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The Quality Payment Program

Date
2016-10-25
Title
The Quality Payment Program
Contact
press@cms.hhs.gov

The Quality Payment Program

On October 14, 2016, the Department of Health and Human Services (HHS) issued its final rule with a comment period implementing the Quality Payment Program that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Quality Payment Program improves Medicare by helping you focus on care quality and the one thing that matters most — making patients healthier. MACRA ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. If you participate in Medicare, you are part of the dedicated team of clinicians who serve more than 55 million of the country’s most vulnerable Americans. The Quality Payment Program’s purpose is to provide new tools and resources to help you give your patients the best possible, highest-value care.

The Quality Payment Program policy will reform Medicare payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system. You can choose how you want to participate in the Quality Payment Program based on your practice size, specialty, location, or patient population.

The Quality Payment Program has two tracks you can choose from:

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

An Alternative Payment Model (APM) is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.

Under the Quality Payment Program, created through MACRA, Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to patients’ outcomes. You may earn a 5% incentive payment during 2019 through 2024 and be exempt from MIPS reporting requirements and payment adjustments if you have sufficient participation in an Advanced APM. Earning an incentive payment in one year does not guarantee receiving the incentive payment in future years.

Advanced APMs must meet the following requirements:

  • Be CMS Innovation Center models, Shared Savings Program tracks, or certain federal demonstration programs
  • Require participants to use certified EHR technology
  • Base payments for services on quality measures comparable to those in MIPS
  • Be a Medical Home Model expanded under Innovation Center authority or require participants to bear more than nominal financial risk for losses. The final rule with comment period defined the risk requirement for an Advanced APM to be in terms of either total Medicare expenditures or participating organizations’ Medicare revenue (which may vary significantly). This enhanced flexibility allows for the creation of more Advanced APMs tailored to physicians and other clinicians, such as advanced practice nurses, generally, and small practice participation in particular.

In order to qualify for the 5% APM incentive payment for participating in an Advanced APM during a payment year, you must receive a certain percentage of payments for covered professional services or see a certain percentage of patients through the Advanced APM during the associated performance year.

Table X: Requirements for APM Incentive Payments
for Participation in Advanced APMs
(Clinicians must meet payment or patient requirements)

Performance Year

2017

2018

2019

2020

2021

2022 and later

Percentage of Medicare Payments through an Advanced APM

25%

25%

50%

50%

75%

75%

Percentage of Medicare Patients through an Advanced APM

20%

20%

35%

35%

50%

50%

For performance years 2017 and 2018, the participation requirements only apply to Medicare payments and patients. Starting in performance year 2019, clinicians may also meet an alternative standard for Advanced APMs that will include non-Medicare payments and patients.

Increasing Advanced APM Opportunities

In a companion announcement to the final Quality Payment Program policy, CMS stated its intent to broaden opportunities for clinicians to participate in Advanced APMs by retrofitting existing models to qualify as Advanced APMs and using the CMS Innovation Center to create new models, including those recommended by the Physician-Focused Payment Model Technical Advisory Committee.

One opportunity CMS is considering is an ACO Track 1+ model that would be a new Advanced APM in 2018 with lower risk levels than those currently available to Medicare ACOs. The Quality Payment Program final rule also eases the risk criteria for Advanced APMs from the proposal, allowing a broader range of future models, including those tailored to small practices or specialties.

For the 2017 performance year, we estimate that approximately 70,000 to 120,000 clinicians will participate in Advanced APMs and qualify for the 5% incentive payment.

For the 2017 performance year, we anticipate that the following models will be Advanced APMs:

  • Comprehensive ESRD Care Model (Large Dialysis Organization (LDO) arrangement)
  • Comprehensive ESRD Care Model (non-LDO arrangement)
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Shared Savings Program ACOs - Track 2
  • Medicare Shared Savings Program ACOs - Track 3
  • Next Generation ACO Model
  • Oncology Care Model (two-sided risk arrangement)

We will publish a final list prior to January 1, 2017.

For the 2018 performance year, we estimate that more than 125,000 clinicians will participate in Advanced APMs and qualify for the 5% incentive payment.

For the 2018 performance year, we anticipate that the following models would be Advanced APMs (in addition to the list above).

  • ACO Track 1+
  • New voluntary bundled payment model
  • Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Record Technology (CEHRT) track)
  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)

We will publish a final 2018 performance year Advanced APM Model list before January 1, 2018. CMS anticipates re-opening applications for new practices and payers in CPC+ and new participants in the Next Generation ACO model for the 2018 performance year.

For performance years 2026 and later, you may earn a 0.75% fee schedule update for sufficiently participating in an Advanced APM, while those clinicians that do not achieve sufficient participation in Advanced APMs will earn a 0.25% fee schedule update and may also be subject to MIPS reporting requirements and payment adjustments.

Physician-Focused Payment Model Technical Advisory Committee

The MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and assess Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee. The final rule with comment period finalizes criteria for the committee to use in reviewing these proposals and providing recommendations to the Secretary of the Department of Health and Human Services (HHS). The criteria require that proposed Physician-Focused Payment Models are anticipated to reduce cost, improve care, or both. PTAC provides a unique opportunity for individuals and stakeholders to have a key role in the development of new APMs and to ensure that proposals recommended to the Secretary meet the established criteria and are well-developed.

We expect that the PTAC will assist HHS with improving the process for model development. By engaging with stakeholders early in the development of criteria and review processes, HHS anticipates that PTAC will encourage and facilitate submission of models that have a high likelihood of being implemented and represent the diversity of care provided by physicians across the country.

For more information on PTAC, information to support the development of proposals, and the proposal submission process, go to https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee.

The Secretary is required to review the comments and recommendations submitted by the PTAC and post a detailed response to these recommendations. If CMS considers a physician-focused payment model, it will go through the CMS developmental process for APMs, including design changes as necessary, public announcement, and a request for applications. The decision to test a model recommended by the PTAC will not require stakeholders to submit a second proposal to CMS.

We want to hear from you

The Quality Payment Program final rule with comment period incorporates input received to date, but it is only the next step in an iterative process for implementing the new law. We welcome additional feedback from patients, caregivers, clinicians, health care professionals, Congress, and others on how to better achieve these goals. HHS looks forward to feedback on the final rule with comment period and will accept comments until December 17, 2016.

Comments may be submitted electronically through our e-Regulation website at http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking

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