Quality Payment Program (QPP)

The Quality Payment Program (QPP) changes the way Medicare pays clinicians for Part B services, offering financial incentives for providing high value care, and adjusting payments accordingly by the year 2019. Established as part of the Final Rule for the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), the QPP has two distinct paths:

  1. The Merit-Based Incentive Payment System (MIPS)
  2. Advanced Alternative Payment Models (Advanced APMs or AAPMs)

Most Medicare Part B clinicians will participate in MIPS. Some (~5-8% nationally) will become qualified participants through participation in an Advanced APM (AAPM). 


As you'll see from the following information, MIPS is complicated. How you decide to approach your participation in the program now will make a big difference down the road. Subject-matter experts at Purdue Healthcare Advisors have carefully studied how each MIPS performance category is scored in order to help you best plan your strategy for Performance Year 2017. Contact PHA's Natalie Stewart to discuss how we can work with you to maximize your efforts. Check our events page for webinars and conferences on the topic. If you are a small-practice provider, learn more about the new QPP Resource Center™ of the Midwest.


MIPS affects “traditional Medicare” (i.e. Part B) and combines facets from legacy programs (i.e value-based purchasing initiatives) set to phase out over the next two years, shifting payments to a performance-based system with these categories:

  1. Quality Measures: Key changes from Physician Quality Reporting System (PQRS) program include reduced reporting from 9 measures to 6, with no NQS Domain requirement; and an emphasis on outcomes measures.
  2. Resource Use: Key changes from Value-based Modifier program include adding 40+ episode specific measures to address specialty concerns.
  3. Advancing Care Information: Key changes from the Medicare Meaningful Use (MU) EHR Incentive Program* include no “all or nothing” and threshold measurement; removal of “one-size-fits-all” perspective; removal of redundant measures; removal of CDS and CPOE objectives; and reduction of public health reporting measures.
  4. Improvement Activities: This is a brand new category.

 

MIPS Legacy Programs

MIPS PERFORMANCE YEAR 2017

QPP Timeline
  • Performance year is one full calendar year.
  • The program is structured as a two-year look back just like Medicare MU, PQRS and VM programs.
  • 2017 designated as a transitional year.
  • *MIPS does not change the requirements under the Medicaid EHR Incentive Program. 

Clinicians eligible to participate in 2017-2018

  • Physicians (MD/DO & DMD/DDS)
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified RN Anesthetists

Additional clinicians eligible to participate in 2019 and beyond

  • Physical Therapists
  • Occupational Therapists
  • Speech/Language Pathologists
  • Audiologists
  • Nurse Midwives
  • Clinical Social Workers
  • Clinical Psychologists
  • Dietitians & Nutritional Professionals

Clinicians who will not participate in MIPS:

  • Clinicians newly enrolled in Medicare
  • Clinicians below the low-volume threshold: Medicare Part B-allowed charges less than or equal to $30K/year OR those who see 100 or fewer Medicare Part B patients per year.
  • Clinicians significantly participating in Advanced APMs

MIPS PICK YOUR PACE / PERFORMANCE MEASURES

Providers can "pick their pace" in 2017, meaning they have the option to choose one of the following:

  1. Do not submit any data and receive a negative payment adjustment.
  2. Test the QPP: Submit a minimum amount of data.
  3. Partial Participation Year: Submit a partial set of data to avoid a negative payment adjustment.
  4. Full Participation Year: Submit all the required data for a potential modest positive payment adjustment.

Providers are assessed annually in four weighted categories (shown below). Flexibility within categories allows clinicians to choose activities & measures most meaningful to them. A Composite Performance Score (CPS) is then assigned, based on a 0-100 scale. Performance decrees payment adjustments, which increase over time.

QUALITY

Year 1 weighting: 60%

Choose six (6) measures on which to be evaluated

Select from individual measures or a specialty set

RESOURCE USE (COST)

Year 1 weighting: 0%

No reporting requirement for clinicians in 2017

CMS calculates based on adjudicated claims

IMPROVEMENT ACTIVITIES

Year 1 weighting: 15%

Nine (9) categories

90+ Improvement Activities / Must select at least one (1) to avoid zero score

PCMH receives full credit 

ADVANCING CARE INFORMATION

Year 1 weighting: 25%

Five (5) required objectives

Participate as individual or group

Flexible scoring for measures

MIPS weighted categories

Adjustments are applied on a linear sliding scale two years after the performance year. The performance threshold is a mean or median of the composite score for all MIPS providers, and the score methodology accounts for:

  • weights of each performance category;
  • exceptional performance (a final score of 70 or above qualifies);
  • flexibility of measures for various categories of clinicians (e.g. specialty, individual or group reporting); and
  • special circumstances for small practices, rural practices, and non-patient-facing MIPS eligible clinicians.

*MIPS does not change the requirements under the Medicaid EHR Incentive Program. If you are participating in Medicaid MU, you must continue to comply with the established requirements under that program.  If you are a Medicaid MU participant who also has Medicare Part B claims, then you will report to both programs.

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