Bracing for the Cuts

For years, Medicare physicians have been encouraged to report on quality measures, earning incentives for being successful reporters under the Physician Quality Reporting System (PQRS) since 2006.  In their efforts to improve patient outcomes while controlling costs, Congress and the Centers for Medicare and Medicaid Services (CMS) have expanded the role of quality reporting in Medicare physician payment.  Congress then included a penalty for not reporting measures in statute, but for many, that potential penalty always seemed so far in the future.  But now the penalty phase is just around the corner.  Will physicians be ready?

Beginning in 2015, the CMS will assess penalties for physicians not meeting the requirements of the PQRS and the new value-based modifier as outlined in the recently released CY 2013 Physician Fee Schedule proposed rule.  Since when is 2015 right around the corner?  In order to collect and review data without making retroactive payment adjustments, CMS will be basing physician payment in 2015 on data and measures reported during 2013.   

For those who have not participated in the PQRS, the time to learn how to report is now with just over 5 months until the first of the year.  CMS provides an array of reporting options and methods: quality measures can be reported either individually or as a group through administrative claims, claims, registries, or a group practice web interface.  The good news for those not familiar with the program and these options is CMS is providing a bit of grace period, making the criteria to avoid penalties of 1.5 and 2 percent in the first two years only reporting one measure or measures group.

If figuring out how to report on quality measures was not daunting enough, physicians groups of 25 or more will also be subject to the value-based modifier (VBM).  Mandated by the Affordable Care Act, the VBM will provide for differential payments to physician groups based on the quality of care provided to Medicare beneficiaries as compared to the cost.  Because the statute requires this to be done in a budget neutral manner, the cost of the positive payments will not be known until CMS determines to which practices the -1.0 percent adjustment will apply.

The VBM’s negative adjustment will be on top of whatever adjustment a group practice is subject to under the PQRS.  If you are waiting for the good news, here it is: CMS has done its best to standardize the reporting requirements for these programs as well as the other quality programs it administers, like the EHR Incentive Program and hopes to further standardize the requirements in future years.
Greater detail about both of these programs can be found in CMS’ CY 2013 Physician Fee Schedule proposed rule.  CRD Associates has experts in these programs and physician payment and can make sure that your members are prepared for the new requirements Medicare is attaching to their payment. 

Erika Miller
Vice President

Lisa Ellington

Big Thinkery, LLC, 1011 Kenilworth Court Northwest, Concord, NC, 28027