Alphabet Soup! Physician Quality Reporting and Reimbursement
PQRS… VPM... MU… MIPS. No, it’s not a catchy tune that helps kids learn the alphabet. It’s a complex world of quality reporting requirements that physicians must adhere to if they want to maximize their reimbursement and ensure the sustainability of their practice.
The trend away from Fee-For-Service towards more value-based reimbursement models, now commonly referred to as the shift “from volume to value,” has meant an increased emphasis on quality of care and outcomes. For physicians, this means that it’s not just high-quality care that is important; it’s the recording and reporting of quality metrics to healthcare payers.
Pay-for-performance programs in healthcare began in earnest in 2006 with the Physician Quality Reporting System, or “PQRS” (formerly known as the Physician Quality Reporting Initiative, or “PQRI”). The program is voluntary, but passage of the Affordable Care Act gave it teeth in 2010 by attaching penalties for failing to report quality measures to the Center for Medicare and Medicaid Services; those who did not successfully report one quality measure to CMS for 2013 received a downward adjustment to their Medicare reimbursements for 2015. In 2015, physicians must report nine quality measures to avoid a downward adjustment to their 2017 payments.
The Value-based Payment Modifier (“VPM”) and Meaningful Use (“MU”) programs followed quickly on the heels of PQRS, each with their own carrots and sticks approaches to incentivizing quality. The result was three different programs with separate reporting requirements that left physicians and their staff shaking their heads in despair.
But the April 2015 passage of the Medicare Access and CHIP Reauthorization Act (“MACRA”) gave physicians two reasons to celebrate: the first, repeal of the Sustainable Growth Rate formula for Medicare Reimbursement, was obvious to all. The second, the Merit-based Incentive Payment System (“MIPS”), aims to streamline these multiple reporting systems into one uniform reporting program.
MIPS will assign physician practices a Composite Performance Score based on quality, resource use, clinical practice improvement activities, and meaningful use of certified Electronic Health Records. Reimbursement adjustments will begin in 2019, and will be based on these composite scores. Positive, neutral, or negative readjustments will be made to the tune of plus or minus 4% in 2019, scaling up to plus or minus 9% in 2022 and onward. Physicians who participate in eligible Alternative Payment Models (“APMs”) that take on financial risk will receive bonus payments.
The stakes are high for physician practices as they struggle to remain financially viable, and now is the time to prepare for quality reporting under MIPS. Physicians must be proactive and take the time to develop a strategy for both the short and long-term. The success of their practice depends on it!
