Medicare Advantage

Quality Payment Program Tool

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As the payment model for healthcare services moves from a fee-for-service to a fee-for-value model, the Centers for Medicare and Medicaid Services (CMS) has rolled out a number of new metrics and tools to help track patient care for healthcare service providers. Recently, the CMS unveiled the Merit-based Payment System (MIPS), an incentive program that pays providers a more positive reimbursement rate based on measurable patient outcomes. To bring this vision to reality, the CMS also built the necessary tools to track key patient data that measures these quality outcomes by developing the Quality Payment Program (QPP).

To participate in the QPP, a healthcare provider must bill Medicare more than $30,000 a year with care provided to more than 100 Medicare patients a year. Providers must be physicians, physician assistants, nurse practitioners, clinical nurse specialists or certified registered nurses, or nurse anesthetists. The purpose of this overhaul of the reimbursement program is to help incentivize healthcare practitioners based on four key factors:

  • Quality of care
  • Use of resources
  • Clinical practice improvement activities
  • Meaningful use of certified electronic health record (EHR) technology

Overall, MIPS will use the existing quality measures set by previous programs, including the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM) and the Medicare EHR Incentive Program for Eligible Professionals. Ultimately, the payment adjustments previously awarded under those programs will be phased out by the end of 2018 and replaced with the incentives outlined in the new MIPS beginning January 1, 2019.

How Does QPP Work?

The process to receive these positive payment adjustments requires practitioners to join the Advanced APM after meeting the above criteria, then send in data about the care provided throughout the year and submit this data by a deadline of March 31, 2018 for care provided in 2017. By sending in quality data through the Advanced APM, providers can earn an additional 5 percent incentive payment. After Medicare gives feedback about the performance based on the data, practitioners can earn a positive MIPS payment adjustment for 2019 if the data for 2017 was submitted by the deadline.
Quality incentive plan adjustments begin at 4 percent in 2019 and go up gradually to 9 percent in 2022, effectively making it a rewards program for healthcare practitioners who give their patients high-quality care over a longer time period.

Streamlining the Process for Providers

Entering all the necessary data to qualify for these incentive payments can be a daunting task, especially given the already increasing workloads of the nation’s providers. Given the move to electronic medical records, ensuring the data is entered and also protected under HIPAA privacy requirements can present a challenge as well. In response to this, the CMS launched an Advanced Program Interface (API) in October 2016 that allows developers to create interfaces for healthcare practitioners where they can more easily enter patient records securely for reimbursement.

Kate Goodrich, MD, director of the CMS Centers for Clinical Standards and Quality, noted that this new tool was based on user experience. She also reiterated that the CMS remains committed to making this process easier while supporting efforts to improve quality care across the country. The new API is publicly available on the CMS website.

Paying for the necessary technology to participate in the QPP can be overwhelming for small practices that may only have a single physician. Therefore, the Department of Health and Human Services has made $100 million available to help small practices prepare for QPP. This funding will support training and education for Medicare clinicians in practices with 15 clinicians or fewer, specifically targeting rural communities and historically under-resourced areas.

Response from Providers

The American College of Physicians supports the new CMS API, praising the CMS for designing and sharing an accessible interface that helps simplify the process for physician participation in the Quality Payment Program. President of the ACP, Nitin S. Damle, said that the new interface is in line with the organization’s ongoing effort to transition from “volume-based” to “value-based” care.

The CMS hopes that as the program grows, the possibility of being rewarded for providing better care will also improve. The new API tool should make it easier for providers to provide the necessary data, which in turn will allow them to spend more time with patients. More focused care over time should yield better patient outcomes in the long run.

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