Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula and replaced it with a 0.5% annual rate increase through 2019 through the Quality Payment Program (QPP). The QPP includes two tracks: the Merit-based Incentive Payment System (MIPS) track and the Advanced Alternative Payment Models (APMs) track. You can choose how you want to participate based on your practice size, specialty, location, or patient population.

You're a part of the Quality Payment Program in 2017 if you are in an Advanced APM or if you bill Medicare more than $30,000 a year and provide care for more than 100 Medicare patients a year. You must both meet the minimum billing and the number of patients to be in the program. If you are below either, you are not in the program.

1. Merit-based Incentive Payment System (MIPS) combines existing Medicare reporting requirements (Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-based Payment Modified (VPM) into a single program that ties fee-for-serve payment to performance. Physicians will receive payment adjustments based on Quality, Advancing Care Information (use of certified EHR), Clinical Improvement Activities, and Cost (resource use). 
   
   
2. Advanced Alternative Payment Models (APMs) is a payment approach that lets practices earn more for taking on some risk related to patients' outcomes. You may earn 5% Medicare incentive payment during 2019 through 2024 and be exempt from MIPS reporting requirements and payment adjustments if you have sufficient participation in an Advanced APMs. 
   
   

Who is in the Quality Payment Program? 

MIPS will be the pathway for a majority of Orthopaedic Surgeons to participate in QPP. MIPS combines CMS's three existing reporting programs - Physician Quality Reporting System (PQRS), Value-based Modifier, and EHR Meaningful Use, under a single entity. 

2017 MIPS Metrics
To calculate your MIPS score, CMS will evaluate your performance in four categories. Scores in each area will be weighted. CMS will adjust the weights for each category each program year. 

1. Quality (Replaces PQRS) - 60%
   • Must report 6 measures, 1 must be an outcome measure or high-priority measure
   • You must report measures for 50% of your population regardless of payer
   • Reporting may be completed via registry or through an EHR
   • You will receive 3-10 points for each measure based on how your performance compares to the benchmark
   • You can select any 6 measures or pick from the orthopaedic specialty measure set - In development
2. Advancing Care Information (ACI) (replaces MU) - 25%
   • Assigns credits for your use of a certified EHR. You will receive an overall score comprised of several elements:
     • Base Score
     • Performance Score
     • 5 Bonus Points for participating in a registry 
     • 10 Bonus Points for completing improvement activities related to Advancing Care Information 
     • Required reporting may be completed via registry, your EHR or the CMS portal
3. Clinical Improvement Activities (CPIA) - 15%
   • New category in 2017 that focuses on care coordination, beneficiary engagement, and patient safety
   • There are over 90 practice improvement activities to choose from, with medium or high weightings. 
   • 15 or Few Eligible Providers: Participate in one high-weighted or two medium-weighted activities to receive the full score of 20 points.
   • 16 or more Eligible Providers: Participate in two high-weighted or four medium-weighted activities to receive the full score of 40 points.  
   • Report on these activities through a data registry or EHR
   • List of orthopaedic-related improvement activities - In development
4. Cost (replaces VBM) - 0% for 2017
   • No reporting will be required for this category. CMS will calculate your score based on claims data in 2017 and report it to you via feedback report
   • Will not account for overall score in 2017

Scoring: A single MIPS composite performance score will factor in performance in the four weighted categories. Orthopaedic Surgeons can receive positive or negative payment adjustments based on their composite performance score. There will be "winners" and "losers". 

In the MACRA Final Rule, CMS announced physicians will be able to "pick their pace of participation" for the first performance period beginning Jan. 1, 2017. To avoid a payment penalty in 2019, physicians choosing the MIPS pathway must choose one of the options below: 

Individual vs. Group

Physicians will report either as an individual or group. If electing to report as a group, you must register as a group by June 30, 2017.

Advanced APMs will be the less chosen pathway for Orthopaedic Surgeons in 2017. This option lets practices earn more for taking on some risk related to their patients' outcomes. If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model. 

Once you're in an Advanced APM, you'll earn the 5% incentive payment in 2019 for Advanced APM participation in 2017 if:

• You receive 25% of your Medicare Part B payments through an Advanced APM or
• See 20% of your Medicare patients through an advanced APM

Those who participate in an Advanced APM but do not qualify for the 5% bonus payment may still be able to omit MIPS participation, however, many clinicians will participate in both APMs and MIPS. In 2017, clinicians participation in APMs and MIPS will at least receive full credit in the improvement activities category. 

View a list of approved Advanced APMs