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The elimination of the Sustainable Growth Rate (SGR) formula, which would have resulted in lower physician payments, was a critical component of the Medicare Access and CHIP Reauthorization Act of 2015.

MACRA wants to ramp up the transition to a healthcare system that rewards quality and value over quantity and improves patients’ health outcomes. Medicare reimbursement will undergo the most significant change in decades under the new QPP – Meaning of Quality Payment Program for Medical Billing.

QPP - Meaning of Quality Payment Program for Medical Billing

What is the Quality Payment Program (QPP)?

The new Quality Payment Program (QPP) is designed to reward physicians for providing high-quality care or participating in new care models that reward quality and efficiency.

Clinicians have two options for participating in the Quality Payment Program:

  1. The Merit-based Incentive Payment System (MIPS):                                                                                                                                      A performance-based adjustment will be made if you qualify for MIPS requirements.
  2. Advanced Alternative Payment Models (APMs):                                                                                                                                           Clinicians who participate in “Advanced APMs” can earn a 5% bonus for each year they meet the qualifying criteria.

Overall, QPP offers the opportunity to drive true health system reform that results in patient- and family-centered care. As a result, success will be assured in the long run. The Quality Payment Program (QPP) is expected to evolve, according to the Centers for Medicare & Medicaid Services (CMS). The rule will allow for a 60-day comment period to gather additional feedback from clinicians, patients, and others.

Clinicians can use the new Quality Payment Program website to identify the measures and activities that are most relevant to their specialty or practice. This tool can help clinicians and practice managers find the program that best meets their needs.

The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law in 2015, effectively repealing the Sustainable Growth Rate (SGR) payment system that governed how physicians and other clinicians were paid under Medicare Part B. MACRA replaced the SGR and its fee-for-service reimbursement model with the Quality Payment Program, a new two-track value-based reimbursement system (QPP). This program is the most recent in a series of steps taken by the Centers for Medicare and Medicaid Services (CMS) to reward high-quality care over service volume.

Medicare providers will be paid based on quality and value under the Quality Payment Program

The MACRA reinstated the Sustainable Growth Rate (SGR) for Medicare payments, providing providers with predictable annual payments. Payments to health care providers will be linked to either the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models  (APMs) beginning in 2019. The Quality Payment Program is made up of these two tracks (QPP).

In 2017, providers will begin reporting QPP performance data, and payment adjustments will start in 2019. Taking time between reporting performance data and making payment adjustments allows adequate time for submission and feedback. As part of the first reporting year, providers will be able to decide how much data to report.

Moreover, the implementing rule for QPP explains how Medicare providers will be reimbursed under both payment systems. While the Centers for Medicare & Medicaid Services (CMS) works with different stakeholders to implement and develop new rules, the requirements for providers are likely to change.

What is a Merit-Based Incentive Payment System?

MIPS is notable for building on the traditional fee-for-service Medicare model while rewarding providers for providing high-quality care and improving health outcomes. Even though the majority of Medicare providers will be in MIPS when the program begins, the law intends for them to transition to APMs. As a result, it paves the way for the healthcare industry to shift from fee-for-service to value-based care.

MIPS evaluates providers in four performance categories:

  1. Quality. Existing Medicare quality reporting programs will be included in the Quality category (including the Physician Quality Reporting System). Most providers will report on six quality measures, including one outcome measure, from a pool of more than 200 measures for 90 days. The traditional rulemaking process will define and develop additional evidence-based measures for MIPS, with an emphasis on outcomes-based measures in the long run. MIPS’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) allows providers to earn bonus points for reporting on patient experience metrics.
  1. Cost. The existing Medicare Value-Based Payment Modifier will be incorporated into CMS’s cost category. As a result, the modifier provides differential payment based on the quality of care provided versus the cost. CMS does not require providers to provide additional data for scoring purposes; the cost measures are derived from claims data. This year, the Cost category will be weighted at 0%, so it will not contribute to the MIPS Final Score. According to CMS, the weight of this category will be increased in future MIPS performance periods.
  1. Advancing Care Information (ACI) is the replacement of the Medicare EHR Incentive Program (Meaningful Use). Clinicians’ use of EHR technology will be judged under this category, focusing on interoperability and information sharing. ACI will make up 25% of an eligible clinician or group’s final MIPS score in 2017.
  1. Improvement Activities is a new performance category that includes a wide range of activities designed to reward clinicians for providing care that is focused on beneficiary engagement, care coordination, and patient safety. Providers will be able to choose from nearly 95 activities, each of which is either “medium-weighted” or “high-weighted.” Most MIPS providers will be required to participate in two to four activities for at least 90 consecutive days, depending on their weighting. Furthermore, providers who participate in a patient-centered medical home (PCMH) receive the highest clinical improvement activity score. Providers enrolled in APMs (other than PCMHs) will, however, receive half the points toward full credit in this category. Some providers may be eligible for full credit in APMs.

What is an Advanced Alternative Payment Models (APM)?

Advanced APMs are payment models that take new payment models a step further by allowing organizations to share the savings gained from providing high-quality care at low costs while often assuming the downside risk if the care is more expensive than the plan.

Providers in an Advanced APM receive an automatic 5% bonus each year. The APM may also provide them with incentives or penalties, such as shared savings or losses within an Accountable Care Organization (ACO).

Among the advanced APMs are:

  • Oncology Care Model (OCM)
  • Primary Care First (an evolution of CPC+)
  • Medicare Shared Savings Program (tracks 2 and 3)

The QPP – and APMs in particular – have the potential to move us toward more comprehensive, coordinated, patient and family-centered care while driving down costs if implemented with a patient- and family-centered approach.

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