Value-based Payment Modifier

What is the Value-based Payment Modifier?

The value-based modifier program is a budget neutral payment modifier based on relative quality and cost of care. Quality and Resource Use Reports will provide the quality-related feedback. Medicare plans to adjust physician payments using quality outcomes data from the Physician Quality Reporting System (PQRS) and cost data from Medicare claims for fee-for-service patients.

According to the Patient Protection and Affordable Care Act, the modifier must be applied to all physicians and physician groups by January 1, 2017. This is a pay for value (i.e., quality relative to cost) program– higher value gets higher pay; lower value gets lower pay, based on quality tiering.

In 2019 and beyond, the value-based payment modifier will be replaced by the merit-based incentive payment system (MIPS).

The Centers for Medicare & Medicaid Services site(www.cms.gov) has more information on the value-based payment modifier.

Performance Year

Value Modifier Year

Physician Group Size

Possible Outcomes Based on Quality Tiering

Performance Year

:

2013

Value Modifier Year

:

2015

Physician Group Size

:

100+ eligible professionals (EPs)

Possible Outcomes Based on Quality Tiering

:

Downward adjustment (max -1.0%)

No adjustment

Upward adjustment (max +2x)*

Performance Year

:

2014

Value Modifier Year

:

2016

Physician Group Size

:

100+ EPs

Possible Outcomes Based on Quality Tiering

:

Downward adjustment (max -2.0%)

No adjustment

Upward adjustment (max +2x)*

Performance Year

:

10-99 EPs

Value Modifier Year

:

No adjustment

Upward adjustment (max +2x)*

Performance Year

:

2015

Value Modifier Year

:

2017

Physician Group Size

:

10+ EPs

Possible Outcomes Based on Quality Tiering

:

Downward adjustment (max -4.0%)

No adjustment

Upward adjustment (max +4x)*

Performance Year

:

2-9 and solo practitioners

Value Modifier Year

:

Downward adjustment (max -2.0% non-reporting)

No adjustment

Upward adjustment (max +2x)*

Performance Year

:

2016

Value Modifier Year

:

2018

Physician Group Size

:

All groups and solo practitioners

Possible Outcomes Based on Quality Tiering

:

Downward adjustment (% TBD)

No adjustment

Upward adjustment (TBD)

*The “x” in the upward adjustment is a factor dependent on the total amount of downward adjustments in the same period, since the VBPM is budget-neutral. EPs are eligible for an additional +1.0x if average beneficiary risk score is in the top 25% of all beneficiary risk scores.