Quality Payment Program

What are MACRA & the Quality Payment Program?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law in April 2015. It replaces the Sustainable Growth Rate formula with a new approach to paying physicians for the value and quality of care they provide. This new payment system, the Quality Payment System (QPP) will go into effect in 2017 and includes two pathways for participation:

  • Merit Based Incentive Payment System (MIPS)
  • Advanced Alternative Payment Models

Professionals are a part of the Quality Payment Program if they bill Medicare more than $30,000 a year or provide care for more than 100 Medicare patients a year. The first reporting period begins January 1, 2017 and payment adjustments will begin in 2019.

What is the Merit Based Incentive Payment System (MIPS)?

The Merit Based Incentive Payment System (MIPS) is a new program that combines parts of the Physician Quality Reporting System ( PQRS), the Value Modifier  (VM) , and the Medicare Electronic Health Record (EHR) incentive program into one single program the Quality Payment System in which  Eligible Professionals (EP’s) will be measured on.

Components:

Surgeons participating in MIPS will receive a composite performance score (0-100) based on four categories. Each professional’s composite score

  1. Quality (replaces the Physician Quality Reporting System):  2017 category weight: 60%
  2. Improvement Activities (new category):  2017 category weight: 15%
  3. Advancing Care Information (replaces the Meaningful Use program): 2017 category weight: 25%
  4. Cost (replaces value based modifier program): counted beginning in 2018

Professionals who choose the MIPS pathway are able to “pick their pace” in 2017 reporting from the following options:

  1. No participation- negative 4% payment adjustment
  2. Submit something- If a professional submits a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), she/he may avoid a downward payment adjustment.
  3. Partial: If a professional submits 90 days of 2017 data to Medicare, he/she may earn a neutral or small positive payment adjustment.
  4. Full: If a professional submits a full year of 2017 data to Medicare, he/she may earn a moderate positive payment adjustment.

What are Alternative Payment Models?

Alternative Payment Models are defined as a new approach to paying for medical care through Medicare that incentivizes quality and value.  However, not all APMs are “eligible APMs.” Eligible APMs are the most advanced APMs that meet the following criteria:

  • They base payment on quality measures comparable to those in MIPS.
  • They require the use of certified EHR technology.
  • They either (1) bear more than nominal financial risk for monetary losses OR (2) are a PCMH as expanded under the CMS Innovation Center authority.

Additional Resources:

CMS Information on MACRA

Quality Payment System website: https://qpp.cms.gov/

MIPS participation: https://qpp.cms.gov/learn/getprepared

MIPS measure information: https://qpp.cms.gov/measures/performance

Alternative Payment Models information: https://qpp.cms.gov/learn/apms