Cooperating for better care.

sustainable growth rate

Tag Archives

A field guide to CMS’s value-based modifier


Here’s a guide for physicians on how to deal with CMS’s new value-based modifier.

As Medscape notes: “VBM could increase your income by up to 2% in the first year, or lower your income by 1% in 2015 and 2% in 2016.”

A VBM is  an incentive or a penalty to be applied to  a physician’s Medicare revenue, on the basis of how CMS has judged the quality and efficiency of  patient care.  And, Medscape reports, “under  bipartisan bills introduced in both houses of Congress, ‘value-based payments’ to doctors would entail incentives or penalties of 4% in 2017, rising to 10% in 2020 and possibly to 12% in 2021 and beyond. These amounts would combine the current bonuses and penalties in the VBM, the Physician Quality Reporting System (PQRS), and the meaningful use programs. These carrots and sticks would replace the loathed Sustainable Growth Rate (SGR).”

To read the entire guide, please hit this link.

How to live with MIPS


Many physicians are asking whether they can opt out of Medicare’s Merit-Based Incentive Payment System (MIPS), which is replacing the Sustainable Growth Rate formula.

Well, probably not. But in any case, suggests Medscape, physicians can reduce  their MIPS reporting burden by reporting with other physicians together in single submission.

“It would be administratively simple to report as a group,” says , founder and CEO of SA Ignite, a Chicago company that helps organizations manage value-based programs, told Medscape. Of course, this would be easier for  a large practice or group of hospital-employed physicians with the staff and IT capabilities to centralize reporting.

The Centers for Medicare & Medicaid Services (CMS) defines a clinical group as having at least two “eligible clinicians”. That could be a physician and a nurse practitioner or physician assistant in one practice.

Under its  proposed rule, CMS would let solo and small practices to get together in “virtual groups,” but owing to the difficulties of implementing such arrangements, this wouldn’t be possible in the first year of MIPS reporting.

Dr. Lee told Medscape that a downside of reporting in a group is that “you would have limited ability to choose specific measures. You may be forced to accept measures for activities where you don’t perform that well.”

To read the full article, please hit this link.

Maximizing provider reimbursement under MACRA

Here’s some guidance on finding the best way to maximize provider reimbursement under the Medicare Access and CHIP Reauthorization Act (MACRA),  signed into law last year.

The law  is designed, among other things, to restructure how reimbursement rates are calculated for individual doctors in the Medicare Physician Fee Schedule.

MACRA  repealed the flawed Sustainable Growth Rate formula for  Medicare payments for clinicians’ services, and established  a new framework for rewarding physicians based on “value” rather than volume.

Modern Medicine noted that “By comparing physician compliance against national averages with mandated regulations across many specifically defined quality metrics and measures, CMS hopes to reduce what it considers costly medical redundancies and improve overall patient health and safety.”

According to the legislation, all eligible providers, “including physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists… shall receive annual payment increases or decreases based on their performance as measured by standards the Secretary [of Health and Human Services] shall establish according to specified criteria” from 2019 on.

Post SGR battle, still tough realities for physicians


David Cutler, a healthcare economist at Harvard, writes in JAMA that while physicians are relieved that the fight over the Sustainable Growth Rate for Medicare payments is over, they should know that the pressure on them is far from over. He says at the end of his essay:

“When the SGR was repealed, physicians may have thought they were going back to the good old days of Medicare, before the SGR was introduced. But that is not in the cards. To paraphrase the old expression that war is too important to be left to the generals,’ healthcare payers have concluded that medicine is too important to be left to physicians alone.

“Physicians may not like living under alternative payment systems or being judged on outcomes for patients who avoid necessary care because of cost-sharing. But they will have to accept these new realities.  Over time, they may even come to embrace them. After all, what is the alternative?”

Life after the SGR


Robert Doherty discusses how physicians should deal with the exit of the Sustainable Growth Rate and the arrival of the Merit-Based Incentive Payment System.


Explaining the Senate’s SGR delay


Discussion between Mary Agnes Carey, of Kaiser Health News, where this originated, and Jennifer Haberkorn, of Politco Pro:


MARY AGNES CAREY:  Welcome to Health on the Hill, I’m Mary Agnes Carey. The troubled Medicare Physician payment formula is one step closer to repeal. After 17 short-term fixes over the last decade, the House of Representatives voted overwhelming to scrap Medicare’s Sustainable Growth Rate, or SGR, and replace it with a system that pays doctors based on the quality of care rather than the quantity.

The Senate is expected to act on the measure next month. Jennifer Haberkorn of Politico Pro joins us now with the latest. Thanks, Jen.


AGNES CAREY:  The House voted 392-37 to pass an SGR overhaul. President Obama supported this plan and there was a lot of pressure on the Senate to act, but it didn’t. Why didn’t the chamber vote on the SGR bill before it left town for a two-week recess?

JENNIFER HABERKORN, POLITICO PRO:  The Senate was wrapping up its “vote-o-rama,” which is a purely Washington term for 15 hours of straight voting on amendments to the budget. Some hoped, and some thought that they would then move to this and pass this Sustainable Growth Rate repeal immediately. But the Senate feels like they have some time – the Obama administration can delay Medicare payments, essentially delaying the cuts to doctors, for two weeks. So they have time to return to this and pass it before physicians would actually see a cut in their rates.

Also the Senate really wanted to amend this policy. It was passed by the House, they were kind of miffed that they weren’t involved. So they want to be able to vote on making some changes to policy. Those amendments are unlikely to be approved, but they want to be able to make a point. There was also some concern that they didn’t have enough time to read the legislation and then all of the budget votes, and they were skeptical of passing this at about 4 in the morning.

MARY AGNES CAREY:  The Senate doesn’t come back until April 13, and that leaves a lot of time for lobbying on this package – maybe people who like it, people who don’t. What are you expecting?

JENNIFER HABERKORN, POLITICO PRO:  Traditionally in Washington, the more time you have, the more opportunity there is for opposition to fester. That should be a concern in this case because it is two weeks before the Senate returns, but the House vote, as we said, was overwhelming: 392 votes. Advocacy groups are pretty overwhelmingly supportive of it. And I don’t see any real opposition brewing unless something new comes out – something unexpected like there’s a provision in the bill that no one realizes was there or something really significant like that. So I see the next two weeks – physician groups putting some lobbying time into ensuring the Senate vote is as strong as possible.

MARY AGNES CAREY:  You mentioned Senate amendments a moment ago. What sort of amendments are we likely to see when the Senate takes up this package?

JENNIFER HABERKORN, POLITICO PRO:  The Senate really wants four years of funding for the Children’s Health Insurance Program. The policy right now is only two years and they want to be able to vote on doubling that to four. I don’t think that is likely to pass, particularly because it is a pretty expensive policy change. We are also likely to see an amendment on a budget point of order, which is really just acknowledging that this policy is not fully paid for, so it would add to the deficit in the first ten years and particularly conservative budget hawks would like to be able to voice opposition to adding to the deficit.

MARY AGNES CAREY:  Let’s go back to that House vote for a minute. Just want to get your impressions, I mean I found it so interesting that House Speaker John Boehner could convince many conservative Republicans to vote for this, even though as you say it wasn’t fully paid for. Nancy Pelosi, the Democratic leader, also got her troops mostly to go along, even though they had concerns, same concerns as Senate Democrats about the Children’s Health Insurance Program funding, there were some concerns that beneficiaries are picking up too much of this package. How did that all come together?

JENNIFER HABERKORN, POLITICO PRO:  I think a couple really strategic decisions by leadership were key. Conservatives were able to get the early support of Americans for Tax Reform, which is really influential with conservatives who are concerned about the budget. That kind of quelled some of that opposition. Nancy Pelosi very early on made it clear that she wanted more money for the CHIP program, but just wasn’t going to be able to get it in this deal.  And so, that really tapped down opposition from the far ends of both sides, Republicans and Democrats.  Also, this policy was just so widely hated that there was a lot of support for getting rid of it even if you had to accept some things that you didn’t like.

MARY AGNES CAREY:  Do you think that House vote, coupled with the likely Senate action on the sustainable growth rate scrapping this formula once and for all, is this a sign that we are going to see more bipartisan cooperation on healthcare in the future?

JENNIFER HABERKORN, POLITICO PRO:  You know, it’s certainly a sign that it’s possible. Whether we are going to see more of this, it’s really hard to say at this time.  This deal seemed to come out of nowhere. You know, we’ve been doing “doc fixes” like you mentioned earlier for a decade. No one thought the policy would going to get repaired anytime soon. And it was perhaps less about healthcare and more about just this recurring, very Washington, problem of fixing this budget problem.  But I will say, this was the number one policy concern of just about every physician organization, a lot of the hospital organizations because they were always taxed to pay for these doc fixes. So it kind of clears the plate of health advocacy organizations and helps health policy people on Capitol Hill.

MARY AGNES CAREY:  We’ll see were it goes. Thanks so much Jennifer Haberkorn of Politico Pro.


Contact Info

(617) 230-4965

Wellesley, Mass