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Medicare Value-based Payment Programs

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Quality Payment Program (as Required by MACRA)

The Centers for Medicare & Medicaid Services (CMS) began the Quality Payment Program (QPP) on January 1, 2017. The QPP fulfills the mandate of the Medicare Access and CHIP Reauthorization Act (MACRA) to implement an incentive program that rewards Medicare-participating clinicians for high quality, cost efficient, value-based care. The QPP comprises two tracks: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). ID physicians may choose which track to participate in based on practice size, location, or patient population. CMS' infographic summarizes participation requirements and key dates for the 2019 performance year.

Most ID physicians will participate in the MIPS. For information on your MIPS eligibility, enter your 10-digit National Provider Identifier (NPI) into the CMS QPP Participation Status tool.

CMS updates the Quality Payment Program and physician payment formulas annually, typically through issuing first a proposed rule, on which it receives public comment, and then a final rule. IDSA submitted a comment letter  to CMS on the proposed CY2019 QPP/ Physician fee schedule rule.

QPP Resources 

The American Medical Association (AMA) prepared several resources to help physicians and their staff prepare for participation in the QPP. The AMA has podcasts, learning modules, and webinars to view here

The Merit-Based Incentive Payment System (MIPS) is a performance-based payment program for clinicians who bill under Medicare Part B and meet the minimum volume threshold requirements implemented by CMS. Clinicians participating in MIPS are evaluated based on four separate categories:

  • Quality: Clinicians must select and report on quality measures that evaluate care processes and patient outcomes.
  • Improvement Activities: activities or programs that may improve clinical practice or care delivery, and that will likely result in improved patient outcomes. Clinicians must select at least two from a list updated annually by CMS.
  • Promoting Interoperability: measures of effective electronic health record technology. The use of Certified Electronic health record technology (CEHRT) is required.
  • Cost: CMS scores clinicians on multiple cost measures, based on data already submitted through the Medicare administrative claims process for an entire performance year.

Data for MIPS can be reported at the individual clinician or group practice level.  CMS combines performance in each of the four categories to create a composite score to assess overall performance and determine the applicable payment adjustment.  There is a two-year lag between the year for which the data are collected—the performance year--and the payment impact (i.e., quality scores collected in performance year 2018 will affect payment in 2020).  See the chart below to determine the relative weighting of each category by performance year.

mips score.PNG

CMS will report on the public Physician Compare website the clinician or group's scores for each category, as well as the final score.

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. IDSA suggests to report on the following measures, depending on where the physician sees patients:

  • Measure #110: Preventive Care and Screening Influenza Immunization
  • Measure #111: Pneumococcal Vaccination Status for Older Adults
  • Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
  • *Measure #130: Documentation of Current Medications in the Medical Record 
  • Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • *Measure #407: Appropriate Treatment of Methicillin Sensitive Staphylococcus aureus (MSSA) Bacteremia 
  • Measure #474:  Zoster (Shingles) Vaccination
  • Measure #475: HIV Screening

*Indicates high-priority measures

For more details, refer to the list of recommended measures here or the explore quality-measures tool. 

Clinical Practice Improvement Activities

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. IDSA encourages physicians to review the entire list of improvement activities 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 to Study the Use and Reporting of Improvement Activities

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. To apply to participate in the study, visit the Clinical Practice Improvement Study Information website.

Example of MIPS Clinical Practice Improvement Activities

  • Patient Safety and Practice Assessment: Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics
  • Expanded Practice Access: Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults, or teleaudiology pilots that assess ability to still deliver quality care to patients.
  • Emergency Response and Preparedness: Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.
  • Population Management: Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/or conduct periodic, structured medication reviews.
  • Population Management: Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.
  • Population Management: Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).

Additional Resources

CMS developed the 2017 QPP Experience Report  and provided an appendix of specialty specific quality 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

Alternative Payment Models (APMs)

Alternative Payment Models are arrangements that reward participants for providing high-quality cost-effective care.  Alternative Payment Models can apply to a specific condition, care episode, or population, and typically rely on care coordination and integration to achieve better results for their patients.  CMS designates two kinds of Alternative Payment Models within the Quality Payment Program:

  • MIPS APMs: These models include MIPS-eligible clinicians and provide financial incentives for performance on cost, utilization, and/or quality measures at either the participating clinician or APM entity level. Physicians who participate in an MIPS APM are still evaluated on the four MIPS domains (quality, improvement activities, cost, and promoting interoperability), but the MIPS APM performance category weighting differs from the general MIPS scoring methodology, assigning “cost” a category weight of zero and providing higher weights for quality, improvement activities, and promoting interoperability.  Unlike the general MIPS program, these weights do not change from year to year.  MIPS APMs also allow participants to use quality measure reporting at the APM level, reducing the quality measure reporting burden for the individual physician or practice.
  • Advanced APMs: These APMs also hold participants responsible for performance on cost and quality, but in addition require participants to assume downside financial risk.  Advanced APM participants must also use 2015 Certified Electronic Health Record Technology (CEHRT).  In exchange, Advanced Alternative Payment Models offer a 5% bonus, and allow clinicians to be excluded from MIPS reporting requirements.  The APM itself will also offer APM-specific rewards based on its design.  Clinicians can be eligible for advanced APMs if they meet certain threshold requirements for percentage of Medicare patients/percentage of Medicare Part B payments receiving care through the Advanced APM.

For more information, refer to the list of care models designated as MIPS APMs and Advanced APMs.

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