Understanding the Quality Payment Program

Web Exclusives - Reimbursement
Andrea Zlatkus, CPM, CHRC

On January 25, 2017, the National Organization of Rheumatology Managers (NORM) hosted a Centers for Medicare & Medicaid (CMS) webinar on the Quality Payment Program—which is based on the Medicare Access and CHIP Reauthorization Act (MACRA)—for NORM members.

Lemeneh Tefera, MD, Physician and Adjunct Associate Professor of Emergency Medicine, The George Washington University Hospital, Washington, DC, delivered the webinar to approximately 123 members. Dr Tefera serves as Medical Officer and Policy Advisor for the group that runs CMS’s value-based purchasing programs and new Merit-Based Incentive Payment System (MIPS), one of the components of the new Quality Payment Program.

Whether you have been researching the Quality Payment Program, or are just delving into it for the first time, the webinar provides several pearls of wisdom. A recording of the webinar is available for members on the NORM website under the tab for 2017 webinars.

I had the opportunity to interview Dr Tefera following the webinar. Note that this article will only address the Quality Payment Program and MIPS.

Andrea Zlatkus: Rheumatology consists of many small practices. Under the Quality Payment Program, what constitutes a small practice, and how can this type of practice receive assistance?

Lemeneh Tefera, MD: Practices with ≤15 physicians are considered small practices. Physicians in small practices who report their performance can do just as well as physicians in mid-sized practices.

MACRA provides $20 million each year for 5 years to fund training and education for Medicare physicians in individual- or small-group practices of ≤15 physicians, and those working in underserved areas. As of December 2016, local, experienced organizations can use this funding to help small practices select appropriate quality measures and health information technology to support their unique needs, train physicians about the new improvement activities, and assist in evaluating their options for joining an Advanced Alternative Payment Model. Providing these tools to help physicians and other healthcare providers in small practices and practices in underserved areas navigate new programs is key to making sure they are able to focus on what is most important—the needs of their patients.

Ms Zlatkus: Practices are grateful for the Quality Payment Program’s option to pick your own pace, which encourages all of our physicians to “do something” and test the waters in 2017. How does this work?

Dr Tefera: We want to ease physicians into the Quality Payment Program, and offer many opportunities to successfully report measures and activities. The option to pick your own pace allows a physician who submits any measure or activity to avoid the payment penalty. However, if a physician chooses not to participate, or decides not to submit anything at all in 2017, then the physician would receive a −4% payment adjustment.

The 3 options in the Quality Payment Program’s pick your own pace program for physicians include:

  • Test: Physicians submitting a minimum amount of 2017 data (eg, 1 quality measure or improvement activity for any point in 2017) to Medicare can avoid a downward payment adjustment.
  • Partial: Physicians who submit 90 days of 2017 data to Medicare may earn a neutral or positive payment adjustment
  • Full: Physicians who submit a full year of 2017 data to Medicare may earn a positive payment adjustment.

The size of the payment adjustment will depend on how much data is submitted, and the physician’s performance results.

Ms Zlatkus: How will MIPS be reported? And how does CMS know that a physician is reporting?

Dr Tefera: The first performance period opened January 1, 2017, and closes December 31, 2017. During 2017, physicians will record quality data and how they used technology to support their practice. The 2017 reporting deadline is March 31, 2018. Medicare gives you feedback about your performance after you submit your data. Physicians may earn a positive MIPS payment adjustment beginning January 1, 2019, if they submit ≥90 days of 2017 data. The MIPS payment adjustment is broken down into 4 categories:

Quality Reporting: 60% of 2017 category weight

  • Most participants: Report up to 6 quality measures, including an outcome measure, for ≥90 days
  • Groups using the Internet interface: Report 15 quality measures for a full year.

Improvement Activities: 15% of 2017 category weight

  • Most participants: Attest that you completed up to 4 improvement activities for ≥90 days
  • Groups with

Advancing Care Information: 25% of 2017 category weight

  • Fulfill the required measures for a minimum of 90 days (Security Risk Analysis, e-Prescribing, Provide Patient Access, Send Summary of Care, Request/ Accept Summary of Care)
  • Choose to submit up to 9 measures for ≥90 days for additional credit
  • If these measures do not apply, you may not need to submit measures for Advancing Care Information (eg, there is an option to attest that you do not have an electronic health rec­ord in your practice).

Cost: Does not count toward your score in 2017

  • No data submission required
  • CMS calculates your score from adjudicated claims
  • You will receive a feedback report on your category score
  • For the second year of the program, cost will count for 10% of your score.

Ms Zlatkus: Rheumatology practices are growing as the demand to treat patients with immunologic diseases increases. Many practices are adding physicians and mid-level providers. What are the exclusion criteria for MIPS?

Dr Tefera: Newly enrolled Medicare clinicians (eg, clinicians who enroll in Medicare for the first time during a performance period) are exempt from reporting on measures and activities for MIPS until the following performance year. In addition, clinicians who are below the low-volume threshold (eg, they have Medicare Part B–allowed charges ≤$30,000 or ≤100 Medicare Part B patients), and clinicians who are significantly participating in Advanced Alternative Payment Models.

Ms Zlatkus: If a physician started out the year in 1 practice and has since joined a new practice in 2017, does that physician have to report his or her activity for both practices? And if a physician is new to Medicare, does he or she have to report for 2017?

Dr Tefera: Yes, that is correct.

Ms Zlatkus: Do you have any closing advice for our readers?

Dr Tefera: The Quality Payment Program offers many opportunities to successfully report data and avoid any penalties in the MIPS program. Further, by allowing this transition year, we are hoping to show physicians who are already successfully reporting in the Physician Quality Reporting System, Value Modifier, and Electronic Health Records-Meaningful Use programs that they will be successful in reporting to the Quality Payment Program.

Ms Zlatkus: Thank you, Dr Tefera, for all of the great advice. As we can see, the MACRA program is designed for success. It is built on existing infrastructure that we have been using for many years. With pick your own pace, physicians have the option to submit something that can be a quality measure for 1 patient or they may choose to submit an Improvement Activity that they tried for a 90-day period, submit for 90 days, or go for the full year. Each and every rheumatologist can be successful.

NORM will continue to provide more educational opportunities throughout the year. We will be holding additional Town Hall meetings that delve into each Quality Payment Program category one at a time in greater detail. Look for details in our members’ only community forums.

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Last modified: June 11, 2020
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