Under the Medicare Access and CHIP Reauthorization Act, The Quality Payment Program (QPP) replaces the sustainable growth rate formula in determining physician reimbursement by Medicare. The QPP replaces three previous programs—the physician quality reporting system, the value-based modifier, and meaningful use. In their stead is one budget-neutral program, the Merit-based Incentive Payment System (MIPS).
Within the MIPS pathway, clinicians will be subject to three weighted categories—quality, advancing care information, and clinical practice improvement activities (CPIA) (Fig. 1). Cost will not become a weighted category until 2018. Weights may be adjusted if certain categories do not apply to the eligible professional.
Quality reporting will make up 60 percent of the 2017 MIPS score. Most groups will need to report up to six quality measures with one outcome measure or one high-priority measure. An explanation of how to complete quality reporting and a full list of all the possible quality measures can be found online (https://qpp.cms.gov/measures/quality).
The advancing care information category requires certified electronic health record technology. Clinicians must attest for a minimum of 90 days to the following:
- performing security risk analysis
- patient access
- sending a summary of care document
- requesting/accepting summary care documents
Groups can choose to submit up to nine measures to earn additional credit. Each measure has a 90-day minimum. Advancing care information may not apply to all groups under the Centers for Medicare & Medicaid Services (CMS) guidelines. A summary can be found online (https://qpp.cms.gov/measures/aci).
CPIA is a new category, which will account for 15 percent of an eligible clinician's MIPS score in year one. It is designed to assess participation in activities believed to improve clinical practice and includes incentives that drive participation in certified patient-centered medical homes and alternative payment models. There are eight categories of CPIA activities. Practitioners will attest up to four improvement activities for a minimum of 90 days, with special considerations for small groups or clinician-shortage areas.
The cost category is weighted at zero in 2017, but will be calculated in 2018. Clinicians will not need to submit anything in this category because CMS will pull data from claims. Providers will be given feedback on the cost category in 2017 to help them prepare for the performance year 2018. Cost will be based on total per capita cost and Medicare spending per beneficiary, and will be calculated through episode-based measures. The cost category will be 10 percent of total MIPS scoring in 2018, and 30 percent thereafter.
Making the transition
The 2017 performance year is considered a transitional period, and is the only year during which clinicians have the option to pick their pace. Scores for each category will be compared to a benchmark set at the beginning of the performance period. The clinician can decide not to submit any data and will receive an automatic payment reduction. Submitting the minimum amount of data will avoid a downward adjustment; submitting 90 days of data may earn a positive adjustment; and submitting a full year of data may not only earn a positive adjustment but is the best way to earn the largest payment adjustment. The adjustments are based on the performance reported and not the duration of the reporting period or amount of data submitted.
CMS recognizes that transferring to a new payment model may be overwhelming for clinicians who are already overextended in the clinical setting. The Transforming Clinical Practice Initiative (TCPi) is one of the largest federally funded grant initiatives to engage and equip physicians to thrive under MIPS. (Fig. 2).
TCPi is a nationwide, peer-based, collaborative network designed to promote positive, large-scale healthcare change through transformation at the practice setting. The program provides mentors for clinicians through the transition and provides assistance through the development of the core skills needed to thrive in a value-based environment.
CMS selected 29 practice transformation networks (PTNs) across the country to assist in this transformation and provide support to both primary and specialty practices. The PTNs provide hands-on technical assistance and support clinicians on current initiatives at no cost to the clinician/clinics. PTNs target clinicians who are not already participating in an APM. Often, these are small independent groups. The goal is to prepare them to be high performers under the MIPS reimbursement system.
The TCPi program promotes quality and movement through the following five phases of transformation:
- setting aims
- using data to drive care
- achieving aims
- achieving benchmark status
- thriving as a business
Assistance is customized to the practice with coaching, tools, and improvement plans to help guide the practice to become successful in value-based reimbursement or other models of care.
There is no cost for participating in the program, but clinics will need to commit time and invest in the transformation to value-based health care. Designated quality improvement advisors are available to mentor clinicians through the transformation by providing educational resources, hands-on support, or help in guiding the clinician through the QPP and the selection of measures that best fit that clinician or practice.
By using the TCPi program, clinicians will learn how to achieve benchmark status, have the opportunity to create positive change for patients, and influence future healthcare changes. Joining a PTN ensures a direct link to CMS and will support clinician development of the core competencies needed to thrive under the MIPS reimbursement model and practice transformation.
Participants in a PTN can also access Support and Alignment Networks (SANs) at no cost. SANs support workforce development through professional organizations, educational materials, and continuing medical education. SANs use evidence-based resources and tools to aid in rapid cycle transformation in the clinic setting.
The TCP initiative is recognized as a high-weighted activity under the CPIA. For some practices, TCPi will be the only initiative they will need to attest to. The program is designed to support clinicians at all levels of transformation so they can thrive in this new era of health care and stay abreast of the legislative changes.
Practices or providers who are interested in joining a PTN can find a list of PTNs in their state on the CMS website (https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices).
Clinicians who are participating in an accountable care organization can receive assistance and support through one of the 14 Quality Innovation Networks-Quality Improvement Organizations (http://qioprogram.org/contact-zones?map=qin). Additional information on the QPP is available at https://qpp.cms.gov/
The authors wish to thank the members of the AAOS Health Care Systems Committee for contributing to this article.
Melissa Kapping, MSN, RN, is Project Director-Compass PTN of the Iowa Healthcare Collaborative. Craig R. Mahoney, MD, is a member of the Board of Councilors Committee on Economic Issues.