Multiple Chronic Conditions Blog

April 27th, 2016 The US Department of Health and Human Services Issued a Proposal to Align and Modernize how Medicare Payments Are Tied to the Cost and Quality of Patient Care

Monday, 02 May 2016 08:11 / by Dr Kim Kuebler

On April 27, the Centers for Medicare and Medicaid Services (CMS) released the long awaited proposed rule establishing the new Quality Payment Program, a framework that includes the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These policies were established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Medicare currently measures providers for value and quality care through Alternative Payment Models that include Accountable Care Organizations, the Comprehensive Primary Care Initiative, and the Medicare Shared Savings Program. Most providers in the US participate in the Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program.

Last week, the Congress streamlined these multiple programs into a single framework to help providers transition from payments based on volume to payments based on value. This proposed rule will provide a unified framework called the Quality Payment Program and includes 2 unique paths for providers. Eligible providers include: physicians, nurse practitioners, physician assistants, certified registered nurse anesthetists.

  • The Merit-based Incentive Payment System (MIPS)
  • Advanced Alternative Payment Models (APMs).

Merit-based Incentive Payment System (MIPS)

The MIPS Quality Payment Program first performance period will begin next year in 2017 and will provide CMS with the basis for 2019 payment adjustment. MACRA provides the direction for 3 distinct Medicare quality programs in MIPS to include:

  • Physician Quality Reporting System;
  • Value-Based Modifier Program;
  • Meaningful Use’ of electronic health records.

Providers will receive a composite score based on performance in each of four categories. Quality measures from core domains are determined annually, data gained from provider performance on these measures will be transparent and available via on the Physician Compare website.

The four performance categories include:

  1. Quality: 50 percent of total score in year 1;
  2. Advancing Care Information: 25 percent of total score in year 1, previously known as EHR Meaningful Use;
  3. Clinical Practice Improvement Activities: 15 percent of total score in year 1, this domain has recently been added by CMS; and
  4. Cost or Resource Use: 10 percent of total score in year 1, based on Medicare claims data from provider submission.

Advanced Alternative Payment Models

The bipartisan MACRA legislation further created the Alternative Payment Model (APM), where providers become qualifying participants who can earn incentives for participation. The Advanced APM must meet 3 MACRA requirements:

  • Use of certified electronic health records (EHRs);
  • Reimbursement is based upon comparable quality measures; and
  • Becoming an enhanced medical home or reporting more than nominal risk for losses

APMs must provide CMS with a clear thesis on what measures will be tested, and require a formal provider agreement with CMS. CMS works individually with each APM to evaluate and assess specific measurements. CMS will provide transparency to the public on which APMs quality for Advanced APMs prior to each performance period – proposed to begin no later than January 1, 2017.

For more information on this recent proposal please visit: http://go.cms.gov/QualityPaymentProgram

Dr Kim Kuebler

Dr Kim Kuebler

Dr. Kim Kuebler, DNP, APRN, ANP-BC, Founder and Director Multiple Chronic Conditions Resource Center, CEO Advanced Disease Concepts LLC, Savannah, GA. Provider, Asante Physician Partners, Orthopedics and Sports Medicine, Asante Three Rivers Medical Center, Grants Pass, OR