CMS Starts Cutting Pay for Doctors Who Don't Measure Up

Bruce Gould, MD

The new Value-Based Payment Modifier program from the Centers for Medicare & Medicaid Services (CMS) may not be high on the list of concerns for the average oncologist, but with immediate payment reductions of up to 1% for large practices that don’t meet cost and quality benchmarks, its impact could be huge.

Much larger adjustments for all practices are just a few years away.

Those who practice oncology aren’t always the ones following the business end of it, and as a result, there any many practitioners who likely don’t know about the value modifier program at all, Bruce Gould, MD, president and medical director of the Northwest Georgia Oncology Centers in Marietta, Georgia, told Oncology Business Management. Gould is also president of the Community Oncology Alliance, a nonprofit organization focused on community oncology.

“I have not heard a lot about it from other oncologists; there’s been more press about it than feedback from physicians about it,” says Gould.

As one way to try to contain the spiraling costs of the US healthcare system, CMS began implementing the value modifier program this year. The program will determine payment for care of Medicare patients based on cost and quality ratings from prior years, instead of reimbursing all physicians equally as in the past. Improving the overall quality of care is also a goal.

The program, mandated as section 3007 of the Affordable Care Act, will gradually affect all physicians over the next two years and non-physician practitioners by 2018.

As of January of this year, oncologists who are part of group practices with more than 100 eligible providers (EPs) who all bill for services under a single tax ID must maintain standards established by CMS to qualify for full payment. Payment incentives were established in prior years to encourage practices to begin using quality measures and reporting tools.

Beginning in 2016, the value modifier will apply to physician payments under the Medicare Physician Fee Schedule for groups with 10 or more eligible professionals.

The value modifier can also result in no payment change at all or a payment increase, based on whether standards are met or exceeded, but “The program is budget-neutral, and downward and upward payments will balance each other,” CMS said in a statement.

Payment adjustments will become more dramatic as the program continues.

Under the 2017 value modifier (which will be based on 2015 performance criteria), the maximum downward adjustment for groups of 10 or more EPs will be —4% and the maximum upward adjustment will be based on a formula that takes into account the budget for physician reimbursement, CMS said.

Also in 2017, for groups of 2 to 9 and solo practitioners, the downward adjustment will be a maximum of —2%.

The quality measures are designed to ensure that patients get the right care at the right time. Providers must quantify how often they are meeting particular quality metrics. Feedback reports provided by CMS help practices to measure their performance against others’.

Healthcare providers who qualify as EPs under the value modifier program include doctors of medicine, osteopathy, podiatric medicine, optometry, oral surgery, dental medicine and chiropractic, as well as physician assistants, nurse practitioners, registered dieticians, and clinical psychologists.

Strange Standards

It’s a program, however, that some in the oncology field feel harms them and that may negatively affect cancer care. “Over time, physicians will become more aware of the program’s existence,” Gould says. Because the majority of practices consist of fewer than 100 providers, he believes it’s likely that the program just hasn’t affected most practitioners yet.

Gould says that while he appreciates the concept of paying physicians based on the value of services they provide, the value modifier program isn’t a meaningful measure of oncology quality. “The way this program goes about it is unfair,” he says.

The reports being used as a basis for measuring quality—Quality Resource and Use Reports (QRURs)—have been used in prior years, Gould says, but the measures have nothing to do with cancer care: for instance, whether a patient with diabetes had an annual eye exam, or whether a patient with lung disease was being properly treated for asthma. “I’m being judged based not on the work I do, but on the work my colleagues do. There’s no measure for how well I give chemotherapy or whether I give it for appropriate purposes, or if patients have ready access to me if they get ill.”

He added that the system was designed to have physicians hold one another to task so that quality and cost can improve. “But that’s very hard to do when you’re taking care of your own patients,” he said. “We don’t have time to be our brother’s keeper.”

Intricate Details

Barbara McAnemy, MD, CEO of the New Mexico Cancer Center, a practice with 78 medical oncologists, and the chair of the board of trustees of the American Medical Association, agreed that most physicians aren’t aware of the value modifier program yet. “It’s a strangely constructed program, by which what you do in 2015 will affect how you are reimbursed in the future.” she said. It’s also very difficult to comply with all the regulations, she added, and that for a program to have meaningful use, it requires 100 percent compliance. “There’s a huge number of things outside our control.”

She pointed out that one measurement is to show what percentage of patients use a medical practice’s Internet portal to be aware of different aspects of their medical care. “I can set it up and tell them about it, but I can’t make them use it,” she said. “How do I make that happen? Similarly, if I want to really comply with the regulations for transition-of-care visits, I need to send medical records to an HIPAA-compliant electronic health records system. But if I can’t send it to you electronically, am I going to clog up your fax machine with 70 pages of duplicated records? Getting bogged down in huge quantities of information may hinder a practice’s ability to find the information needed to continue to care for Medicare patients.”

Such efforts could lead to more cost-cutting measures. “Half of our patients have Medicare, so we’ve had to get lean,” she added. “I think this is why we see so many practices closing satellites, consolidating or selling practices, or begging hospitals to buy them.”

Calls for Change

Oncology is a complex specialty and should be assessed as such. Ted Okon, executive director for the Community Oncology Alliance, said in an interview that he believes the value modifier will “drastically harm cancer care.”

There are approximately 900,000 physicians in the United States, only about 5000 of whom are oncologists who will be affected by this program— those who work with Medicare patients not primarily through hospitals. “They are being penalized for something not in their control, and this is a program not ready for prime time,” said Okon. “It is virtually meaningless for oncologists.”

Instead, said Okon, the answer to spiraling healthcare costs is meaningful payment reform, “so you have quality and costs that are really attributable to that cancer patient being measured.”

Members of Congress, led by Representative Cathy McMorris Rogers (R-WA), have a bill in draft form that will specifically address oncology payment reform, said Okon. “We’ve been working with the energy commerce committee and taking the lead in helping to develop the oncology medical home model.” This model includes oncology-specific reforms such as episode-based payment, emphasis on practice transformation, and multi-payer design. “These kinds of things are a step in the right direction—not these stopgap measures” like the value modifier, he said.