What is the Quality Payment Program?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law with bipartisan support on April 16, 2015 and is starting January 1, 2017.  The law does many things but most importantly it establishes new ways to pay physicians for caring for Medicare beneficiaries.  The law also includes new funding for technical assistance to providers, funding for measure development and testing, enables new programs and requirements for data sharing, and establishes new federal advisory groups.   It is comprehensive legislation that has the potential to significantly restructure U.S. healthcare.

It is proposed that all Medicare Part B providers will enter into a new payment framework called the Quality Payment Program (QPP). The QPP replaces the Sustainable Growth Rate (SGR) Formula that formerly determines the Medicare Part B reimbursement rates.

Without reading all 962 pages of this law, the MACRA QPP changes how Medicare pays eligible providers who give care to Medicare beneficiaries by replacing the previous Medicare Part B reimbursement schedule with a new payment program that is based on performance and focused on quality of care, value and accountability.

Under the QPP, participating providers will be paid based on the quality and effectiveness of the care they provide. A growing percentage of physician payment will be based on value – not on volume – like the current fee-for-service system. High value care will be defined by measures of quality and efficiency and providers will earn more or less depending on their performance against those measures.

The program’s measures have been outlined — and are under the guidance of the Centers for Medicare and Medicaid Services (CMS) — in the two paths listed below to allow incentivization for care quality rather than volume. The goal of the MACRA QPP is that providers will earn more or less depending on their performance against these measures.

  1. Merit-Based Incentive Payment System (MIPS)
  2. Advanced Alternative Payment Models (APMs)

MIPS and Advanced APMs will go into effect over a timeline from 2015 through 2021 and beyond.


Azalea Health customers who have any questions on this topic can contact Customer Relations at CR@AzaleaHealth.com

What is the Merit-Based Incentive Payment System (MIPS)?

The MIPS is a pathway within the QPP that sunsets the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program.

Using a composite performance score based on the 4 performance categories below,  eligible professionals (EPs) will either receive an incentive bonus, payment adjustment or no adjustment at all.

  1. Quality
  2. Resource use
  3. Clinical practice improvement
  4. Meaningful use of certified EHR technology

Performance for MIPS began on January 1, 2017 and will annually measure eligible providers in four performance categories to derive a “MIPS score” (0 to 100). The MIPS score can significantly impact a provider’s Medicare reimbursement in each payment year from -9% to +27% by 2022. The four performance categories are weighted:

  • 50% for Quality (formerly PQRS)
  • 25% for Promoting Interoperability (formerly Advancing Care Information/Medicare Meaningful Use)
  • 15% for Improvement Activities
  • 10% for Cost (formerly VM)

The points provided for each category will shift over time to place an increasing focus on more resource use.

What are Alternative Payment Models (APMs)?

APMs give us new ways to pay health care providers for the care they give Medicare beneficiaries. For example:

  • From 2019-2024, pay some participating health care providers a lump-sum incentive payment
  • Increased transparency of physician-focused payment models
  • Starting in 2026, offers some participating health care providers higher annual payments

The list of Advanced APMs is expected to update annually. To see a full list of Advanced APMs, check out the QPP resource center.

What should I do to prepare the the Quality Payment Program? 

1. Determine which pathway works best for your practice

2. Educate and engage your providers

3. Assess your current technology

4. Know your quality measures

5. Track provider performance

6. Form a steering committee

7. Implement a charge management program

8. Consider partnership opportunities

9. Develop care management capabilities

10. Create a road map

How is Azalea Health prepared to assist me with the Quality Payment Program? 

Azalea EHR is a currently Drummond Certified with 2015 Edition Certification.

In addition to in-house support, Azalea has aligned with a number of QPP reporting and attestation assistance partners, like CareOptimize, to help our clients to best navigate everything from selecting the proper track and measures under which to report, to actually pulling the proper data and submitting successfully. Our goal for clients is not simply to avoid penalties, but to qualify for available positive adjustments.

Please contact your Client Engagement Specialist to learn more about our available QPP support options.