Quality Payment Program

Learn about Medicare’s Quality Payment Program (QPP) and see information on how Medicare is reimbursing rheumatologists and other providers for services. See definition of common QPP terms in the glossary.

Quality Payment Program Tracks

The Quality Payment Program (QPP) has three tracks to choose from which allow you to participate based on your practice size, specialty, location, or patient population: MIPS, APMs, and MVPs.

Merit-Based Incentive Payment System (MIPS)

  • MIPS changes how Medicare links performance to payment.
  • MIPS consolidates three current programs: the EHR Incentive Programs/Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value Based Modifier (VBM) into one quality program.
  • MIPS will evaluate four performance categories: Quality, Resource Use, Clinical Practice-Improvement Categories and Advancing Care Information (MU) . An eligible professional’s (EP) performance score will be used to determine if an EP receives a positive, negative or zero payment adjustment.
  • For physicians who select the MIPS track, a methodology will be used to assess their total performance for Medicare beneficiaries and each MIPS eligible physician will receive a composite quality score for each performance period.

Note: Details on MIPS will be the subject of policymaking for several years, but it is important to understand that some of the assessments made at the effective date of 2019 will be based upon 2017 data.

MIPS composite score

MIPS adjustment to provider base rate

Alternate Payment Models (APMs)

  • MACRA promotes the development of an eligible professional’s participation in Alternate Payment Models (APMs), which create a payment incentive program for qualifying participants.
  • From 2019 through 2024, qualifying APM participants will receive a lump sum incentive payment equal to five percent of the prior year’s estimated aggregate expenditures under the fee schedule. Qualifying APM participants will not be subject to MIPS adjustments
  • Eligible APMs are the most advanced APMs that meet the following criteria according to the MACRA law: Accountable Care Organizations, Patient Centered Medical Homes and bundled payment models.
  • Base payment on quality measures will be comparable to those in MIPS.

MIPS Value Pathways (MVPs)

Information about MIPS value pathways coming soon.


MACRA Frequently Asked Questions

Find answers to frequently asked questions about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

How does MACRA impact my Medicare payments?

This law repeals the Medicare sustainable growth rate (SGR) formula that was used to determine Medicare payments for health care providers’ services. MACRA establishes an alternative set of predictable annual baseline payment updates and two payment pathways: the Merit-Based Incentive Payment System (MIPS) path and the Alternative Payment Model (APM) path.

The following is a timeline for MACRA implementation:

  • 2016 through 2019 - Medicare physician payments increase by 0.5 percent annually
  • January 1, 2017 - This is the date that data about your practice will start counting for Medicare reimbursement in 2019
  • January 2019 - Based on eligibility, physicians choose either the MIPS path or the APM path
  • 2020 through 2025 - annual baseline Medicare physician fee-for-service payments remain at 2019 levels with zero updates

Details on both MIPS and APMs will be the subject of policymaking for several years and the ACR will keep the membership informed.

What can I do now to prepare for MACRA implementation?

The ACR is committed to providing its members with resources and support to steer through the complication of MACRA.

  • Choose a payment pathway. Almost without exception, everyone in the United States will be forced into one of two tracks: MIPS or APM. The ACR is highly engaged in working to influence the rules that define APMs and MIPS so that they make the most sense for rheumatologists and the medicine you practice and we will keep you informed as the details unfold.
  • Join RISE. Rheumatology Informatics System for Effectiveness (RISE) is a Qualified Clinical Data Registry (QCDR), created and administered by the ACR. RISE represents a vital tool for survival in the pathway called MIPS.

What is the Merit-Based Incentive Payment System (MIPS)?

The Merit-Based Incentive Payment System is a new program in the Medicare fee-for-service payment system. It consolidates three existing programs—meaningful use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBPM)—into a single program.

The MIPS will assess individual physician performance in four categories to generate a composite score on a 0- to 100-point scale. The categories are:

  1. Quality (50% of total adjustment in 2019 shrinking to 30% of total adjustment in 2021)
  2. Resource use (10% of total adjustment in 2019 growing to 30% of total adjustment by 2021)
  3. Clinical practice-improvement activities (15% of total adjustment)
  4. Advancing care information (MU) (25% of total adjustment)

How will MIPS adjust my payments?

Beginning in 2019, physicians participating in the MIPS will be eligible for positive, negative or neutral Medicare payment adjustments that start at 4 percent and gradually increase to 9 percent for 2022. The threshold for these payment adjustments will be the mean composite score for all MIPS-eligible professionals during the previous performance period.

Participation in an APM can help with composite score for a MIPS professional

Positive Adjustments
Physicians whose composite score is at the threshold (i.e., earn the mean composite score) will not receive a MIPS payment adjustment.

Zero Adjustments
Physicians whose composite scores are above the threshold will receive positive payment adjustments on each claim for the following year.

Negative Adjustments
Physicians whose composite scores are below the threshold will receive negative payment adjustments on each claim for the following year.

Physicians with high composite scores will be eligible for a positive payment adjustment that is up to three times the baseline positive payment adjustment for a given year. For example, the baseline positive payment adjustment for 2019 will be 4 percent, so high performers will be eligible for a positive payment adjustment of up to 12 percent.

Beginning in 2026, all physicians participating in the MIPS will be eligible for a 0.25 percent increase in their payments each year.

What is an Alternative Payment Model?

MACRA defines any of the following as an alternative payment model:

  • An innovative payment model expanded under the Center for Medicare & Medicaid Innovation(CMMI) under section 1115A (other than Health Care Innovation Award)
  • Medicare Shared Savings Program (MSSP)
  • A demonstration under the Health Care Quality Demonstration Program
  • A demonstration program required by federal law

Does MACRA specify additional qualifying criteria for APMs?

Yes. An APM must require participants to meet all of the following criteria:

  • Uses quality measures comparable to measures under the MIPS
  • Uses certified electronic health record (EHR) technology
  • Bears more than nominal financial risk OR is a designated patient-centered medical home
  • APM must comprise increasing/significant share of provider revenue or patients

How would I be paid under an APM?

Eligible physicians who choose to participate in a qualifying APM will receive a 5 percent lump-sum bonus on their Medicare payments for 2019 through 2024. Beginning in 2026, all physicians participating in qualified APMs will be eligible for a 0.75 percent increase in their payments each year.

How can RISE help me navigate MACRA?

Registry use counts in all domains of MIPS, including practice improvement, quality improvement, and EHR use. RISE contains a number of important features, including:

  • The ability to seamlessly report practice data under the quality component of MIPS
  • Minimal impact on provider workflow; duplicate entry
  • An interactive dashboard that gives access to practice trend data and identifies potential areas for improvement

Participation in a registry like RISE, a Qualified Clinical Data Registry (QCDR), will positively impact scores in clinical practice improvement activities under MIPS. Contact RISE@rheumatology.org to learn how to sign up for free.

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