(a) The value-based payment modifier amount for a group and a solo practitioner subject to the value-based payment modifier is based upon a comparison of the composite of quality of care measures and a composite of cost measures.
(b) Quality composite and cost composite are classified into high, average, and low categories based on whether the composites are statistically above, not different from, or below the mean composite scores.
(1) Quality composites that are one or more standard deviations above the mean are classified into the high category. Quality composites that are one or more standard deviations below the mean are classified into the low category.
(2) Cost composites that are one or more standard deviations below the mean are classified into the low category. Cost composites that are one or more standard deviations above the mean are classified into the high category.
(c)(1) The following value-based payment modifier percentages apply to the CY 2015 payment adjustment period:
(1) The following value-based payment modifier percentages apply to the CY 2015 payment adjustment period:
CY 2015 Value-Based Payment Modifier Amounts for the Quality-Tiering
Approach------------------------------------------------------------------------
Average High cost
Quality/cost Low cost cost (percent)------------------------------------------------------------------------High quality..................... + 2.0x* + 1.0x* + 0.0Average quality.................. + 1.0x* + 0.0% -0.5Low quality...................... + 0.0% -0.5% -1.0------------------------------------------------------------------------* Groups of physicians eligible for an additional + 1.0x if (1)
reporting Physician Quality Reporting System quality measures through
the GPRO web-interface or CMS-qualified registry, and (2) average
beneficiary risk score is in the top 25 percent of all beneficiary
risk scores.
(2) The following value-based payment modifier percentages apply to the CY 2016 payment adjustment period:
CY 2016 Value-Based Payment Modifier Amounts for the Quality-Tiering
Approach------------------------------------------------------------------------
Average High cost
Quality/cost Low cost cost (percent)------------------------------------------------------------------------High quality..................... + 2.0x* + 1.0x* + 0.0Average quality.................. + 1.0x* + 0.0% -1.0Low quality...................... + 0.0% -1.0% -2.0------------------------------------------------------------------------* Groups of physicians eligible for an additional + 1.0x if reporting
Physician Quality Reporting System quality measures and average
beneficiary risk score is in the top 25 percent of all beneficiary
risk scores.
(3) The following value-based payment modifier percentages apply to the CY 2017 payment adjustment period:
(i) For groups with 10 or more eligible professionals:
CY 2017 Value-Based Payment Modifier Amounts for the Quality-Tiering Approach for Groups With 10 or More
Eligible Professionals----------------------------------------------------------------------------------------------------------------
Cost/quality Low quality Average quality High quality----------------------------------------------------------------------------------------------------------------Low Cost............................................... + 0.0% * + 2.0x * + 4.0xAverage Cost........................................... -2.0% + 0.0% * + 2.0xHigh Cost.............................................. -4.0% -2.0% + 0.0%----------------------------------------------------------------------------------------------------------------* Groups eligible for an additional + 1.0x if reporting Physician Quality Reporting System quality measures and
average beneficiary risk score is in the top 25 percent of all beneficiary risk scores, where `x' represents
the upward payment adjustment factor.
(ii) For groups with two to nine eligible professionals and solo practitioners:
CY 2017 Value-Based Payment Modifier Amounts for the Quality-Tiering Approach for Groups With Two to Nine
Eligible Professionals and Solo Practitioners----------------------------------------------------------------------------------------------------------------
Cost/quality Low quality Average quality High quality----------------------------------------------------------------------------------------------------------------Low Cost............................................... + 0.0% * + 1.0x * + 2.0xAverage Cost........................................... + 0.0% + 0.0% * + 1.0xHigh Cost.............................................. + 0.0% + 0.0% + 0.0%----------------------------------------------------------------------------------------------------------------* Groups and solo practitioners eligible for an additional + 1.0x if reporting Physician Quality Reporting
System quality measures and average beneficiary risk score is in the top 25 percent of all beneficiary risk
scores, where `x' represents the upward payment adjustment factor.
(d)(1) Groups of physicians subject to the value-based payment modifier that have an attributed beneficiary population with an average risk score in the top 25 percent of the risk scores of beneficiaries nationwide and for the CY 2015 payment adjustment period elect the quality-tiering approach or for the CY 2016 payment adjustment period are subject to the quality-tiering approach, receive a greater upward payment adjustment as follows:
(1) Groups of physicians subject to the value-based payment modifier that have an attributed beneficiary population with an average risk score in the top 25 percent of the risk scores of beneficiaries nationwide and for the CY 2015 payment adjustment period elect the quality-tiering approach or for the CY 2016 payment adjustment period are subject to the quality-tiering approach, receive a greater upward payment adjustment as follows:
(i) Classified as high quality/low cost receive an upward adjustment of + 3x (rather than + 2x); and
(ii) Classified as either high quality/average cost or average quality/low cost receive an upward adjustment of + 2x (rather than + 1x).
(2) Groups and solo practitioners subject to the value-based payment modifier that have an attributed beneficiary population with an average risk score in the top 25 percent of the risk scores of beneficiaries nationwide and for the CY 2017 payment adjustment period are subject to the quality-tiering approach, receive a greater upward payment adjustment as follows:
(i) Classified as high quality/low cost receive an upward adjustment of + 5x (rather than + 4x) if the group has 10 or more eligible professionals or + 3x (rather than + 2x) if a solo practitioner or the group has two to nine eligible professionals; and
(ii) Classified as either high quality/average cost or average quality/low cost receive an upward adjustment of + 3x (rather than + 2x) if the group has 10 or more eligible professionals or + 2x (rather than + 1x) if a solo practitioner or the group has two to nine eligible professionals. [77 FR 69368, Nov. 16, 2012, as amended at 78 FR 74822, Dec. 10, 2013; 79 FR 68008, Nov. 13, 2014]