Use Case 4: Make VBM (Value-Based Payment Modifier) reporting for all groups publicly available

From Demand-Driven Open Data for HHS
Jump to: navigation, search


Use case summary


  • On Value-Based Payment Modifier (VBM) reporting, provide the quality composite and cost composite scores for each provider groups and performance year. Currently, these scores are only available within each group's private QRUR report. So providers can't do any benchmarking and comparison across their peer groups.


  • Value to customer: Important to deliver insights for provider customers and assist in MU attestation.
  • Value to industry/public:
  • Greater transparency to provider quality and cost rankings is valuable for consumer choice.
  • Provide earlier and greater visibility into metrics. Added value of peer pressure.


  • SA Ignite

Current data and limitation

Composite cost quality in QRUR.png

  • Challenge: There's insufficient granularity to provide insights into which reporting method is advantageous for each situation and no way to get it from other sources. Scatter plot along cost composite and quality composite metrics shows 1200 blue dots representing groups. But source data for the plots isn't provided, making it impossible to do analytics against peers and other factors.


  • Fields:
    • Unique name + HQ address (As proxy for TIN)
    • Performance year
    • Standardized Quality composite score -- QCS Based on national level
    • Average Quality composite score -- QCS Based on individual score (Needs to be added)
    • Cost composite score
  • Update frequency: Annual
  • Lag time:
    • Make avail in Q2, rather than Nov. Because can’t do much in Nov for prior year. (PQRS measures due 3/31)
  • Joins between datasets:
    • Recognizing that TIN must be kept private, another unique identifier is needed for metrics in QRUR reports


Primary request

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.

Additional references:

  • 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

Secondary request

Providers without PQRS benchmarks

A secondary request associated with this use case is to get a list of physicians with missing PQRS benchmarks. That is, those who are eligible for MU, but didn't submit.

  • Medicare Individual Provider List is a list of eligible providers
  • Limitations: Can't match practice names or TINs that each NPI is part of for Medicare billing purposes
  • Description for Medicare Individual Provider List:
    • In an effort to prepare the prescribers and Part D sponsors for the December 1, 2015, enforcement date, CMS is making available an enrollment file that identifies physician and eligible professional who are enrolled in Medicare in an approved or opt out status. The file contains production data but is considered a test file since the Part D prescriber enrollment requirement is not yet applicable. An updated enrollment file will be generated every two weeks and continue through the December 1, 2015 enforcement date. The file displays provider eligibility as of and after November 1, 2014 (i.e., currently enrolled, new approvals, or changes from opt-out to enrolled as of November 1, 2014). Any inactive providers or periods of inactivity for existing providers prior to November 1, 2014, will not be displayed on the enrollment file. However, any enrollments that become inactive after November 1, 2014, will be on the file with its respective end dates for that given provider. For opted out providers, the opt out flag will display a Y/N (Yes/No) value to indicate the periods the provider was opted out of Medicare. The file will include the provider’s: • National Provider Identifier (NPI); • First and Last Name; • Effective and End Dates; and • Opt Out Flag