Overview of the Quality Payment Program (QPP)

What is the Quality Payment Program?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare Sustainable Growth Rate (SGR) methodology for updates to the Physician Fee Schedule (PFS) and replaces it with the Quality Payment Program.  The Quality Payment Program (QPP) rewards clinicians for delivery of high-quality patient care through two tracks:

  1. Advanced Alternative Payment Models (Advanced APMs) and
  2. the Merit-based Incentive Payment System (MIPS).

CMS states that the QPP "emphasizes high-quality care and patient outcomes while minimizing burden on eligible clinicians" and that the QPP "is flexible, highly transparent, and improves over time with input from clinical practices." CMS expects that the QPP will evolve over multiple years.

CMS states that the Quality Payment Program aims to:

  1. Support care improvement by focusing on better outcomes for patients, decreased provider burden, and preservation of independent clinical practice;
  2. Promote adoption of Alternative Payment Models that align incentives across healthcare stakeholders;
  3. And advance existing efforts of Delivery System Reform, including ensuring a smooth transition to a new system that promotes high-quality, efficient care through unification of CMS legacy programs.

What are Advanced Alternative Payment Models?

An Alternative Payment Model (APM) is a payment approach that provides added incentives to clinicians to provide high-quality and cost-effective care.  APMs can apply to a specific clinical condition, a care episode, or a population. Advanced APMs are a subset of APMs where practices can earn more by taking on some risk related to patient outcomes. MACRA provides incentive to clinicans who participate in qualified APMs at certain threshold levels and it exempts these clinicians from the requirements of MIPS.  The final rule established the definition of Qualifying APM Participants (QPs) in Advanced APMs

If an Eligible Clinician (EC) receives 25% of Medicare covered professional services or 20% of Medicare patients through an Advanced APM in 2017, they they can earn a 5% Medicare incentive payment in 2019.

For more information on Advanced APMs or participation in this track of the Quality Payment Program, please see: qpp.cms.gov.

What is MIPS?

If you decide to participate in traditional Medicare, rather than an Advanced APM, then you will participate in MIPS. MIPS consolidates three existing program including the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program (Meaningful Use). MACRA streamlines these programs into the new Merit-based Incentive Payment System or MIPS. If you decide to participate in traditional Medicare Part B, rather than an Advanced APM, then you will participate in MIPS where you can earn a performance-based payment adjustment to your Medicare payment.

MIPS focuses on four categories including:

  1. Quality
  2. Cost*
  3. Improvement Activities
  4. and Advancing Care Information

*The Cost category will be calculated in 2017, but will not be used to determine the providers payment adjustment.  In 2018, CMS will begin using the cost category to determine the providers payment adjustment.

Who Can Participate in the Quality Payment Program?

MIPS participants will be called "MIPS Eligible Clinicians".  MIPS Eligible Clinicians will include:

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists
  • Groups that include such clinicians who bill under Medicare Part B

Clinicians who will be excluded from MIPS:

  • Newly Medicare-enrolled MIPS eligible clinicians
  • Qualifying APM Participants (QPs)
  • Certain partial QPs
  • Clinicians that fall under the finalized low-volume threshold defined as those clinicians with less than or equal to $30,000 in allowed charges or less than or equal to 100 Medicare patients

When Do I Start Participating in the Quality Payment Program?

Providers can choose when to start participation in the Quality Payment Program. Providers can begin as early as January 1, 2017. Providers can also choose to delay and start participation anytime between January 1 and October 2, 2017.  All providers will need to send in their performance data by March 31, 2018.

The first payment adjustment goes ito effect on January 1, 2019.  Depending on the data you submit by March 31, 2018, your 2019 Medicare payments will be adjusted (up, down, or remain the same). It is expected that CMS will provide additional information in 2017 on payment adjustments for 2020 and beyond.

Pick Your Pace for 2017

Providers who choose the MIPS path of the Quality Payment Program have four options:

  1. Submit for a Full Year: If you submit for a full year in 2017, you may be able to earn a moderate positive payment adjustment in 2019. Positive payment adjustments will be based on the performance data and performance information submitted, not on the amount of information or length of time that information was submitted.
  2. Submit for a Partial Year: If you submit for a 90 day performance period in 2017, you may earn a neutral or small positive payment adjustment in 2019.
  3. Submit Something: If you submit a minimum amount of data in 2017 (for example, one quality measure or one improvement activity for any point in 2017), then you can avoid a downward payment adjustment in 2019.
  4. Don't Participate: If you do not participate in 2017 and do not send in any data, then you will receive a negative 4% payment adjustment in 2019.

The amount of any payment adjustment will be dependent both on the quantity of data you submit and your quality results.

Submit Something: What is a "Minimum Amount of Data"

CMS has indicated that submitting a "minimum amount of data" in 2017 will avoid a downward payment adjustment in 2019.  What is considered a "minimum amount of data"? CMS defines this as:

  • 1 Quality Measure OR
  • 1 Improvement Activity OR
  • 4 or 5 Required Advancing Care Information Measures

What are the Reporting Requirement for MIPS?

Quality - 60%

Quality - 60%

The Quality category replaces the Physician Quality Reporting System (PQRS) and the quality portion of the Value Modifier (VM).

Most Participants will select 6 quality measures to report on for a minimum of 90 days to be eligible for the maximum payment adjustment.

Quality measure selection - 1 quality measure must be:

  • An outcome measure OR
  • A high-priority measure: defined as an outcome measure, appropriate use measure, patient experience measure, patient safety measure, efficiency measure, or care coordination measure.

This category has a weight of 60% for 2017.

Advancing Care Information - 25%

Advancing Care Information - 25%

The Advancing Care Information category replaces the Medicare EHR Incentive Program (Meaningful Use).  In 2017, there are two measure sets for reporting based upon the EHR edition that the clinician is using.  With SOAPware, you will attest towards the 2017 Advancing Care Information Transition Objectives and Measures or a combination of the two measure sets, since SOAPware is currently certified towards the 2014 Certification Edition.

To receive points for the ACI category, clinicians must fulfill the required measures for a minimum of a 90 day reporting period:

  • Security Risk Analysis
  • ePrescribing
  • Provide Patient Access
  • Send Summary of Care
  • Request/Accept Summary of Care

Providers can choose to submit up to 9 measures for a minimum of 90 days for additional credit. *Note: If the Advancing Care Information measures do not apply to you, you may not need to submit these measures (see CMS for details/qualifications).

For bonus credit, providers can:

  • Report Public Health and Clinical Data Registry Reporting measures
  • Use certified EHR technology to complete certain improvement activities in the improvement activities performance category

This category has a weight of 25% for 2017.

*Note: If clinicians face a significant hardship and are unable to report Advancing Care Information measures, they can apply to have their performance category score weighted to zero. If objectives and measures are not applicable to a clinician, CMS will reweight the category to zero and assign the 25% to the other performance categories to offset the difference in the MIPS final score.

Improvement Activities - 15%

Improvement Activities - 15%

The Improvement Activities category is a new category. MIPS participants will attest to participation in activities that improve clinical practice, such as shared decision making, patient safety, and coordinating care activities.

Most participants will attest that you completed up to 4 improvement activities for a minimum of a 90 day reporting period. There are other options and special considerations for Groups, practices with 15 or fewer clinicians, participants in PCMH or other AMPs, please see qpp.cms.gov for details.

Choose from 90+ activities under 9 subcategories, including:

  • Expanded Practice Access
  • Population Management
  • Care Coordination
  • Beneficiary Engagement
  • Patient Safety and Practice Assessment
  • Participation in an APM
  • Achieving Health Equity
  • Integrating Behavioral and Mental Health
  • Emergency Preparedness and Response

This category has a weight of 15% for 2017.

Cost - 0% for 2017 (Begins in 2018)

Cost - 0% for 2017 (Begins in 2018)

No data submission is required for this measure in 2017.  This measure will be calculated from adjudicated claims. CMS has stated that they will be providing feedback on how you perform on this category in 2017, but it will not affect your Medicare payments in the 2019 payment year.

The Cost category uses measures that were previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR), but they will be scored differently.

What is the MIPS Scoring Methodology?

What is the MIPS Scoring Methodology?

Quality Scoring

The Quality category will account for 60% of your final MIPS score. Clinicians will report on 6 quality measures for a minimum of a 90 day reporting period.

Clinicians will receive 3 to 10 points for each quality measure based on their performance against benchmarks. If a clinician fails to submit performance data for a measure, then 0 points will be earned for this category.

The score for Quality is calculated using the following formula:

  • Total Quality Performance Category Score = [Points earned on required 6 quality measures] + [bonus points earned] / Maximum Number of Points

*Notes: The maximum score cannot exceed 100%. The maximum number of points is the # of required measures (in this case 6) times 10.

Advancing Care Information Scoring

The Advancing Care Information category will account for 25% of your final MIPS score. Clinicians will report on 5 required measures and can choose to submit up to 9 measures for a minimum of 90 days for additional credit. Bonus credit can be earned for reporting on Public Health and Clinical Data Registry Reporting measures or using certified EHR technology to complete certain improvement activities in the improvement activities performance category.

Clinicians can earn points based on the measures they report:

  • 50 points is based on the required base measures
  • 90 points is based on the clinicians performance score
  • 15 points is based on bonus points

Clinicians can earn up to 155 points, however the score will be capped at 100 points. Clinicians need to fulfill the base required measures, otherwise 0 points will be earned in the Advancing Care Information performance category.

The score for Advancing Care Information is calculated using the following formula:

  • Advancing Care Information Performance Category Score = [Base Score] + [Performance Score] + [Bonus Score]

Improvement Activities Scoring

The Improvement Activities category will account for 15% of your final MIPS score. Clinicians will attest towards participation in improvement activities.

Clinicians will be able to earn points based on weights for the activities chosen:

  • Medium = 10 points
  • High = 20 points

*Alternate Activity Weights: Clinicians who are in small, rural, and under-served practices or with non-patient facing clinicians or groups, will earn points based on the following weights: Medium = 20 points; High = 40 points.

*Clinicans in a patient-centered medical home, Medical Home Model, or similar specialty practice receive full credit in this category.

The score for Improvement Activities is calculated using the following formula:

  • Improvement Activities Performance Category Score = [Total number of points scored for completed activities] / [Total maximum number of points (40)] x 100

*Note: The maximum score cannot exceed 100%.

Cost Scoring

The Cost category will not be counted towards the final MIPS score in 2017. In the future, the Cost category will not have any submission requirements, but will be based on claims data that is reported to Medicare.

In the future, clinicians will earn a maximum of 10 points per episode cost measure.

The score for Cost is calculated using the following formula (for 2018 and beyond):

  • Total Cost Performance Category Score = [Points assigned for scored measures] / 10 x Number of Scored Measures

How is My Final Score for MIPS Calculated?

Final Score = [Clinican Quality Performance Category Score x Actual Quality Performance Category Weight] + [Clinician Cost Performance Category Score x Actual Cost Performance Weight] + [Clinician Improvement Activities Performance Category Score x Actual Improvement Activities Performance Category Weight] + [Clinician Advancing Care Information Performance Category Score x Actual Advancing Care Information Performance Category Weight] x 100

How Will My Final Score Affect My Medicare Payments?

How Will My Final Score Affect My Medicare Payments?

The above chart from CMS indicates how your final MIPS score in 2017 will affect your Medicare payments in 2019.  

For More Information...

For more information about the Quality Payment Program, please visit https://qpp.cms.gov.