Use Case 35: Physician Based Modifier Results on Provider Level
Use case summary
- Title: Physician Based Modifier Results on Provider Level
- Work item: https://github.com/demand-driven-open-data/ddod-intake/issues/35
- Status: Closed. CMS has a stated promise to keep each provider's data confidential. In addition, the Value Modifier is being sunsetted as an independent payment adjuster. See the Solution section for more information.
- CMS evaluates physician groups -- and soon individual physicians -- on cost and quality and adjusts the pay upward, downward or not all all based on the results. CMS has released the aggregate results for more than 1,000 physician groups: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2015-Value-Modifier-Results.pdf
CMS should releasd how each provider scored on cost and quality and what their payment adjustment is -- just as CMS releases this for hospitals in the Hospital Value-Based Payment Program. CMS should release parallel data for each physician group/physician, showing which PQRS measures were used in their scoring, how they scored, what cost and quality scores CMS calculated for them and what payment adjustment occurred. CMS already provides this information to each provider on the QRURs.
- Kaiser Health News
- This use case is closely related to Use Case 4: Make VBM reporting for all groups publicly available, which asks for VBM reporting at the group (rather than the individual) level.
- As documented in Use Case #4:
There's not a solution yet, due to stated promise by CMS to keep each provider's data confidential. In addition, the Value Modifier sunsets as an independent payment adjustment program after 2018 payment adjustments, which would be based on a 2016 performance period, and will be replaced by the Merit-Based Incentive Payment System (MIPS).
Practical workarounds still need to be identified. There have been FOIA requests in the past. But need to identify whether they have been successful. There are a couple challenges:
- It's difficult to get accurate data even internally... There’s no realtime system that makes this data available. So a query against the source system needs to be run. But the results are different depending on the day. (For example, if run January 1, payments may not have been processed. There are 250K records in the result set, but 6-8K more will change)”
- The General Counsel (GC) needs to agree that there is a legal (statutory and regulatory) right to see other providers info. Note: This ruling may be turned over in cases of FOIA requests. (But FOIA is expensive and gets executed based on resource availability.)
- CMS will be faced with a challenge of how to communicate to providers that previously “confidential feedback” reports are in the public domain.
- Lag time Not much can be done to improve now, but may be made available quarterly, per SGR bill. (Illustration: ”In 2015, physician groups ...subject to the payment modifier, based on performance in calendar year 2013.”)
- Reporting of composite scores would have to be done through rule making.
- Due to the imminent sunsetting of the Value Modifier, along with the EHR Incentive Program and PQRS, it is unlikely that CMS would be willing to undergo the effort to share the QRUR data.
Tip: If going the FOIA route, specifying the name of the internal system of record and query to be run might expedite the request and yield consistent results between multiple requests. Immediate.
- While these documents do not allow for individual analytics, Value-Based Modifier impact and experience report documents that provide insight into performance are available on the CMS website:
- CMS has also proposed in this year's physician fee schedule to place a green checkmark on Physician Compare to indicate positive performance under the Value-Based Modifier Program