Quality Payment ProgramResource to Navigate Changes in Medicare Payments

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula for Medicare reimbursement. For eligible clinicians, the Quality Payment Program (QPP) replaces previous Medicare Part B payment programs with the Merit-based Incentive Payment Program (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Explore information and resources to learn how this affects your practice. Questions? Email us at govt-prof@endocrine.org.

What is MACRA?
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is legislation that established a new payment system for doctors who treat Medicare patients, changing the way Medicare doctors are reimbursed. Under MACRA, the Sustainable Growth Rate (SGR) Formula was repealed, and providers are instead paid based on the quality and effectiveness of the care they provide.

What is the Quality Payment Program?
Quality Payment Program (QPP) is the name of the Medicare payment program set in place by MACRA. QPP allows Medicare providers to choose one of two payment tracks: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs).

How does this affect me or my practice?
You can find out whether you are part of the QPP by entering your provider number into the tool on this page: qpp.cms.gov/learn/eligibility. Providers are part of the QPP if:

  • You participate in an Advanced APM or
  • You bill Medicare more than $90,000 in Part B allowed charges per year OR provide care for more than 200 Medicare patients per year

There is additional technical support available for practices in Small, Rural and Health Professional Shortage Areas (HPSAs). If you meet the eligibility requirements above, you must begin participation in the QPP on January 1 of the reporting year. Performance data for Year 1 must be submitted by March 31, 2018 in order to avoid a payment penalty.

Understanding the Measurement Criteria and Reporting Requirements

The Merit-based Incentive Payment System (MIPS) uses performance-based measures to determine Medicare payment adjustments. Medicare will use the four categories below to determine whether eligible physicians participating in MIPS will receive a positive, negative, or neutral payment adjustment to their Medicare payments. Click on the icons below to select and download the measurement CSV files for Quality, Advancing Care Information, and Improvement Activities. For Year 2, the categories will be weighted as follows:

QualityQuality (50%)
Replaces PQRS. Report at least six measures for the full calendar year.


Advancing Care InformationAdvancing Care Information (25%)
Replaces Medicare EHR Incentive Program (Meaningful Use). Fulfill the required measures for a minimum of 90 days.


Improvement ActivitiesImprovement Activities (15%)
110+ activities focused on care coordination, beneficiary engagement, and patient safety. Attest that you completed up to 4 Improvement Activities for a minimum of 90 days.


CostCost (10%)
Replaces Value-Based Modifier. No data submission required. Calculated from adjudicated claims.

 

Pick Your Pace
"Pick Your Pace" was a transition period in 2017 that allowed eligible clinicians participating in MIPS to choose when and how to begin participation. Data will be evaluated in 2018, and payment adjustments will be applied to 2019. Failure to submit data by March 31, 2018 will result in a 4% decrease in Medicare Part B payments in 2019. Participants have three options for 2017 performance data collection:

  • Test: Submit a minimal amount of data to avoid penalties.
  • Partial: Submit 90 days of performance data to avoid penalties and earn a neutral or modest increase in payment.
  • Full: Submit a full year of performance data to avoid penalties and earn up to a 5% increase in payment.

Participating in Advanced APMs

You may be exempt from MIPS if you participate in an alternative payment model. Alternative Payment Models (APMs) are payment approaches that give incentives for high-quality and cost-efficient care. Advanced APMs are a type of APM that allow practices to take on some risk related to patient outcomes. To find Advanced APMs accepting enrollment, please visit innovation.cms.gov.

In 2018, clinicians who participate in one of the Advanced APMs listed below will be exempt from the MIPS reporting requirements and will receive a 5% payment bonus from 2019 – 2024. If you leave an Advanced APM during 2018, make sure you have met the Advanced APM threshold or submit MIPS data to avoid a penalty.

Endocrine Society

2018 QPP Year 2 Changes
2018 QPP Final Rule Summary
QPP Year 2 Requirements Infographic
QPP Infographic
QPP Overview Slides
Slides from an ENDO 2017 presentation
Private Practice Prep for QPP
Slides from an ENDO 2017 presentation
Making Sense of ACOs
Slides from an ENDO 2017 presentation
Surviving the Transition to New Quality Payment Programs
2016 Clinical Endocrinology Update (CEU) Session (Please note that this presentation was presented prior to the finalization of the QPP requirements and contains information that may no longer be relevant)

Centers for Medicare & Medicaid Services

Quality Payment Program
A regularly updated resource to help eligible providers understand QPP components. Includes:

Transforming Clinical Practice Initiative
The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely.
Support for Small Practices
List of QPP technical assistance by region for practices with 15 or fewer clinicians.

MIPS Quick Start Guide

Medicare Shared Savings Program and Quality Payment Program Fact Sheet

MIPS APM Fact Sheet

American Medical Association
MIPS Action Plan
A resource for physicians not yet participating in the new Medicare payment program is designed to help practices prepare for, and operate under, the regulation.
Medicare Payment Reform
Offers resources to understand the QPP, including an interactive payment model evaluator
Preparing Your Practice for Value-based Care
This module will help the user transition to a value-based care model.
Inside Medicare's New Payment System (Podcast Series)
Podcasts presented by ReachMD that cover various topics related to QPP, such as MACRA for small practices and how to use an EHR to participate in MACRA

American College of Physicians
MACRA and the Quality Payment Program resource center

MACRA
Medicare Access and CHIP Reauthorization Act of 2015 is landmark legislation that changes how Medicare pays physicians.

QPP
Quality Payment Program is the new Medicare Part B payment program focused on care quality.

MIPS
Merit-based Incentive Payment System is the payment system for eligible clinicians who are not participating in an Advanced APM. The payments in MIPS are based on four categories: Quality, Improvement Activities, Advancing Care Information, and Cost.

APM
An Advanced Payment Model is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care.

Advanced APM
Advanced Alternative Payment Models are a subset of APMs that let practices earn more for taking on some risk related to their patients' outcomes.

CMS
Centers for Medicare & Medicaid Services is a US federal agency under the Department of Health and Human Services which administers Medicare, Medicaid, and the State Children's Health Insurance Program.

HHS
United States Department of Health and Human Services

Important Dates

January 1, 2018
Data collection begins. Find out about reporting here.

March 31, 2018
Last day to submit MIPS data for calendar year (CY) 2017.

October 2, 2018
Last day to begin data collection for Advancing Care Information and Improvement Activities.

January 1, 2019
Payment adjustments begin based on CY 2017 performance.

March 31, 2019
Last day to submit MIPS data for Year 2.