Quality Payment Program (QPP)

The Quality Payment Program (QPP) is a healthcare payment program implemented by the Centers for Medicare and Medicaid Services (CMS) in the United States. It was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to shift the healthcare payment system from volume-based fee-for-service to value-based care. The QPP aims to improve the quality of care provided to Medicare beneficiaries while also controlling healthcare costs.

The QPP consists of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). These tracks provide eligible clinicians with different pathways to participate in the program based on their practice size, specialty, and level of readiness for value-based care.

The Merit-based Incentive Payment System (MIPS) is one of the two tracks within the Quality Payment Program (QPP). MIPS consolidates and replaces three previous Medicare programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program.

MIPS measures eligible clinicians' performance in four categories: Quality, Promoting Interoperability, Improvement Activities, and Cost. Each category contributes to a composite performance score, which determines the payment adjustment clinicians receive under Medicare Part B. The payment adjustment can be positive, negative, or neutral, based on the clinician's performance compared to the performance threshold set by CMS.

Quality Category

The Quality category within MIPS focuses on assessing the quality of care provided by eligible clinicians. It replaces the previous Physician Quality Reporting System (PQRS) and requires clinicians to report on various quality measures. These measures cover a wide range of clinical areas, such as preventive care, chronic disease management, patient safety, and care coordination.

Clinicians must report on a minimum number of quality measures, depending on their specialty and practice size. The performance on these measures is compared to benchmarks, and a score is assigned accordingly. The Quality category contributes to 45% of the MIPS composite performance score.

Promoting Interoperability Category

The Promoting Interoperability category, formerly known as Advancing Care Information under the Medicare EHR Incentive Program, focuses on the use of certified electronic health record (EHR) technology to improve patient care coordination, health outcomes, and information exchange. It encourages eligible clinicians to adopt and effectively use EHRs to enhance interoperability and patient engagement.

This category assesses clinicians' performance on measures related to e-prescribing, health information exchange, patient access to health information, and secure messaging. It also includes measures to prevent information blocking and promote the use of standardized clinical terminologies. The Promoting Interoperability category contributes to 25% of the MIPS composite performance score.

Improvement Activities Category

The Improvement Activities category evaluates eligible clinicians' efforts to improve clinical practice and care delivery. It recognizes and rewards activities that enhance patient engagement, care coordination, population health management, and patient safety. These activities can be performed individually or as part of a group or virtual group.

Clinicians must attest to completing a certain number and combination of improvement activities to receive credit in this category. The activities are classified into different subcategories, such as achieving health equity, care coordination, beneficiary engagement, and patient safety. The Improvement Activities category contributes to 15% of the MIPS composite performance score.

Cost Category

The Cost category assesses the total cost of care provided by eligible clinicians. It replaces the previous Value-Based Payment Modifier (VM) and evaluates clinicians' performance based on Medicare claims data. The Cost category measures the cost of care during the episode of care or over a specific time period, depending on the measure.

Clinicians do not need to report any additional data for this category, as the cost measures are calculated using administrative claims data. The Cost category contributes to 15% of the MIPS composite performance score.

Advanced Alternative Payment Models (APMs) are the second track within the Quality Payment Program (QPP). APMs are innovative payment models that provide eligible clinicians with the opportunity to earn additional incentives and bonuses by taking on financial risk related to patient outcomes and costs.

To qualify as an Advanced APM, a payment model must meet specific criteria set by CMS. These criteria include the use of certified EHR technology, the assumption of more than nominal financial risk, and the implementation of quality measures comparable to those in MIPS. Clinicians who participate in Advanced APMs are exempt from MIPS reporting requirements and may earn a 5% Medicare Part B incentive payment.

The main difference between MIPS and Advanced APMs lies in the level of financial risk and the reporting requirements. MIPS is a track within the Quality Payment Program that allows clinicians to earn payment adjustments based on their performance in four categories: Quality, Promoting Interoperability, Improvement Activities, and Cost. MIPS does not require clinicians to assume financial risk, and reporting is mandatory for eligible clinicians.

On the other hand, Advanced APMs are innovative payment models that require clinicians to assume more than nominal financial risk related to patient outcomes and costs. Clinicians participating in Advanced APMs are exempt from MIPS reporting requirements and may earn additional incentives and bonuses based on their performance in the APM. Advanced APMs provide a pathway for clinicians to transition to value-based care and take on greater accountability for patient outcomes.

Example 1: Dr. Smith, a primary care physician, participates in the Quality Payment Program (QPP) through the Merit-based Incentive Payment System (MIPS). She reports on quality measures related to preventive care, chronic disease management, and patient safety. Dr. Smith also engages in improvement activities to enhance care coordination and patient engagement. Based on her performance, she receives a positive payment adjustment under Medicare Part B.

Example 2: ABC Medical Group, a multi-specialty practice, participates in the Quality Payment Program (QPP) through an Advanced Alternative Payment Model (APM). The medical group assumes financial risk related to patient outcomes and costs and implements quality measures comparable to those in MIPS. As an Advanced APM participant, ABC Medical Group is exempt from MIPS reporting requirements and may earn additional incentives and bonuses based on their performance in the APM.

In conclusion, the Quality Payment Program (QPP) is a comprehensive healthcare payment program implemented by CMS to transition the payment system from volume-based fee-for-service to value-based care. It consists of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). MIPS assesses clinicians' performance in four categories: Quality, Promoting Interoperability, Improvement Activities, and Cost, while APMs provide a pathway for clinicians to assume financial risk and earn additional incentives. The QPP aims to improve the quality of care provided to Medicare beneficiaries while controlling healthcare costs.