Understanding the Medicare’s Physician Quality Payment Program

In order to strengthen value-based care program, MACRA put forward a new Medicare value-based payment scheme which will be starting next year. This new scheme is named as the Quality Payment Program (QPP) abolishes the Sustainable Growth Rate Formula plus undertakes 2 payment pathways:

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

It is required for every physician, charging below the Medicare Physician Fee Schedule, to know about the pre-requisites and modifications in the reimbursements under MACRA as they will get paid on the basis of the performance and value they delivered. In general, the Quality Payment Program (QPP) intends to recompense the caregivers on the basis of the quality they put in the treatment of their patients rather than paying them on the basis of the quantity of the patients. As a fragment of the CMS final rule, the details to implement QPP were decided in October 2016. MIPS: One of the two payment tracks being The Merit-Based Incentive Payment System (MIPS) put together the Value-Based Payment Modifier (VBPM), the Physician Quality Reporting System (PQRS), and the Medicare EHR Incentive Program (Meaningful Use). The reason behind this grouping is measuring the performance of qualified physicians for 4 different classes:

  • Quality of care: Eligible Clinicians are subject to report the quality they incorporated into the process of care delivery. It asks for the reporting of any scalable outcome or at least a highly-prioritized result.
  • Cost (Used Resources)
  • Advancing Care Information (which assesses the meaningful use of specialized EHR expertise): It put together the base score and the score achieved through To earn a base score, the clinicians are required to report quality measures as much as they can.
  • Developmental Activities (formerly known as Clinical Practice Improvement Activities): This class of performance demands the clinicians to report 4 average- weighted quality measures or 2 high- weighted activities to achieve a good score.

The clinicians get score points on the basis of their performance in each class of MIPS. These score points are then joined together to evaluate a single score called the MIPS Composite Score. Under the light of the MIPS Composite Score, the payments of the physicians are decided. Throughout 2017, the estimated value of used resources turned out to be 0%. For this reason, the MIPS Composite Score will take into account the other 3 performance classes for payment adjustment. However, it is up to the clinicians to get into a full, partial or minimum participation in the MIPS. APMs: The other payment pathway devised by MACRA under the QPP is the Alternative Payment Models (APMs). Basically, APMs are new routes to fund the caregivers for their delivery of care to the patient. Rendering to MACRA, the definition of Alternative Payment Model (APM) can be as any of the below-mentioned ones:

  • It is an expanded and unique payment approach proposed by the Center for Medicare & Medicaid Innovation (CMMI) for physicians except those who received the Health Care Innovation Award.
  • It is a Medicare Acute Care Episode Demonstration course or a Medicare Health Care Quality Demonstration plan

Eligibility Criteria for MIPS: Below mentioned professionals are entitled to MIPS

  • Medical doctors
  • Osteopaths
  • Dentists
  • Podiatrist
  • Optometrist
  • Chiropractors
  • Assistants of the Physician
  • Practitioners as Nurse
  • Specialists as Clinical Nurse
  • Licensed Qualified Nurse Anesthetists

MACRA has decided to give length to this list after 2019 to pay to the following professionals as well:

  • Physical Therapists
  • Audiologists
  • Nurse Midwives
  • Clinical Psychologists
  • Speech-language Pathologists
  • Clinical Social Workers
  • Nutritionist/Dietitians