“As difficult as it is, when it comes to determining what quality is in health care, we [physicians] need to be the ones defining it.”
ties for each program overlap, and Medicare policy generally back-dates the reporting re- quirements, meaning physicians face a pen- alty based on their performance in the two years prior. (See “Penalties Add Up,” page 31.)
PQRS penalties start at 1.5 percent in
2015, based on 2013 reporting, and remain a flat 2 percent starting in 2016; MU pen- alties increase over time. Payment reduc- tions or incentives under the VBM depend on physicians’ level of participation and performance in the various programs, and Medicare is phasing in the program starting with larger practices.
• In 2015, practices with 100 or more eligi- ble professionals face possible penalties, or incentives, of 1 percent, based on 2013 cost and PQRS reports.
• In 2016, practices with 10 or more are in- cluded, with possible penalties increased to 2 percent based on 2014 data.
• In 2017, all physicians face possible fee adjustments, based on 2015 PQRS and cost data, with the possible penalties in- creased to 4 percent.
The tricky thing for physicians to re-
member, says Dr. Ragain, is those counts include the other professionals in the prac- tice, such as nurse practitioners, physician assistants, social workers, therapists, and di- etitians. “So you might think you only have eight doctors, but if you have four midlevels, you’re at 12, and you’re in.” Ms. Kinney also cautions that the VBM
payment cuts are not limited to Medicare- participating physicians; they also affect the limiting charge for nonparticipating physi- cians. The VBM does not apply to physi- cians who formally opt out of Medicare.
AREN’T THESE PROGRAMS JUST A BUREAUCRATIC NIGHTMARE?
Physicians continue to sound the alarm on the administrative complexity of Medicare’s value-based care programs and looming threats to practices’ viability and ultimately Medicare participation. “No other segment of the health care industry faces penalties as steep as these,
32 TEXAS MEDICINE April 2015
and no other segment faces such challeng- ing implementation logistics. The tsunami of rules and policies surrounding the pen- alties are in a constant state of flux due to scheduled phase-ins and annual changes in regulatory requirements. In fact, the rules have become so complex that no one, often including the staff in charge of implement- ing them, can fully understand and inter- pret them,” American Medical Association Executive Vice President and Chief Execu- tive Officer James L. Madera, MD, wrote in an Oct. 21, 2014, letter to former Centers for Medicare & Medicaid Services (CMS) Ad- ministrator Marilyn Tavenner. “Ironically, the environment makes it difficult for phy- sicians to invest in health information tech- nology, as well as make desired payment and delivery reforms.” In his introduction to TMA’s Healthy
Vision 2020, Second Edition, TMA Presi- dent Austin I. King, MD, puts it in simpler terms: “Our government must make it easier
— not more difficult — for us to care for our patients.” The MU program and PQRS each have
so many different sets of measures require- ments, submission processes, and reporting periods that Dr. Ragain’s file on the pro- grams is nearly two inches thick. He describes the 300 PQRS metrics —
which change year to year — as “mind-bog- gling.” His group must choose nine mea- sures to report, which have to fall within the National Quality Strategy’s (NQS’) six domains of quality measurement. “Then each measure has its own exclusion crite- ria, and it matters if you look at your patient population what choice you make, so you re- ally have to dig in to find out what you want to do. It’s a lot to take in fairly quickly. And of course there’s an expense to all of this.” TMA’s 2014 health information technol-
ogy (HIT) survey shows that Texas physi- cians are doing their part with 69 percent now using an EHR. Nevertheless, CMS numbers suggest more than half of profes- sionals eligible for the MU program will face penalties this year for not meeting pro- gram criteria. TMA also has received sev- eral calls from physicians who incorrectly believe that if they report the quality mea- sures in the MU program, they have com- plied with PQRS.
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