Revenue Cycle Management Blog | GroupOne Health Source

Pay For Performance/Value Based Purchasing Initiative Heats Up

Written by Kaitlyn Houseman | May 7, 2012

Thousands of physicians received a sneak-peek at their future recently when CMS sent them quality reporting data that could be used to determine Medicare payments. 

Each physician received a report titled, “Confidential 2010 Quality And Resource Use Report Medicare Fee-For-Service” from Medicare providing information about the quality of care provided to Medicare fee-for-service (FFS) patients he/she treated in 2010; the amount that Medicare paid the provider for that care; and, how the individual provider compared to other Medicare providers within the same specialty.

The report notes that it is for informational purposes only. It does not affect the provider’s Medicare payment or his/her ability to participate in the Medicare Program.

Eventually, CMS intends to send similar reports to every provider who sees Medicare patients.  More importantly, the information contained in these reports will be used to determine provider payments in the future. 

Physicians in Kansas, Missouri, Iowa and Nebraska received the initial reports.  The purpose is to allow these physicians to:

  • Highlight the degree of involvement with patients treated by the provider.
  • Identify possible components of a payment modifier that would be used to establish a “payment differential” based upon quality of care.

In published reports, former CMS Administrator Don Berwick, a strong proponent of this type of value based purchasing, said, “It may be the most difficult measurement challenge in the whole world of value-based purchasing.  We do have to be cautious in this case. It could lead to levels of gaming and misunderstanding and incorrect signals to physicians that might not be best for everyone.”

In fact many health policy analysts who agree with the principle of value based purchasing also believe that it may be impossible to actually design a system that is both fair and accurate and that is not subject to provider gaming.  Although this particular report is exclusively about care and cost of care relative to Medicare beneficiaries, several private insurers have expressed interest in developing similar reports for providers caring for their commercially insured patients.

HBMA –Washington Report – April 2012