Business Briefs: Providing an Overview of the New Quality Payment Program

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Early on the morning of Oct. 14, the U.S. Department of Health & Human Services (HHS) issued a final rule (with a comment period) that implemented the Quality Payment Program as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which ended the sustainable growth rate formula that for 13 years threatened Medicare-participating clinicians with potential payment cliffs. The new Quality Payment Program will reform Medicare payments (beginning Jan. 1, 2019) for more than 600,000 clinicians across the country and represents a major step forward in improving care across the entire healthcare delivery system. The final rule is more than 2,000 pages long. Throughout the months and years to come, Business Briefs will address many details about this new payment system.

Program Particulars

1) The reporting period for the new Quality Payment Program will begin in 2017. 

2) There will always be a two-year period between the performance-reporting year and the Quality Payment Program adjustment year (eg, 2017 = performance year; 2019 = payment adjustment).

3) Eligible clinicians can choose how they want to participate in the Quality Payment Program (one of two tracks) based on their practice size, specialty, location, or patient population. The two tracks offered are: Advanced Alternative Payment Models (APMs), in which incentive payments are earned for participating in an innovative payment model; and the Merit-Based Incentive Payment System (MIPS), in which performance-based payment adjustments are earned.

4) Five types of clinicians (physicians, nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and physician assistants) may be eligible to participate in the MIPS track. 

5) Three types of clinicians are excluded from the MIPS track: new Medicare enrollees, clinicians below the low-volume threshold, and Advanced APM participants with sufficient participation.

6) Three of the current physician quality programs will be consolidated into the new MIPS performance standards: Physician Quality Reporting System, Physician Value-Based Payment Modifier, and Medicare Electronic Health Record (EHR) Incentive Program.

7) MIPS-eligible clinicians can select one of four performance participation options in 2017. (See Table 1) 

8) The 2019 MIPS Quality Payment Program’s Medicare adjustments will vary depending on each eligible clinician’s 2017 level of performance and the length of his/her participation. (See Figure 1) 

9) The MIPS payment adjustment will increase over a four-year period. (See Figure 2) 

10) An APM is a payment approach that provides added incentives for clinicians to deliver high-quality, cost-efficient care. APMs are developed in partnership with the clinician community and can apply to a specific condition, a care episode, or a population. Under the Quality Payment Program, Advanced APMs are a subset of APMs that allow practices to earn more for taking on some risks related to patients’ outcomes. Advanced APMs must meet four requirements to participate in the Quality Payment Program: 1) Serve as a Centers for Medicare & Medicaid Services’ Innovation Center Model; Medicare Shared Savings Program track or certain federal demonstration program; 2) Participants (at least 50%) must use a certified EHR; 3) APM must provide payment for services based on quality measures comparable to MIPS quality measures; and 4) Be a medical home model or require participants to bear more than nominal financial risk for losses.       

11) Eligible clinicians participating in Advanced APMs may earn a 5% incentive payment during 2019 and through 2024, and may be exempt from MIPS reporting requirements and payment adjustments if they have sufficient participation in the Advanced APMs. NOTE: Earning an incentive payment in one year does not guarantee receiving an incentive payment in future years. (See Figure 3) 

12) Although the Quality Payment Program requires four performance categories, eligible clinicians participating in either MIPS or Advanced APMs will not be required to report the cost category in 2017.

Figure 4 displays the MIPS and Advanced APM 2017 performance category weights by percentage. 

Figure 5 displays how the MIPS performance category weights will change once the cost category is reported. 

Resources For Quality Payment Program Success

Wound care clinicians can connect with the Quality Payment Program’s service center by calling 866-288-8292. Quality Payment Program MIPS inquiries can be directed to Molly MacHarris at 410-786-4461. Quality Payment Program Advanced APM inquiries should go to James P. Sharp at 410-786-7388. For Quality Payment Program suggestions for improvement, email QPP@cms.hhs.gov.

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