Medicare’s Quality Payment Program: Getting Paid for Value Instead of Volume

by  ChiroCode
December 28th, 2016

The government has become increasingly concerned with how they spend money in the healthcare sector. As part of the latest proposal to fix this, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015. This law changes reimbursement to remunerate providers more when they provide high quality care rather than just more care. It rewards value over volume. It also ends the flawed Sustainable Growth Rate (SGR) formula that had been in use to determine Medicare payment for many years. And, it combines three other quality-based programs into one. It’s biggest and lasting impact may be how it influences the way that patients select the provider they choose to see.

Regardless, many providers do not have to participate in this new program in 2017. If you are in your first year of practice, or you don’t see over 100 Medicare (CMS) beneficiaries in 2017 OR you bill Medicare less than $30,000 in allowed charges, participation is optional. However, this model is the beginning of a whole new way to get paid for healthcare and not only does Medicare have plans to expand it, but private payers are likely to follow someday.

Even if you choose not to participate in 2017 because you don’t have to, you need to know what the future holds. There are three more reasons why you should consider participating in this value-based payment model:

In October of 2016, CMS released the final rule for implementing the Quality Payment Program (QPP) as mandated by MACRA. The rule is over 2400 pages. Half of that is responses to comments on the proposed rule that came out six months earlier. Fortunately, CMS has been very sensitive to feedback on the proposed rule. They have reduced the criteria and extended the timeline to make it easier for providers to get in line.

The Quality Payment Program offers two tracks to providers: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Advanced APMs require 25% of payments to come from CMS or 20% of patients to be seen through an Advanced APM in 2017.

These entities take on some risk related to patient outcomes and CMS estimates that around 100,000 clinicians will qualify the first year.

MIPs is sort of a gateway program into this model. Advanced APMs will likely not apply to most chiropractors. Around 500,000 providers will participate in MIPS in 2017 where clinicians can earn a performance based payment adjustment to Medicare reimbursements. It will be focused on evidence-based and practice-specific quality data and depends on how much data is submitted and the performance score (see Figure 1).

If you are eligible, but choose not to participate in 2017, you will receive a 4% negative adjustment in 2019. If you submit one measure, you can avoid a downward payment adjustment. If you submit for 90 days during 2017, you may earn a neutral or small positive adjustment. And, if you think you have this thing figured out and you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment (see Figure 2).

The penalty and reward increases each year to a current maximum of 9% in 2022 (see Figure 3). You have until March 31, 2018 to submit your data, but most small practices will likely submit via their EHRs or on claims, so data should be provided to CMS as care is delivered.

You can participate as an individual if you have a single NPI tied to a single tax ID, or as a group if you share a common tax ID with other providers. Some parts of MIPS are reported via your certified EHR if you have one. Other categories of MIPS may be reported via claim forms, or a certified registry.

MIPS is divided up into four categories, and combined into a composite performance score, which will be made publicly available to help beneficiaries make informed decisions.

The categories are as follows: 

What now? 

If you are not required to report on MIPS because you are too small, don’t worry about it. But, it might be a good idea to at least consider reporting Quality Measures (formerly PQRS) as you always have. Minimal reporting will cancel out the possibility of a negative adjustment. In fact, take the time to learn a little more and report the Improvement Activities and Advancing Care Information for 90 days in 2017 as well. It might earn you a little bonus in 2019. You can start as late as October 2, 2017.

Check out your status at There you can access your Quality Resource Utilization Report (QRUR). It will identify cost performance, quality performance, specialty adjusted benchmarks, PQRS/MIPS measure performance, and episode costs for a given tax ID number.

Essentially your QRUR can tell you how you would be scored if MIPS were enacted today. Some of the data from this report will go onto Medicare’s Physician Compare web site so that potential patients can see how you compare to your peers. Think of it as the Consumer Reports, or Yelp! of healthcare.

Our healthcare system is in need of an overhaul. It is hoped that the Quality Payment Program will address some of the problems and change provider behavior for the better. Medicare has promised to be flexible and listen to feedback. They expect the program to adapt in the future. But they also realize that there are only a few ways to change clinician behavior - pay them more, improve their satisfaction and help them avoid public humiliation (like poor quality scores posted on a public website). MIPS pays them more, consolidates multiple other government programs, and provides flexibility to give clinicians every opportunity to make their quality scores look good.

Medicare’s Quality Payment Program: Getting Paid for Value Instead of Volume. (2016, December 28). Find-A-Code Articles. Retrieved from

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