment amounts over the next several months.

As you know, ASCRS has significant concerns with the VBPM attribution method for cost measures. Specifically, CMS looks to see if a beneficiary was treated by a primary care provider during the reporting period. If the beneficiary did not see a primary care provider, then CMS looks to see which provider billed the most E/M services for the beneficiary during a reporting period and if so, the beneficiary is attributed to that provider. Therefore, we have many members, who under the current attribution method, have patients with medical care unrelated to ophthalmology attributed to them. A similar attribution method was previously used to assign beneficiaries to Accountable Care Organizations (ACOs). ASCRS and other medical specialty groups pointed out the issues with the ACO attribution method to CMS, and they changed the method to exclude specialties, such as ophthalmology. We have repeatedly informed CMS that this current attribution method is flawed and needs to be reworked, and we will continue to urge CMS to address this as they move forward developing the resource use category under MIPS.

For more information, view CMS’ Value Based Payment Modifier webpage.

As a reminder, the Value Modifier will apply to all providers in 2017 based on their 2015 performance.

If you have any questions, please contact Ashley McGlone, ASCRS manager of regulatory affairs, at 703-591-2220 or the CMS quality help desk at 1-888-734-6433.