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How Value-Based Care Looks Under the Quality Payment Program

CMS released a fact sheet on the Quality Payment Program, which explains the value-based care models under the proposed MACRA rules.

By Jacqueline LaPointe

- In light of the recent notice of proposed rulemaking for MACRA implementation, CMS has released a fact sheet on the Quality Payment Program, which outlines the new programs for assessing and reimbursing value-based care.

CMS explains value-based care models under the proposed Quality Payment Program

The proposed Quality Payment Program offers two paths for value-based reimbursement, including the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payments Models (APMs).

CMS designed the payment models to increase flexibility for healthcare providers with quality and certified EHR use reporting as well as simplify the reimbursement process.

“In implementing the new law, we were guided by the same principles underlying the bipartisan legislation itself: streamlining and strengthening value and quality-based payments for all physicians; rewarding participation in Advanced APMs that create the strongest incentives for high-quality, coordinated, and efficient care; and giving doctors and other clinicians flexibility regarding how they participate in the new payment system,” explained the fact sheet.

According to the fact sheet, all eligible healthcare providers would report through the Merit-Based Incentive Payment System for the first year of the Quality Payment Program, which is scheduled to begin in 2017.

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Under the proposed law, MIPS would combine aspects of the Physician Quality Reporting System, the Value Modifier Program, and the Medicare EHR Incentive Program to consolidate and improve how CMS measures quality care.

“Consistent with the goals of the law, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide. MIPS allows Medicare clinicians to be paid for providing high quality, efficient care through success in four performance categories,” stated CMS.

Healthcare providers would receive a composite MIPS score based on cost (10%), quality (50%), clinical practice improvement activities (15%), and success with the Advancing Care Information program (25%).

CMS noted that MIPS would allow for more flexibility with quality and certified EHR use reporting because eligible providers could select what measures to report.

Based on the final MIPS scores, reimbursement payments would be adjusted to account for quality care.

“The law requires MIPS to be budget neutral,” reported the fact sheet. “Therefore, clinicians’ MIPS scores would be used to compute a positive, negative, or neutral adjustment to their Medicare payments. In the first year, depending on the variation of MIPS scores, adjustments are calculated so that negative adjustments can be no more than 4 percent, and positive adjustments are generally up to 4 percent, with additional bonuses for the highest performers.”

CMS would start to measure value-based care for physicians and clinicians in MIPS starting in 2017 and providers can expect the adjusted payments in 2019.

The other path in the Quality Payment Program is the Advanced Alternative Payment Model, which provides eligible healthcare providers with a five percent Medicare Part B incentive payment rather than a MIPS reimbursement adjustment.

APMs are designed for providers that participate in more advanced care delivery models.

“Under the new law, Advanced APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily-required demonstrations where clinicians accept both risk and reward for providing coordinated, high quality, and efficient care. These models must also meet criteria for payment based on quality measurement and for the use of EHRs,” stated CMS.

To qualify, clinicians would need to receive a specific portion of their payments or care for enough patients under a qualifying APM, such as the Comprehensive Primary Care Plus, Medicare Shared Savings Program Track 2 and Track 3, and the Next Generation ACO Model.

CMS Advanced APM Requirements

Through the proposed rule, CMS would have the ability to regularly update the list of qualifying APMs and help to improve existing models to push them towards qualification.

“We expect that the number of clinicians who qualify for the incentive payments from participating in Advanced APMs will grow as the program matures and as physicians take advantage of the intermediate tracks of the Quality Payment Program to experiment with participation in APMs,” explained CMS.

CMS also intends to open the value-based payment model to include APMs by non-Medicare payers, including private insurers and state Medicaid programs, by 2019.

Additionally, the proposed rule would create the Physician-Focused Payment Technical Advisory Committee. The group would be tasked with reviewing and evaluating reimbursement models suggested by healthcare stakeholders.

Under MACRA, CMS will also offer eligible providers an intermediate option for value-based reimbursement. The agency aims to give providers the option to move between the models of the Quality Payment Program.

For example, some Advanced APM participants, who do not meet the payment or patient participation requirements, would be able to choose whether they want to receive the MIPS payment adjustment. In some cases, MIPS participants, who also take part in an APM, would receive points toward scores in the Clinical Practice Improvement Activities category.

CMS stated that it will attempt to align the standards between the two reimbursement models to make it easier for eligible providers to fluidly move between them.

Through the Quality Payment Program, CMS aims to do away with the “one-size-fits-all” nature of previous value-based care programs and create payment models that incorporate relevant physician needs.

Image Credit: CMS

Dig Deeper:

Value-Based Care Reimbursement Needs Greater Customization

What We Know About Value-Based Care Under MACRA, MIPS, APMs



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