Modernizing Medicare with the QPP
Keeping Medicare’s Promise to Families Today and Tomorrow
Blling managers are uniquely positioned to support clinicians in succeeding under the new program. For example, you can assist physician and other clinical practices in:
- Determining whether they need to participate in the Quality Payment Program (QPP);
- Verifying whether they meet desired thresholds in terms of Medicare fee-for-service (FFS) patient counts and billing amounts;
- Examining the potential impact of various participation options on revenue; and
- Analyzing CMS feedback on cost performance measures.
And, for clinicians who don’t believe they’re prepared to participate, you can help them understand that CMS offers flexible options. We understand that resources and technology vary widely across practices, and we want the broadest participation possible among eligible clinicians. I look forward to continuing to work with the entire healthcare community as we embark on the implementation of the QPP.
In October 2016, HHS launched the QPP with a final rule with comment period implementing certain provisions of MACRA – the Medicare Access and CHIP Reauthorization Act of 2015.
A bipartisan solution, MACRA ended the flawed Sustainable Growth Rate (SGR) formula for Physician Fee Schedule payments, and streamlined existing Medicare quality reporting programs. MACRA was enacted to strengthen Medicare. Clinicians who participate in Medicare are part of a dedicated team that serves 55 million of our country’s most vulnerable Americans. As a result of the SGR formula, physicians and other clinical practices faced payment cliffs for 13 years.
The QPP improves Medicare by helping clinicians focus on care quality and the one thing that matters most – making patients healthier. It emphasizes the value of care by using positive and negative payment adjustments based on performance.
As CMS developed the program, we continually sought input from healthcare providers and patients. Before the QPP launched in October, we reviewed 4,000 formal comments on the proposed rule. We’d also heard from thousands of people at focus groups, design sessions, workshops, physician office visits, and events across the country. The QPP has two tracks to choose from: Merit-based Incentive Program (MIPS) or Advanced Alternative Payment Models (APMs).
Knowing that many clinicians will be reporting on quality measures for the first time, CMS crafted the QPP with a flexible framework for 2017. Known as Pick Your Pace, this approach allows clinicians to select from multiple timelines and performance measures based on factors like:
- Practice size
- Patient population
- Experience with quality reporting and electronic health records (EHRs)
Small practices will be excluded from the MIPS under the QPP if they do not meet certain low-volume thresholds, and the program offers less rigorous reporting requirements to them.
Program Basics for 2017 Transition Year
By understanding a few basic elements, billing managers can support the practices they serve in transitioning to the QPP.
Types of clinicians included: The MIPS track of the QPP applies to the following types of clinicians if they bill Medicare FFS:
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
Physicians are defined as:
- Doctors of medicine
- Doctors of osteopathy (including osteopathic practitioners)
- Doctors of dental surgery
- Doctors of dental medicine
- Doctors of podiatric medicine
- Doctors of optometry
- Doctors of chiropractic (for certain specified treatments, by chiropractors legally authorized to practice by a state in which they perform this function)
Clinicians can participate in MIPS as either:
- An individual, with a payment adjustment based on the clinician’s individual performance. An individual has a single National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN).
- A group, with the group’s payment adjustment based on the group’s performance as a whole. A group is a set of clinicians (identified by their NPIs) sharing a common TIN.
- An Advanced Payment Model (APM) Entity, with the EC’s payment adjustment based on the APM Entity’s performance as a whole. An APM Entity (for example, an ACO) is a set of clinicians (identified by their NPIs) that share a common practice TIN that is participating in a common APM Entity that is in an APM.
Practices that need to participate: Individual clinicians, group practices, and APM entities are not exempt if they or their clinicians:
- Bill more than $30,000 a year to Medicare,and
- See more than 100 Medicare patients a year.
Individual clinicians, group practices, and APM entities are exempt if they or their clinicians:
- Bill $30,000 or less a year to Medicare, or
- See 100 or fewer Medicare patients a year, or
- Are new to Medicare in 2017.
To calculate a practice’s annual patient count and billing amount for the 2017 transition year, CMS will review data from September 1, 2015, to August 31, 2016, with a 60-day claims run-out period.
Excluded practices aren’t required to take any action. They can choose to report to CMS on performance measures to prepare to participate in future years. Such an approach gives practices the opportunity to test systems and workflows, and then refine them as needed. But excluded practices won’t qualify for payment adjustments based on 2017 performance.
Pick Your Pace: The Pick Your Pace framework gives clinicians and practices four ways to participate in the QPP:
- Test: Test the program.
- Partial: Participate for part of the calendar year.
- Full: Participate for the full calendar year.
- Advanced APM: Participate in an Advanced APM. In 2017, the following models are Advanced APMs:
- Comprehensive ESRD Care (CEC) – Two-Sided Risk
- Comprehensive Primary Care Plus (CPC+)
- Next Generation ACO Model
- Shared Savings Program – Track 2
- Shared Savings Program – Track 3
- Oncology Care Model (OCM) – Two-Sided Risk
- Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 – CEHRT)
- Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
Remember: Eligible practices that don’t participate will receive a 4 percent negative payment adjustment.
Streamlining legacy programs with MIPS: The four MIPS performance categories streamline three legacy programs and include a new performance category:
- Quality replaces PQRS, the Physician Quality Reporting System.
- Improvement Activities is a new category to reward:
- Care coordination
- Patient engagement
- Patient safety
- Advancing Care Information replaces the Medicare EHR Incentive Program (also known as Meaningful Use).
- Cost replaces the cost component of the Value-Based Payment Modifier (VBM).
Cost won’t be included when calculating the MIPS final score for the 2017 transition year.
Avoid negative payment adjustments with the MIPS Pick Your Pace Test option: As billing managers, you can reassure clinicians who don’t feel prepared that they have an option that requires only a minimal investment of time.
Practices that choose the test option can avoid a negative payment adjustment by submitting some data on just one quality measure. They also don’t need an EHR to participate.
The test option allows practices to prepare for future participation as they avoid the negative adjustment. Test helps practices to:
- Make sure their systems work
- Prepare for broader participation in 2018 and 2019
Again, practices can meet requirements of the test option by reporting on as little as one quality measure.
MIPS offers a wide variety of measures because we wanted to ensure that practices of all types can report on data relevant to their individual situation. For the quality performance category – which accounts for 60 percent of a practice’s score – a practice needs to choose only six measures of more than 270 measures.
Many practices, both large and small, have a successful track record with legacy programs like the Medicare EHR Incentive Program, and 30 percent of Medicare FFS payments now flow through APMs – up from essentially none in 2010. We expect 25 percent of eligible clinicians to be in Advanced APMs by 2018.
Advanced APMs: Instead of participating in MIPS, clinicians can join an Advanced APM and earn a 5 percent incentive payment as a lump sum.
To qualify for the incentive payment, clinicians need to:
- Receive at least 25 percent of their Medicare payments through an Advanced APM, or
- See at least 20 percent of their Medicare patients through an Advanced APM.
Clinicians who don’t meet one of these thresholds:
- Will not qualify for the 5 percent incentive payment, and
- May need to submit MIPS data to avoid the 4 percent negative payment adjustment under MIPS.
Be sure the clinicians you work with understand that:
- Not all APMs are Advanced APMs. Advanced APMs are only one type of APM.
- APMs that aren’t Advanced APMs do not qualify clinicians for the 5 percent incentive payment, but many APMs offer special scoring and reduced reporting requirements in MIPS, as described below.
To avoid the 4 percent negative payment adjustment under MIPS, clinicians who aren’t in an Advanced APM must participate in MIPS. Clinicians who participate in certain APMs that are not Advanced APMs may still receive MIPS credit for the quality reporting they already do as part of their participation in APM.
Avoid negative payment adjustments by participating in MIPS through an APM: As billing managers, you can reassure clinicians who don’t feel prepared that they have another option that requires only a minimal investment of time. "
Practices that choose to participate in MIPS through an APM (such as Track 1 of the Medicare Shared Savings Program) can avoid the adjustment due to special reporting and scoring requirements (see Table 1).
APM Entities are responsible for submitting quality data through the web interface on behalf of the practices participating in it. For 2017, CMS will assign full points to APM Entities for Improvement Activities.
Each practice participating in an APM is responsible for submitting information for the Advancing Care Information category.
The APM Entity’s performance on the four categories will be assessed and the Final Score will be applied to each of the practices participating in the APM Entity.
How the Quality Payment Program Responds to
Clinician and Patient Needs
Here are a few key things my CMS colleagues and I heard as we consulted with healthcare professionals and patients across the country about how best to preserve and improve Medicare:
- We heard about the dedication that both patients and clinicians have to the Medicare program, but also about frustrations they experience.
- We heard from clinicians who challenged us to prove that MACRA and the QPP wasn’t one more check-the-box program and, instead, allows them to focus on care and quality improvement.
- We heard from physicians who are fed up that their EHRs don’t support patient care. Clinicians want technology that makes their jobs easier, matches their workflows, and gives them access to the data they need.
- We heard patients who were tired of lugging around or repeating their treatment history – who wanted more time with a physician who knows them personally, so that they can get the right treatment at the right time without unneeded repetition or miscommunications.
So, as we built the QPP, CMS:
- Focused on a lighter touch, with less regulation, and
- Allowed clinicians to pick their own pace for transitioning to the program.
At the same time, we recognized that many practices are at an advanced level of quality reporting – and ready to go further. For these practices, we developed more opportunities for clinicians and to allow more innovative models to flourish.
As we move forward, we all need to keep building on what works while systematically demanding improvement where we can do better. My CMS colleagues and I hope you’ll join billing managers around the country in supporting clinicians, as we work together to continually improve the quality and affordability of patient care.
At CMS, we say that a single phrase can recalibrate a tense conversation: “My mom is a Medicare beneficiary.” Almost inevitably, the other person says something like, “Mine, too.” And from that shared sense of responsibility, we can all go forward from the right place – a place focused on figuring out what’s best for beneficiaries.
Medicare provides for our parents’ and grandparent’s healthcare, and if we work together and do our jobs right, our children and our grandchildren will one day benefit from the security Medicare offers.
To learn more, please visit qpp.cms.gov.
Dr. Kate Goodrich joined the Centers for Medicare and Medicaid Services in September of 2011 where she serves as director of the Center for Clinical Standards and Quality (CCSQ) and CMS chief medical officer. Previously, Dr. Goodrich served as the director of the Quality Measurement and Value-based Incentives Group in CCSQ, where she oversaw the implementation of over 20 quality, value-based purchasing and public reporting programs across multiple settings. She also co-led an HHS-wide group to align quality measures across programs, and more recently has worked with numerous private payors to align measures across the public and private sectors.