Value-based Payment Modifier

A note about the value-based payment modifier:

The last performance year for the value-based payment modifier (VBPM) under Medicare was 2016. VBPM under Medicare has been consolidated into the Quality Payment Program (QPP) created by the Medicare Access and CHIP Reauthorization Act (MACRA) starting in 2017.

QPP is the umbrella term for the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). MIPS and AAPMs make up a two-track system that replaces Medicare’s traditional fee-for-service payment model. QPP changes the way physicians are paid and rewards for the quality of care delivered to patients, not the quantity.

Bookmark the MACRA Resources page »


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 Value Modifier Outcomes

Performance Year

:

2013

Value Modifier Year

:

2015

Physician Group Size

:

100+ EPs

Possible Value Modifier Outcomes

:
  • Downward Adjustment max -1% for those elected quality-tiering OR max -1% non-satisfactory PQRS reporting
  • No Adjustment for those who do not elect quality-tiering OR those who elected quality-tiering and were classified as average quality/average cost
  • Upward Adjustment for those elected quality-tiering (max +2 x 4.89%*)

Performance Year

:

2014

Value Modifier Year

:

2016

Physician Group Size

:

100+ EPs

Possible Value Modifier Outcomes

:
  • Downward Adjustment (max -2%)
  • No Adjustment
  • Upward Adjustment (max +2x%*+)

Performance Year

:

10+ EPs

Value Modifier Year

:
  • Downward Adjustment (max -2% non-satisfactory PQRS reporting)
  • No Adjustment
  • Upward Adjustment (max +2x%*+)

Performance Year

:

2015

Value Modifier Year

:

2017

Physician Group Size

:

10+ EPs

Possible Value Modifier Outcomes

:
  • Downward Adjustment (max -4%)
  • No Adjustment
  • Upward Adjustment (max +4x%*+)

Performance Year

:

2-9 and solo practitioners

Value Modifier Year

:
  • Downward Adjustment (-2% non-satisfactory PQRS reporting) 
  • No Adjustment
  • Upward Adjustment (max +2x%*+)

Performance Year

:

2016

Value Modifier Year

:

2018

Physician Group Size

:

All groups and solo practitioners

Possible Value Modifier Outcomes

:
  • Downward Adjustment (% TBD)
  • No Adjustment
  • Upward Adjustment (% TBD)

* Eligible for an additional +1.0x if average beneficiary risk score is in the top 25% of all beneficiary risk scores

+The value of “x” represents the adjustment factor still yet to be determined and depends on the total sum of negative adjustments in a given year.