United States: The Time Is Now To Comply With The New Medicare Quality Payment Program

Last Updated: January 20 2017
Article by Edward J. Cyran

You may have heard that the Medicare physician incentive payment system is undergoing a change. That change is happening now.

Effective Jan. 1, 2017, the "Quality Payment Program" replaced the primary Medicare physician incentive programs, including the Meaningful Use EHR Incentive Program, the PQRS Program and the Value-Based Modifier Program. Data that would have been reported under these Programs this year will be reported as part of the Quality Payment Program.

The Centers for Medicare & Medicaid Services (CMS) will make adjustments to physician and practice reimbursement under the Medicare Physician Fee Schedule in 2019 based on the data reported this year under the Quality Payment Program. Incentive payments and penalties under the legacy Medicare physician incentive programs will continue to be made only through 2017 and 2018 (based on data reported by providers in 2015 and 2016, respectively).

The purpose of the Quality Payment Program is to create one central program that will govern Medicare Part B payments to all eligible clinicians, while incentivizing them to increase quality of care and decrease inefficiencies in the cost of care. Eligible clinicians under the Quality Payment Program include all physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists enrolled in Medicare who bill Medicare more than $30,000 per year and provide care for more than 100 Medicare patients each year ("Clinicians").

The Quality Payment Program will combine the existing Medicare incentive programs described above with a new program called "Clinical Practice Improvement Activities" into a single payment program that will either reward or penalize Clinicians by adjusting their reimbursement rates under the Medicare Physician Fee Schedule. For data reported in 2017, Clinicians will have the opportunity to earn anywhere from a 0% to 4% adjustment to their reimbursement rates in 2019. Clinicians who fail to meet at least one reporting requirement in 2017 (as discussed below) will receive a 4% negative adjustment to their reimbursement rates in 2019.

Compliance with the new Quality Payment Program will be mandatory for all Clinicians, except those in their first year of enrollment with Medicare. Clinicians may elect to report individually or as part of a group practice.

In each reporting year under the Quality Payment Program (including 2017), Clinicians will be required to qualify for one of two payment tracks: the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternate Payment Model (Advanced APM) (which includes certain Accountable Care Organizations and other shared savings programs).

The MIPS is the default payment track, and will be used by most Clinicians for the initial years of the Quality Payment Program. Qualifying for the Advanced APM model requires participation in a CMS-approved Advanced APM. The long-term goal of CMS is for most Clinicians and practices to participate in Advanced APMs.

Basics of the MIPS

Under the MIPS, each Clinician or group practice will earn a composite performance score (CPS) based on the Clinician or group practice's scores within the following four (4) categories:

Quality of Care – 60% of the CPS in 2017

  • Explanation: Scored based on the reporting of "quality measures," which will be published annually by CMS. Physicians will be able to choose which quality measures they will report each year.
  • Replaces: PQRS and quality component of the Value-Based Modifier.

Advancing Care Information – 25% of the CPS in 2017

  • Explanation: Scored based on the reporting of EHR use-related measures with which you are familiar from the current EHR Meaningful Use Incentive Program. However, unlike the existing program, the QPP measures will not have "all-or-nothing" targets.
  • Replaces: EHR Meaningful Use Program.

Clinical Practice Improvement Activities – 15% of the CPS in 2017

  • Explanation: Scored based on attestation by the physician/group that the physician/group has performed certain care coordination, beneficiary engagement, population management, and patient safety activities.
  • Replaces: This is a new program.

Resource Use – 0% of the CPS in 2017, but will increase significantly in subsequent years

  • Explanation: Scored based on per capita patient costs and episode-based measures, as collected by CMS from your claims submissions. No additional reporting will be required.
  • Replaces: Cost component of the Value-Based Modifier.

How You and Your Practice Can Qualify for 2017

Now is the time to get up to speed on the new Quality Payment Program. To ease Clinicians and their practices into the Quality Payment Program (and specifically the MIPS), CMS has reduced the reporting requirements for 2017. No Clinician or group practice will be required to begin collecting data for reporting on January 1, 2017 (but may elect to do so). To receive a neutral or positive payment adjustment of up to 4% in 2019, Clinicians or their group practices will need to report data for a 90-day performance period during the 2017 calendar year.

CMS has also provided for minimum threshold reporting requirements to avoid a 4% negative payment adjustment and full participation requirements that are more likely to result in a guaranteed positive adjustment. The table below organizes the reporting requirements in an easy-to-read format based on the four scoring categories of the MIPS:

Clinicians who participate in an Advanced APM (e.g., certain Accountable Care Organizations) will be exempt from the MIPS, but will have similar reporting requirements and may earn a five percent bonus incentive payment in 2019. If you think that you or your practice may qualify for participation in an Advanced APM, be sure to contact the administrator of your organization.

To learn more about the Quality Payment Program, visit the website CMS has developed on the Program, which can be found at this link: https://qpp.cms.gov

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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Edward J. Cyran
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