Quality Payment Program: What You Need to Know

David White
Search for other papers by David White in
Current site
Google Scholar
Full access

With Kidney Week 2016 in review and the end of the year rapidly approaching, one New Year’s treat is already waiting for everyone. It arrived January 1, 2017, as scheduled. The New Year heralds the beginning of the new Quality Payment Program (QPP) that was created by the Medicare Access and CHIP Reauthorization Act (MACRA).

Congress passed MACRA in 2015 with large bipartisan vote margins in both the Senate and House of Representatives. There is widespread consensus that while parts of the program may have to be adjusted if the Affordable Care Act is repealed or modified, the new Medicare reimbursement program will proceed largely intact.

American Society of Nephrology (ASN) President Raymond C. Harris, MD, FASN, spoke eloquently about the future of nephrology in his Kidney Week President’s Address as ASN marked its 50th anniversary. With the future in mind, Dr. Harris emphasizes that “the move to a quality-driven health care system is real and a part of the future for the nephrology care team and everyone else in medicine. As such, we all need to familiarize ourselves with this new Medicare payment system and get started.”

Responding to concerns raised by ASN and other peer societies regarding the short timeline to prepare for the new program, Medicare determined that 2017 will be a transition year. As such, the Quality Payment Program in 2017 will have reduced reporting requirements and lower scoring thresholds to allow clinicians the opportunity to adjust to the new reimbursement system. Here’s what everyone needs to know.

Who participates in the Quality Payment Program?

You participate in the Quality Payment Program if you bill Medicare Part B more than $30,000 per year and provide care for more than 100 Medicare patients per year, and are one of the following clinicians:

  • Physician

  • Physician assistant

  • Nurse practitioner

  • Clinical nurse specialist

  • Certified registered nurse anesthetist

However, if 2017 is your first year participating in Medicare, you will not be required to participate in MIPS.

There are two paths to participation in the Quality Payment Program.

  • Merit-Based Incentive Program (MIPS)

  • Advanced Alternative Payment Models (APMs)

What is MIPS?

This program replaces three Medicare reporting programs: Meaningful Use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VM). Physicians and practices that participated in the old reporting programs will find that much of MIPS is familiar.

MIPS has four performance categories:

  • Quality—Replaces Physician Quality Reporting System (PQRS)

  • Improvement Activity—New category

  • Advancing Care Information—Replaces Meaningful Use

  • Cost—Replaces Value Modifier; will not be counted until the 2018 performance year

CMS anticipates that most physicians and practices will participate in MIPS for the 2017 calendar year. Per CMS’ Quality Payment Programs Fact Sheet, approximately 500,000 clinicians will be eligible to participate in MIPS in 2017.

What are Advanced APMs?

A smaller number of clinicians participating in the Quality Payment Program will do so via the APM pathway instead of the MIPS pathway. An advanced APM is an APM that must meet these specific requirements:

  • Be CMS Innovation Center models, Shared Savings Program tracks, or certain federal demonstration programs,

  • Require participants to use certified EHR technology,

  • Base payments for services on quality measures comparable to those in MIPS, and

  • Be a Medical Home Model expanded under Innovation Center authority, or require participants to bear more than nominal financial risk for losses.

CMS anticipates that the following models will quality as Advanced APMs in 2017:

  • Comprehensive End State Renal Disease Care Model (Two-Sided Risk Arrangements including non-LDOs as advocated for by ASN)

  • Comprehensive Primary Care Plus

  • Medicare Shared Savings Program Tracks 2 and 3

  • Next Generation ACO Model

CMS is making additions to the list. A final list will be published before Jan 1, 2017.

What does “Pick Your Own Pace” mean?

Since 2017 is a transition year, you have flexibility in reporting and may select the number of measures and timeframe you report. These four options will enable you to avoid a negative payment adjustment, and in certain cases offer the potential for a positive adjustment, in 2019:

  • Test the Quality Payment Program by submitting some data,

  • Participate for part of the 2017 calendar year,

  • Participate for the full 2017 calendar year, or

  • Participate in an Advanced APM in 2017.

Physicians and practices that do not participate at all in 2017 will receive a 4% negative payment adjustment in 2019.

For more information, visit ASN’s Quality Payment Program resource page and CMS’ updated Quality Payment Program website.