The Quality Payment Program: Getting Paid for Value Instead of Volume

By Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CPC-I CCCPC MCS-P CPMA CMQP Chief Revenue Officer of Find-A- Code
December 19, 2016

The government has become increasingly concerned with how they spend money in the healthcare sector. As part of the latest proposal to fix this, they passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This law basically tries to reward providers more when they provide high quality care rather than just more care. It rewards value over volume. It also ends the flawed Sustainable Growth Rate (SGR) formula that had been in use to determine Medicare payment for many years. And, it combines three other quality-based programs into one. But, what does this mean for the average health care provider?

It turns out that it doesn’t mean much if you are in your first year of practice, or you don’t see over 100 Medicare (CMS) beneficiaries in 2017 and you bill Medicare less than $30,000. You don’t need to participate if you fall into this group. However, this model is the beginning of a whole new way to get paid for healthcare and not only does Medicare have plans to expand it, but private payers are likely to follow someday. Even if you choose not to participate in 2017 because you don’t have to, you need to know what the future holds.

In October of 2016, CMS released the final rule for implementing the Quality Payment Program (QPP) as mandated by MACRA. The rule is over 2400 pages. Half of that is responses to comments on the proposed rule that came out six months earlier. Fortunately, CMS has been very sensitive to feedback on the proposed rule. They have reduced the criteria and extended the timeline to make it easier for providers to get in line.

The Quality Payment Program offers two tracks to providers: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Advanced APMs require 25% of payments to come from CMS or 20% of patients to be seen through an Advanced APM in 2017. These entities take on some risk related to patient outcomes and CMS estimates that around 100,000 clinicians will qualify the first year. MIPs is sort of a gateway program into this model. If you think an Advanced APM might apply to you, then visit qpp.cms.gov to learn more.

Around 500,000 providers will participate in MIPS in 2017 where clinicians can earn a performance based payment adjustment to Medicare reimbursements. It will be focused on evidence-based and practice-specific quality data and depends on how much data is submitted and the performance score (see Figure 1). If you are eligible, but choose not to participate in 2017, you will receive a 4% negative adjustment in 2019. If you submit one measure, you can avoid a downward payment adjustment. If you submit for 90 days during 2017, you may earn a neutral or small positive adjustment. And, if you think you have this thing figured out and you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment (see Figure 2). The penalty and reward increases each year to a current maximum of 9% in 2022 (see Figure 3). You have until March 31, 2018 to submit your data.

You can participate as an individual if you have a single NPI tied to a single tax ID, or as a group if you share a common tax ID with other providers. Some parts of MIPS are reported via your certified EHR if you have one. Other categories of MIPS may be reported via claim forms, or a certified registry. MIPS is divided up into four categories, and combined into a composite performance score, which will be made publicly available to help beneficiaries make informed decisions. The categories are as follows:

Quality

This category is worth 60% of your 2017 performance score (see Figure 4). It replaces the Physician Quality Reporting System (PQRS). If you have participated in PQRS for Medicare beneficiaries in the past, then you have little to worry about. It appears that you will continue to do the same thing, only the program now has a different name. You should report up to six measures, one of which must be an outcomes measure. If no outcomes measure applies to your specialty, you can choose a high priority measure instead. There are 271 measures to choose from. The measures can be searched at qpp.cms.gov by specialty.

Improvement Activities

This category is the one that is brand new and it only makes up 15% of your 2017 performance score (see Figure 4). It does not replace any existing program, but focuses on care coordination, beneficiary engagement, and patient safety. Medicare lists 93 activities to choose from, 14 of which have a “high activity weighting.” Most providers will need to report on four and this will likely be done via EHR or an approved registry. Examples include information about patient satisfaction, tobacco use, and engagement of family members.

Advancing Care Information

This category, worth 25% of your score (see Figure 4), replaces the Medicare EHR Incentive Program, also known as Meaningful Use. You may not need to submit Advancing Care Information if the measures do not apply to you. There are two measure sets, depending on the edition of your EHR. Either one has five measures that are required for the base score, but you can submit up to nine measures for additional credit. The five base score measures are:

Security Risk Analysis
e-Prescribing
Provide Patient Access
Send Summary of Care
Request/Accept Summary of Care

If a measure doesn’t apply, then it would not be reported by you and it would not be included in the calculation of your score.

Cost

This category replaces the Value-Based Modifier, but it will not be counted in the 2017 score. Regardless, the provider does not have to do anything because this information will come from the dollar amounts on claim forms. If you can provide lower cost care than your peers, you will receive a higher score in 2018.

What now?

If you are not required to report on MIPS because you are too small, don’t worry about it. But, it might be a good idea to at least consider reporting Quality Measures (formerly PQRS) as you always have. Minimal reporting will cancel out the possibility of a negative adjustment. In fact, take the time to learn a little more and report the Improvement Activities and Advancing Care Information for 90 days in 2017 as well. It might earn you a little bonus in 2019. You can start as late as October 2, 2017.

Our healthcare system has some problems. It is hoped that the Quality Payment Program will address some of them and change provider behavior for the better. Medicare has promised to be flexible and listen to feedback. They expect the program to adapt in the future. But they also realize that there are only a few ways to change clinician behavior - pay them more, improve their satisfaction and help them avoid public humiliation (like poor quality scores posted on a public website). MIPS pays them more, consolidates multiple other government programs, and provides flexibility to give clinicians every opportunity to make their quality scores look good.

Dr. Gwilliam, Chief Revenue Officer of Find-A- Code graduated from Palmer College of Chiropractic as Valediction and is a Certified MIPS Quality Professional, Certified Professional Coding Instructor, Medical Compliance Specialist, and Certified Professional Medical Auditor, among other things. He provides expert witness testimony, medical record audits, consulting, and online courses for health care providers. He also writes books and articles for trade journals, and is a sought-after seminar speaker. He has a Bachelor’s degree in accounting and a Master’s of Business Administration. Find out about new developments in QPP and MIPS at FindACode.com.

Figure 1