Practices that had more than 200 clinicians and that had higher meaningful use of health information technology (IT) were more engaged in reporting quality data and performed at a higher level on quality and cost measures, according to a new study of the first year of Medicare’s Value-Based Payment Modifier program.
In addition, the practices that chose to participate in a pay-for-performance bonus program, based on tiers of quality and cost performance, scored better on quality and cost measures.
“It is perhaps not surprising that practices that elected quality tiering were better performers at baseline, as these practices might have been familiar with their relative performance through the use of registries or other quality improvement initiatives,” write Karen E. Joynt Maddox, MD, MPH, assistant professor of medicine at the Washington University School of Medicine, St. Louis, Missouri, and colleagues.
The results are especially important, as all physicians will be participating in the value modifier program in 2017, the authors write in an article published in the December issue of Health Affairs. In addition, the penalty for not reporting on the quality measures increases to 4% of Medicare fee-for-service billings in 2017, up from 1% in 2015, which was the first year. Performance bonuses have also increased.
Finally, the value modifier program is being used as the basis for the Merit-Based Incentive Payment System, the authors note.
The Centers for Medicare &and Medicaid Services (CMS) has conducted studies on clinician performance in the first year of the value modifier program, finding in at least one such study that patient characteristics are a key driver of performance variation.
Now, Dr Joynt Maddox and colleagues sought to build on that finding and to examine whether the size of a practice or other structural characteristics were associated with performance.
Most Met Minimum Reporting
The value modifier program began in 2013, with 2015 being the first evaluation year. In that first year, physicians in groups of 100 or more were required to report data on at least nine quality measures or through a set of administrative claims-based measures that were designed by CMS to reflect care delivered in 2013.
Those who failed to report would be penalized 1% of their Medicare fee-for-service billing. Those who successfully reported could sign up for “quality tiering,” in which they were eligible to receive a bonus, or a penalty, based on tiers of quality and cost performance.
The authors found 899 practices that had at least one eligible beneficiary and used beneficiary-level claims to obtain patient characteristics. They relied on CMS data for practice performance on individual quality and cost measures, domains, composite scores, program tiering selection, and designations. In addition, they used CMS data for determinations of which practices were high or low quality and high or low cost.
Seventy-one percent (636) of the 899 practices met the minimum reporting requirements, and 263 received a penalty for not reporting performance data. Ninety-one percent of the practices in both groups were in an urban setting. Practices that were penalized had younger patient populations, more black and Hispanic patients, and a greater number of patients dually eligible for Medicare and Medicaid.
The groups that successfully reported were more likely to have more than 200 clinicians and to have a high level of participation in meaningful use of electronic health records (30% vs 13% of the nonreporting practices). Seventy-four percent of the practices that did not meet the minimum reporting had 100 to 199 practitioners.
Choosing to Deliver Higher Quality
Practices that performed better on quality and cost measures tended to have a primary care focus, but more important, most had chosen to participate in the bonus/penalty program based on their performance, said the authors. Those practices had lower hospital readmission rates and lower acute ambulatory care-sensitive admission rates.
The clinician groups that elected to be measured on their quality performance had higher scores on the four quality domains that were examined and an overall quality composite score that was 0.20 standard deviations above the national mean. Practices that did not participate in the voluntary program had scores of 0.15 standard deviations below the national mean.
Overall and condition-specific per capita costs were also lower at those practices that voluntarily participated. The per capita cost for Parts A and B of Medicare for all patients was $10,337 compared with $9608 for patients in practices that elected to receive bonuses or penalties.
Practices with more than 200 physicians had lower costs for patients with diabetes, but similar costs overall and for other conditions.
High Risk, High Reward
The study found that practices that elected to participate in the pay-for-performance program were more likely to get a bonus and less likely to be penalized.
Only 2.4% of those practices were penalized compared with 33.5% of the nonparticipating practices. Very few practices overall received a bonus. However, more of those in the pay-for-performance group and in practices with more than 200 clinicians or high levels of meaningful use received bonuses compared with smaller practices or those that did not participate in quality tiering.
The authors note they were not able to determine which practices did not report because of inadequate infrastructure or because they did not think it was financially worthwhile.
However, they say their findings “suggest that it may be important for Medicare to focus technical assistance efforts and electronic infrastructure support on smaller practices and those without functional [electronic health records].”
Because the Merit-Based Incentive Payment System will also evaluate and reward practices based on their use of health information technology, practices without such capabilities could be especially vulnerable, the authors said.
The study also shows that “benefits of value-based payment might not accrue equally to disadvantaged populations.” Policymakers should ensure that the new MIPS program does “not inadvertently widen existing disparities in care.”
The authors have disclosed no relevant financial relationships.
Health Aff. 2017;36:2175-2184. Abstract
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