Getting a Medicare value-based bonus this year? You are the 1%.

Critics say the program is flawed

For the second year in a row, very few providers will receive bonuses under CMS's value-based payment modifier (VBM) program.


Medicare uses the VBM program to adjust eligible professionals' reimbursement rates based on how physicians or medical groups perform on certain quality and cost measures, with quality metrics varying by specialty. The reimbursement rate adjustments this year are based on 2014 Physician Quality Reporting System (PQRS) data.

There are more than 250 quality metrics in the program. Eligible providers are required to select a number of metrics—typically nine—to report. Failure to adhere to Medicare's reporting standards can subject eligible professionals or medical groups to a penalty.

See last year's data

Currently, only medical groups with 10 or more eligible professionals are subject to the program. All eligible groups this year could receive bonuses, but only groups with 100 or more eligible professionals faced the risk of a penalty. The program is scheduled to apply to all physicians who are reimbursed by Medicare in 2017.

Majority of groups not receiving increased reimbursements

Out of 13,813 physician groups subject to the VBM program, less than one percent—only 128, comprising about 4,300 physicians—will receive bonuses, with their 2016 Medicare reimbursement rates increasing by either 16 or 32 percent. The higher increase will be awarded to practices with the most high-risk patients.

Meanwhile, 5,418 medical groups—totaling more than 130,000 physicians—will incur a 2 percent Medicare pay cut for not submitting their data. Fifty-nine groups, comprised of over 10,000 physicians, will see a pay decrease of 1 or 2 percent because their reported quality measures were too low.

In total, the bonuses for high-performing groups will total about $79.5 million, which will be funded by the groups paying penalties. The claims adjustments will begin within the next six weeks.

Critics worry data are flawed

Anders Gilberg, SVP of government affairs for Medical Group Management Association, argues that the program is flawed. Showing the ability to submit data, he says, is "not a proxy for quality, but for your ability to code and document correctly."

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Most providers, he says, don't believe it is worth the time and effort to submit PQRS data.

CMS "need[s] to hit the reset button and create an equitable program that's administratively easier [for physicians] to report, because that's been the hardest thing," Gilberg says. "It's not about quality as much as the complexity of the reporting."

Meanwhile, CMS spokesperson Jibril Boykin tells Medscape that CMS considers the VBM program to be successful.

"The high number of groups receiving downward adjustments comes from their failure to satisfactorily report quality measures as a group or to have at least 50 percent of their eligible professionals in the group satisfactorily report as individuals," Boykin says.

"We encourage providers to make sure they are reporting quality measures completely, accurately, and timely during the quality reporting cycle." (Dickson, Modern Healthcare, 3/10; Lowes, Medscape, 3/9).

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