What is the Quality Payment Program?
The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) was enacted and replaces the previous Medicare reimbursement schedule with a new pay-for-performance program focused on quality and accountability in patient care. Starting January 1, 2017, eligible Medicare Part B clinicians have entered a new payment framework called the Quality Payment Program, replacing the Sustainable Growth Rate formula. The Quality Payment Program has two paths for participation:
The Merit-based Incentive Payment System (MIPS)
What is MIPS?
The Merit-Based Incentive Payment System (MIPS) is one of the two new payment programs that will be used by CMS to determine Medicare payment adjustments for eligible clinicians under the Quality Payment Program. MIPS combines elements of existing Medicare quality programs -- the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM) Program, and the EHR Incentive Program (Meaningful Use) -- into one MIPS score.
Unlike the previous quality programs, scoring under MIPS is not all-or-nothing, but instead is determined based on an eligible clinician’s participation and performance levels. Once an eligible clinician’s MIPS score is calculated, the clinician may receive a positive payment adjustment or no payment adjustment. Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment. MIPS reporting begins in 2017 and payment adjustments will begin in 2019. Payment adjustments will continue to take effect two years after the relevant reporting year.
How do I know if I am eligible?
To determine whether you need to submit data to CMS for MIPS, you can check CMS's eligibility lookup tool here: Am I Included in MIPS?
In general, the following Medicare Part B clinicians are eligible for MIPS participation:
- Doctors of Medicine (MD)
- Doctors of Osteopathy (DO)
- Doctors of Dental Surgery/Dental Medicine (DMD/DDS)
- Doctors of Podiatry
- Doctors of Optometry
- Physician Assistants (PA)
- Nurse Practitioners (NP)
- Clinical Nurse Specialists
- Certified Registered Nurse Anesthetists
You are a practitioner who is newly enrolled in Medicare.
You are a practitioner who either has 1) less than or equal to $30,000 in Medicare Part B charges, OR 2) less than or equal to 100 Medicare patients.
You are a practitioner who is significantly participating in an Advanced APM.
What are my reporting options for MIPS in 2017?
For a neutral or positive payment adjustment, eligible clinicians must participate in performance reporting for at least a 90-day reporting period during the 2017 transition year. All reporting options for the 2017 reporting year and their subsequent payment adjustments for the 2019 payment year are as follows:
Participate in an Advanced APM
Some practices may have chosen to participate in an Advanced Alternative Payment Model in 2017.
Submit a minimum amount of 2017 data (for example 1 quality measure or 1 improvement activity) and avoid a downward payment adjustment.
Submit 90 days of 2017 data and you may earn a neutral or positive payment adjustment.
Submit a full year of 2017 data and you may earn a positive payment adjustment.
What are my reporting requirements for MIPS in 2017?
For the 2017 reporting year, a clinician’s MIPS score will be based on three performance categories, with a fourth performance category being added beginning in the 2018 reporting year. The four MIPS performance categories are as follows:
Quality: This performance category replaces PQRS. The quality measures included are related to patient outcomes, appropriate use of medical resources, patient safety, efficiency, patient experience and care coordination. Eligible clinicians will report up to 6 quality measures, including at least one patient outcome measure. The Quality performance category will account for 60% of a clinician’s total MIPS score for the 2017 reporting year (Year 1).
Improvement Activities: The measures in this category focus on patient safety, care coordination, beneficiary engagement, population management and health equity. Most participants will complete up to 4 improvement activities for at least 90 days. Groups with fewer than 15 participants, or clinicians in a rural or a health professional shortage area, may complete up to 2 improvement activities for at least 90 days. Examples of Improvement Activities include, but are not limited to:
Use of a certified EHR to capture patient reported outcomes.
Engagement of patients, family and caregivers in developing a plan of care.
Chronic care and preventative care management for empaneled patients.
The Improvement Activities performance category will account for 15% of a clinician’s total MIPS score
for the 2017 reporting year (Year 1).
Advancing Care Information (ACI): This performance category replaces the Medicare EHR Incentive Program (Meaningful Use). This performance category includes measures that exhibit how well clinicians use their certified EHR technology, primarily where it involves interoperability and health information exchange. A clinician can choose to report on the minimum 4 required measures to achieve the ACI base score, which consists of Security Risk Analysis, e-Prescribing, Providing Patient Access, and Health Information Exchange. The ACI base score comprises 50% of the total ACI score a clinician may achieve. If a clinician chooses to pursue a higher percentage, he or she will have the option to report on additional ACI performance score measures to increase the total ACI score and improve the overall MIPS score. The ACI performance category will account for 25% of a clinician’s total MIPS score for the 2017 reporting year (Year 1).
Cost: This performance category will not be counted in MIPS scoring for the 2017 reporting year, but will be added in MIPS scoring beginning in the 2018 reporting year. Also known as resource use, the Cost performance category replaces the VM program and will consist of specialty-based measures that encourage efficient resource use. Cost measures will be determined based on Medicare claims, with no additional reporting requirements for participating clinicians.
MIPS Score Weighting for the 2017 Reporting Year
You can visit Practice Fusion's Quality Payment Program resource center here.
CMS also provides further resources about the Quality Payment Program here.