Public Policy

Value-Based Purchasing Model for Medicare Reimbursement Extends to Physicians


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What: The program, authorized by 2010’s Affordable Care Act, extends CMS’ concept of value-based purchasing to the individual physician level. That means a portion of doctors’ Medicare reimbursements will be contingent on scores designed to measure the quality and efficiency of the healthcare they deliver.

How: The program is designed to be budget-neutral, meaning that doctors will be graded on a curve; some will lose a percentage of Medicare reimbursements, while others will gain increased payments. A prerequisite for any bonus will be participation in the Physician Quality Reporting System (PQRS), which carries its own nonparticipation penalties. The PQRS forms the core of the program, with a beefed-up Physician Compare website and the Physician Feedback Program providing public and private report cards, respectively. The latter will consist of confidential Quality and Resource Use Reports (QRURs), based on information from Medicare claims and the PQRS.

Who: At first, the VBPM program will apply to groups of 100 or more eligible professionals, currently defined as physicians, practitioners, and therapists. By 2017, however, all physicians will participate. Those in rural practices, critical-access hospitals, and federally qualified health centers are exempt; ACO participants are exempt for 2015 and 2016.

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