The CMS Quality Payment Program (QPP) is a program established by the Centers for Medicare & Medicaid Services (CMS) in the United States. It aims to shift healthcare payment models from volume-based to value-based care. The QPP was introduced as part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. QPP started on January 1, 2017.

The QPP consists of two tracks for eligible clinicians to participate in:

1. Merit-based Incentive Payment System (MIPS) &

2.  Advanced Alternative Payment Models (APMs).

Merit-based Incentive Payment System (MIPS): MIPS combines and replaces several previous quality reporting programs. It evaluates eligible clinicians based on four performance categories: Quality, Promoting Interoperability, Improvement Activities, and Cost. Clinicians earn a composite performance score that determines payment adjustments to Medicare reimbursements. Here we have explained MIPS program under 6 different parts-

 Performance Categories: MIPS evaluates eligible healthcare professionals based on four performance categories:

  • Quality: Measures the quality of care provided to patients, including clinical outcomes and patient experience.
  • Promoting Interoperability: Focuses on the use of certified electronic health records (EHRs) and health information exchange to improve patient care coordination and information sharing.
  • Improvement Activities: Recognizes participation in activities that enhance clinical practice, care coordination, beneficiary engagement, and patient safety.
  • Cost: Assesses the cost of care provided to patients, including both Medicare spending and resource utilization.

2. Scoring and Payment Adjustments: Each performance category is assigned a specific weightage, and a clinician’s performance is measured to calculate a MIPS final score. The final score determines positive, neutral, or negative payment adjustments that will be applied to the clinician’s Medicare Part B reimbursements in future years.

3. Eligibility: MIPS eligibility is determined based on factors such as the type of healthcare professional, Medicare billing, and the number of Medicare patients treated. Clinicians who meet the eligibility criteria must participate in MIPS unless they qualify for an exemption.

4. Reporting Options: MIPS offers different reporting options to accommodate various practice sizes and resources. These include individual reporting, group reporting, virtual group reporting, and participation through alternative payment models (APMs).

5. Performance Feedback: CMS provides clinicians with performance feedback reports, which offer insights into their performance in each category, comparisons to peers, and guidance for improvement.

6. Program Evolution: MIPS continues to evolve over time, with CMS regularly updating program requirements, performance measures, and reporting mechanisms to align with changing healthcare priorities.

It’s important to note that the details and specific requirements of MIPS may change over time, so it’s advisable to refer to the official CMS resources or consult with healthcare associations for the most up-to-date information.

 Advanced Alternative Payment Models (APMs)

APMs are alternative payment models that require participation in advanced risk-bearing payment arrangements, such as accountable care organizations (ACOs) or bundled payment models. Clinicians who participate in qualifying APMs may be eligible for enhanced financial incentives.

Advanced Alternative Payment Models (APMs) are a category of payment models within the CMS Quality Payment Program (QPP) in the United States. APMs are designed to incentivize eligible clinicians to provide high-quality, cost-effective care by moving away from fee-for-service reimbursement models.

Key Features & Characteristics of APMs

  • Payment Structure: APMs utilize alternative payment structures that go beyond traditional fee-for-service. They often involve shared savings or risk-based arrangements, where eligible clinicians bear financial accountability for the cost and quality of care provided.
  • Care Delivery Models: APMs encourage care coordination and collaboration among healthcare providers by promoting innovative care delivery models. Examples of APMs include accountable care organizations (ACOs), bundled payment models, and patient-centered medical homes.
  • Quality Measures: APMs typically incorporate quality measures to assess the performance and outcomes of participating clinicians. These measures may focus on clinical outcomes, patient experience, care coordination, and cost-efficiency.
  • Financial Incentives: Clinicians who participate in qualifying APMs may be eligible for financial incentives, including enhanced reimbursement rates, bonus payments, or exemption from certain reporting requirements under the QPP’s Merit-based Incentive Payment System (MIPS) track.
  • Risk and Reward: APMs often involve varying levels of financial risk and reward for participating clinicians. Some models provide shared savings when cost targets are achieved, while others include downside risk where clinicians may be responsible for repaying a portion of spending that exceeds targets.

The specific APMs available can vary, and CMS continues to develop and expand the range of models to provide more options for eligible clinicians. It’s important for clinicians to assess the requirements and benefits of different APMs and determine the most suitable approach for their practice or organization.

CMS provides resources, guidance, and technical support to help clinicians understand and participate in APMs effectively. Eligible clinicians should consult CMS and relevant professional organizations to stay informed about the available APM options and requirements.

Conclusion: The QPP provides a framework to reward clinicians who deliver high-quality care and achieve better patient outcomes while controlling costs. It encourages the use of health information technology, promotes care coordination, and supports ongoing improvement in the delivery of healthcare services.

It’s important for eligible clinicians to familiarize themselves with the specific requirements and reporting mechanisms of the QPP to ensure compliance and maximize potential incentives. CMS provides resources, guidance, and technical assistance to support clinicians in understanding and participating in the program effectively.