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A Refresher: The Quality Payment Program Revisited

February 28, 2018

The Quality Payment Program (QPP) is designed to improve Medicare outcomes by helping focus on care quality and making patients healthier.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which has created a rift between physicians and the government.  This payment model had severe financial repercussions that could erode provider compensation.  The QPP provides new tools and resources to providers that help them provide their patients the best possible care.  If they participate in Medicare Part B, they will have the opportunity to provide services to more than 55 million Americans.

The QPP has two tracts for a provider:

  • Advanced Alternative Payment Models (APMs) or
  • The Merit-based Incentive Payment System (MIPS)

The providers who participate in the APM through Medicare Part B may earn incentive payments for participating.  If they choose MIPS, they earn a performance-based payment adjustment.

Quality Payment Program Participants

To participate in the QPP APM program in 2018, a provider must bill Medicare more than $90,000 in Part B allowed charges annually and provide care for more than 100 Medicare patients a year.

To participate in MIPS providers must be a:

  • Physician
  • Physician Assistant
  • Nurse practitioner
  • Clinical nurse specialist, or
  • Certified registered nurse anesthetist

Providers may earn a performance bonus of five percent under APM by using appropriate technology that supports APM data collection.  Those who participated in APM in 2017 can earn a positive payment adjustment under MIPS if providers send in data about the care they provided before the filing deadline of March 31, 2018.

Quality Payment Program Schedule

The program begun on January 1, 2017, and participants are required to send their performance data to the Centers for Medicare and Medicaid Services (CMS) by March 31, 2018.  Providers can expect the first payment adjustments based on performance go into effect on January 1, 2019.

Quality Payment Program Compensation

Depending on the data submitted by March 31, 2018, the 2019 Medicare payments will be adjusted up, down, or not at all. Participants in the MIPS path of the QPP have four options:

  • If no data is sent in during the 2017 cut off data, then providers will receive a negative four percent payment adjustment.
  • If a minimum amount of 2017 data is submitted to Medicare (for example, one quality measure or one improvement activity for any point in 2017), providers can avoid a downward payment adjustment.
  • If a provider submits 90 days of 2017 data to Medicare, they may earn a neutral or positive payment adjustment and may even earn the max adjustment.
  • If a provider submits the full year of 2017 data to Medicare, they may earn you may earn a positive payment adjustment.

The MIPS payment adjustment is based on the data submitted.  The best way providers can get the maximum MIPS payment adjustment is to participate full year.  By participating the full year, they have the most measures to pick from to submit, more reliable data submissions, and the ability to get bonus points increases.

If a provider participates in the Advanced APM path:

  • They can receive 25 percent of Medicare payments or see 20 percent of Medicare patients through an Advanced APM in 2017, and then they will earn a five percent incentive payment in 2019.
  • The first MIPS payment adjustments go into effect in 2019, with the maximum positive or negative payment adjustments being four percent in 2019, five percent in 2020, seven percent in 2021, and nine percent in 2022.

What the Experts Are Saying

Tom Nickels, executive vice president of government relations and public policy at the American Hospital Association, felt the final rule "continues a flexible approach to the MACRA's physician quality payment program urged by hospitals, health systems, and the more than 500,000 employed and contracted physicians with whom they partner to deliver care."

"While we believe it could be adopted in 2018, we understand CMS' decision to eventually adopt a facility-based clinician measurement option that will allow many hospitals and clinicians to spend less time collecting data, and more time collaborating to improve care," Mr. Nickels said.  "While we applaud CMS for providing much-needed relief from unrealistic and unfunded mandates for EHR capabilities for clinicians, we are disappointed the agency has yet to provide similar relief for hospitals.  We also urge CMS to provide additional avenues for clinicians to earn incentives for partnering with hospitals to provide better quality, more efficient care through advanced alternative payment models."

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association, expressed disappointment.  "MGMA is very disappointed that CMS quadrupled the length of the quality reporting period under MIPS from the current 90 days to 365 days in 2018," he said.  "This fourfold increase to the quality reporting requirements is in stark contrast the agency’s statements ... that the final rule reduces regulatory burdens.  CMS is in effect prioritizing quantity over quality and giving physicians less than 60 days to prepare for the 2018 MIPS requirements."

The jury is still out regarding the overall outcome of the QPP.  Some providers, who are compensated at the highest level, will applaud the program.  Those providers who are penalized for non-participation will view the program as an unnecessary burden.  Ultimately, the QPP program is designed to improve outcomes and patient satisfaction.  Let’s hope those goals come to fruition.