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What Is Quality Payment Program (QPP)?

QPP meaning March 25, 2022

What is the Quality Payment Program (QPP)?

A vital element of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was the elimination of the Sustainable Growth Rate (PDF) (SGR) formula, which would have led to lower physician payments.

MACRA wants to speed up the transition to a health care system that rewards quality and value rather than volume and improves patients’ health outcomes. Under the new QPP, Medicare reimbursement will undergo the most significant change in decades.

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 MIPS requirements.
  2. Advanced Alternative Payment Models (APMs): Medicare may reward you for participating in innovative payment models if you take part in an Advanced APM.

Overall, QPP provides an opportunity to drive true health system reform that results in patient- and family-centered care. Thus, this will ensure success in the long run. The Centers for Medicare & Medicaid Services (CMS) expect the Quality Payment Program to evolve. The rule will allow a 60-day comment period to solicit more input from clinicians, patients, and others.

With the new Quality Payment Program website, clinicians can identify the measures and activities most relevant to their specialty or practice. Clinicians and practice managers can use this tool to find the program that best fits their needs.

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

With the Quality Payment Program, Medicare providers will be paid according to their quality and value.

The MACRA reinstated the Sustainable Growth Rate (SGR) for Medicare payments, thus providing providers with annual payments with a sense of stability. From 2019, payment to health care providers will be tied to either the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). These two tracks make up the Quality Payment Program (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?

A key aspect of MIPS is that it builds on the conventional fee-for-service Medicare model while rewarding providers for delivering quality care and improving health outcomes. Even though most Medicare providers will be in MIPS when the program starts, the law intends for them to switch to APMs. So, it opens the way for the healthcare industry to transition from fee-for-service to value-based care.

MIPS evaluates providers in four performance categories: 

  1. Quality. The Quality category will comprise existing Medicare quality reporting programs (including the Physician Quality Reporting System). For 90 days, most providers will report on six quality measures, including one outcome measure, from more than 200 measures. The traditional rulemaking process will define and develop additional evidence-based measures for MIPS, emphasizing outcomes-based measures over time. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS allows providers to get bonus points for reporting on patient experience measures.
  1. Cost. CMS will incorporate the existing Medicare Value-Based Payment Modifier into its cost category. In this way, the modifier provides differential payment based on the quality of care provided compared to the cost. The cost measures are derived from claims data; CMS does not require providers to supply additional data for scoring purposes. This year, the Cost category will weigh 0%, so it will not count towards the MIPS Final Score. CMS says this category’s weight will increase 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. The new performance category is Improvement Activities. The program offers a broader set of activities and rewards to clinicians that focus on beneficiary engagement, care coordination, and patient safety. For MIPS, most providers must complete at least two to four activities for at least 90 consecutive days, depending on their weighting. Furthermore, providers who participate in a patient-centred medical home (PCMH) qualify for the highest score for clinical improvement activities. However, providers enrolled in APMs (that are not PCMHs) will receive half the points toward full credit in this category. There may be some providers eligible for full credit in APMs.

What is an Advanced Alternative Payment Models (APM)?

By taking new payment models one step further, Advanced APMs are payment models in which the organizations share the savings gained from offering high-quality care at low costs while often assuming the downside risk if the care is actually more expensive than the plan.

In an Advanced APM, providers receive an automatic five percent bonus a year. The APM may also give them bonuses or penalties, such as shared savings or losses within an Accountable Care Organization (ACO). 

Among the advanced APMs are:

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

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