The Centers for Medicare & Medicaid Services (CMS) uses incentive payment programs to reward healthcare providers for the provision of high quality, low cost, efficient healthcare. The newest iteration of CMS paying for high quality, value-based care is the implementation of the provisions set forth under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Under MACRA legislation, CMS is required to establish the Quality Payment Program (QPP) in order to reward Medicare-participating physicians for high quality, high value care. The QPP is composed of two tracks, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMS). ID physicians may choose which track to participate in based on practice size, location, or patient population. In general, most ID physicians will participate in the MIPS, at least in the early years of the program. The QPP began January 1, 2017.
In an effort to educate our members, IDSA sponsored a webinar on the QPP final regulations. The webinar provided background information as well practical information that ID physicians may need when participating in the QPP. The recorded presentation can be viewed below and the slides are available for download (PDF).
The American Medical Association (AMA) has prepared several
resources to help physicians and their staff prepare for participation in the
QPP for Physicians. The AMA resources, including podcasts, learning
modules, and webinars is available here: Understanding
MACRA. The MACRA Assessment tool, which can be found here MACRA Assessment Tool, is
an easy to understand tool that will help providers determine how they fit into
the Quality Payment Program, and will help providers determine the financial
implications of participation. The tool is free to use, requiring a simple
The Quality Payment Program (QPP) as mandated by the Medicare Access and CHIP Reauthorization Act (MACRA) legislation began January 1, 2017. Under MACRA legislation, CMS is required to establish the QPP in order to reward Medicare-participating physicians for high quality, high value care. The QPP is composed of two tracks, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMS). ID physicians may choose which track to participate in based on practice size, location, or patient population. The AMA has had built a practice assessment tool that physicians and practice administrators may use to determine the effects of the new Quality Payment Program. In general, most ID physicians will participate in the MIPS, at least in the early years of the program. In order for ID practices to gain a better understanding of how MIPS might affect the practice of ID, IDSA recommends that ID practices refer to the AMA website for detailed information on the MIPS program.
IDSA has prepared a QPP participation and eligibility document for our members. This documents outlines the criteria for participation in the MIPS track of the QPP.
The Advisory Board Company has created a guide for physicians participating in MIPS. Of note is the section of the presentation starting on slide 54, whereby the Medicare patient attribution methodology is described; this will help ID physicians to be aware of how patients are attributed when it comes to calculating a quality score. The presentation is available here: Medical Group Success Under MACRA
The MIPS is comprised of four separate quality categories:
The physician’s performance in each of the four categories will be used to create a composite score upon which the physician’s overall performance will be assessed. For the 2017 reporting period (2019 payment adjustment), the quality component will comprise 60% of the total score, improvement activities 15%, advancing care information 25% and cost 0%. It is important to note that for hospital-based physicians, defined as a MIPS eligible clinician who furnishes 75 % or more of his or her covered professional services in sites of service for inpatient, hospital, campus outpatient hospital, or the emergency room, will have a higher proportion of their performance based on quality due to re-weighting of the advancing care information category. This is due to the fact that hospital-based clinicians have little to no control over the use or type of the electronic health records systems that their employer uses. IDSA has provided some basic information to assist ID physicians in meeting the requirements of the new QPP.
To satisfy the reporting requirements of the quality category for MIPS in 2017, eligible clinicians or a group practice must report quality data on six measures. Of the six measures, one must be an outcome measure. In cases where an outcome measure is not available for a participating clinician, a high-priority measure can be reported as a substitute. A high-priority measure is defined as an outcome, appropriate use, patient experience, patient safety, efficiency, or care coordination measure. Please see the complete list of 2017 MIPS Quality Measures (.xls).
IDSA is aware of the lack of applicable quality measures to the ID physician and has voiced concerns to CMS regarding this troubling issue. IDSA is currently exploring initiatives to address the inappropriate evaluation of ID physicians by reviewing the feasibility of developing an IDSA-sponsored clinical data registry to promote the value of the ID physician. In the short term, as payment adjustments are increasing, -4% payment penalty for non-participation in MIPS for 2017, IDSA recommends members to report on the following measures to avoid the payment penalties, (Note: the measures indicated below assume that an ID physicians sees patients in the outpatient and inpatient setting. Those shown in bold below only apply to the outpatient setting).
IDSA Recommendation for Reporting Six Quality Measures:
There are a limited number of MIPS measures applicable to those clinicians who practice in the inpatient setting and rely largely on initial and subsequent hospital visit codes. Provided below is a list of these measures for 2017.
Note: In order to ensure compliance in the Quality component of MIPS, ID physicians should report on #130 – Documentation of Current Medications in the Medical Record as a standard practice incorporated in a typical inpatient E&M encounter. The specification language for measure #130 indicates that this measure should be done at each visit, however, only the initial patient encounter CPT codes apply to this measure. As well, some ID physicians may feel that reporting measure #47 - Care Plan may be appropriate for some patient cases. Please be aware that once a provider starts reporting any quality measure, CMS will expect that the provider will report the measure for at least 50% of the cases. Therefore, should an ID physician report measure #47 for an initial or subsequent inpatient visit, then that physician will be expected to report measure #47 for at least 50% of the initial and subsequent patient visits for which they bill. Please see the MIPS quality measure specifications for the specific requirements for each mentioned measure (.zip – 249.3MB).
Applicable Measures for 99221 - 99223:
For subsequent inpatient face-to-face encounters, CMS has identified three quality measures that are applicable, which are listed below. As stated above, there are times when an ID physician may discuss Advanced Care Planning with a patient. Should the ID physician want to report this as a quality measure, they should be aware that CMS will expect that they report it on at least 50% of the subsequent visit codes for which they bill.
Applicable Measures for 99231 - 99233
If an individual clinician is submitting quality data by the claims-based submission method, CMS has developed a claims measures single source identifier tool. This can assist clinicians in identifying potentially applicable quality measures for reporting by searching for diagnosis and/or encounter code. Please see the 2017 MIPS Individual Claims Measure Single Source Tool (.xls).
As a part of the MIPS, CMS will also measure the use and reporting of clinical practice improvement activities, which is a new quality measurement category. Improvement activities are activities (such as expanded practice access) or programs (such as antibiotic stewardship) that may improve clinical practice or care delivery and that will likely result in improved outcomes.
Under the new MIPS program, providers can chose from a list of 90+ improvement activities (IAs) in order to meet the requirements of the improvement activity category. IDSA has prepared a list of improvement activities that ID physicians may wish to report. For the first year of the program, in order to avoid a penalty, a provider only needs to report and attest to one improvement activity. CMS has not released any guidance on the specific types of activities that will fall under each subcategory of improvement activities, therefore IDSA encourages physicians to review the entire list of improve activities and chose activities that may be applicable to your type of practice. The complete list of improvement activities is available from the Quality Payment Program website.
Providers will need to attest that an improvement activity was performed. CMS has stated that while they’re not requiring physicians to submit any documentation to prove an AI was completed, physicians are encouraged to retain medical records or any other data used to support/determine the completion of the activity for up to 10 years following the performance period.
CMS is conducting a Clinical Practice Improvement Activity study to gain a better understanding of how practices and providers will be affected by the new quality category of improvement activities. Those providers and practices who participate in the study will receive full credit for the improvement activities category in the MIPS program. Applications for participation in the study are due January 31st, 2017. To apply to participate in the study, visit the Clinical Practice Improvement Study Information website.
Example of MIPS Clinical Practice Improvement Activities
If you have questions or need assistance with MIPS reporting please contact the Quality Payment Program Service Center. The help desk is available Monday – Friday; 8:00 AM–8:00 PM ET:Phone: 1-866-288-8292 TTY: 1-877-715-6222 Email: QPP@cms.hhs.gov
The cost of healthcare has led policy makers to rethink how care is delivered and providers are paid. Fee-for-service payments are likely to continue their decline as we transition towards a value driven healthcare system that rewards high quality and cost effective patient care. Established under authority of the Affordable Care Act (ACA), the Center for Medicare and Medicaid Innovation will play a central role in this transition by testing and implementing payment models that demonstrate quality improvements and cost savings.
The following resources provide information about some of these payment models that are focused on encouraging high value care delivery through greater integration, improved care coordination, and a focus on patient safety. These models are designed to foster a culture of accountability that rewards high quality and cost effective care.
Accountable Care Organizations (ACOs) are legal entities which are designed to allow integrated networks of providers that improve patient outcomes and lower costs to share in the savings that come from more integrated and coordinated care. With the passage of the Affordable Care Act, the Center for Medicare and Medicaid Innovation (CMMI) has become a leading force in efforts to encourage ACOs and other delivery system reforms.
The Medicare Shared Savings Program is the most well known of these efforts but CMMI also has launched smaller initiatives, such as the Pioneer ACO Model and Advanced Payment Initiative. All of these programs are modeled on Medicare's Physician Group Practice (PGP) Demonstration Project, which demonstrated cost savings from greater integration while preserving fee-for-service payments.
Shared Savings Program
Pioneer ACO Model
Advanced Payment Initiative
IDSA is generally supportive of the ACO concept but believes that their development must coincide with a full range of waivers, safe harbors, and exceptions to federal anti-trust laws as a means encourage greater integration. The Society also strongly supports shared savings payments for infection prevention, antimicrobial stewardship, and other systems-level activities that are focused on avoiding healthcare-related complications and their associated costs.
Mandated by the Affordable Care Act, the Center for Medicare and Medicaid Services (CMS) will begin to apply a value modifier under the Medicare Physician Fee Schedule in 2015. Payment adjustments
will be calculated by cost and quality data for physicians in groups of 100 or more eligible professionals who submit claims to Medicare under a single tax identification number. By 2017, all physicians who participate in fee-for-service Medicare will be impacted by the value modifier based off PQRS quality data.
For more information on the Value-Based Payment Modifier, please read the Physician Feedback, Quality and Resource Use Reports (QRURs) and Value-Based Modifier Programs Medicare Learning Network (MLN) article (PDF) that provides background, provider actions, and overviews regarding the CMS quality programs. Additionally, please visit the CMS Value-Based Payment Modifier page for more
IDSA and other physician groups believe that the performance data underpinning the physician feedback reports and the Value-Based Payment Modifier must be based on clinically valid and risk-adjusted measures that attribute care to the appropriate physicians. The Society's concerns with the Value-Based Payment modifier and Physician Feedback Program can be viewed in the Physicians Fee Schedule Proposed Rule (PDF) and Physician Fee Schedule Final Rule (PDF) comment
Medicare was required by the Affordable Care Act to implement a program by October 2012 that links a portion of hospitals payments to their quality and cost of care. Under the Hospital Value-Based Purchasing (HVBP) Program, hospitals will receive incentive payments based on their relative performance on certain measures or how much their performance improves compared to a baseline period.
The HVBP Program will fund incentive payments through a percentage withhold the hospitals' Medicare payments for each discharge. The initial incentive withhold will be 1 percent but will increase to 2 percent over 5 years. High performing hospitals could receive incentive payments in excess of their initial withhold while payments to low performing hospitals will remain below their initial withhold.
Hospitals Value-Based Purchasing Percent Withhold
Performance measures for the Hospital Value-Based Purchasing Program will be drawn from the Hospital Inpatient Quality Reporting program (Hospital IQR), the Medicare pay-for-reporting program for hospitals. This ensures that hospitals are familiar with reporting measures before basing payments on their performance. The initial performance period (FY 2013) will include 12 clinical process of care measures and 1 patient experience of care measure, which is a composite of several patient experience of care indicators from the Hospital Consumer Assessment of Healthcare Providers & Systems Survey (HCAHPS).
In FY 2014, hospitals payments will be tied to performance on 17 measures: 13 clinical process of care measures, three mortality measures, and the HCAHPS.
Avoidable hospital readmissions are a recognized quality of care issue, costing our healthcare system billions of dollars that could be spent elsewhere. Nearly one in five Medicare patients is readmitted within 30 days representing a cost of over $26 billion annually. The Partnership for Patients acknowledged the magnitude of the problem by establishing as a primary goal a 20 percent reduction in hospital readmissions.
Beginning in 2012, the Affordable Care Act requires Medicare to reduce hospitals' payments for potentially preventable readmissions for the following three conditions: acute myocardial infarction (AMI), pneumonia (PN), and heart failure (HF). These conditions were chosen because they represent high volume and cost readmissions for which there are 30-day risk standardized readmission measures that are endorsed by the National Quality Forum.
For 2015, the readmissions reduction program will expand to include patients admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) and patients admitted for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).
The readmissions payment policy will reduce payments to hospitals that have excess Medicare readmissions for the three conditions (AMI, PN, & HF) by applying an adjustment factor against their base operating DRG payments. This policy will only apply to hospitals with 25 or more relevant discharges. Medicare has the authority to expand the policy to additional conditions in future years and to release information to the public on hospitals' readmission rates through the Hospital Compare Website.
More information can be found on the CMS Readmissions Reduction Program page.
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