What the Quality Payment Program Means for Your Clinic

A Brief History of The QPP and Why it Was Created

   Prior to the Quality Payment Program (QPP), payment increases for Medicare services were set by the Sustainable Growth Rate (SGR) law. SGR put a cap on spending increases in relation to growth in the Medicare population, as well as some allowance for inflation.

Over time, utilization of services increased for clinicians and the reimbursement for each unit of service had to be adjusted downward to hold costs constant. This would have resulted in an unsustainable substantial decrease in the Physician Fee Schedule if SGR went into practice as is. To remedy this, Congress must pass a new law every year to authorize the current fee schedule and to adjust for inflation.

The Centers for Medicare & Medicaid Services (CMS) eliminated SGR with the Medicare Access and Chip Reauthorization Act of 2015 (MACRA). This allows a reduction in payments to clinicians who do not meet performance standards, as well as rewarding high value, high-quality Medicare clinicians with pay increases.

The overall goal of CMS is to improve Medicare so that clinicians spend less time filling out paperwork and more time focusing on caring for their patients. Over time, CMS will improve by listening and changing to help reduce burdens for clinicians and to bring better health outcomes for Medicare patients.

A Broad Overview of the QPP and How it Affects You

   First, let us look at an overview of the Quality Payment Program. This program, authorized by the Medicare Access and Chip Reauthorization Act or MACRA, went into effect in 2015. MACRA authorized the Quality Payment Program to allow clinicians to choose from two different tracks on how they want to participate based on their practice size, specialty, location, or patient population. The two available tracks are the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs).

The bedrock of success for the Quality Payment Program is built upon three core elements:

1. Improve Patient Outcomes
2. Meaningful Feedback
3. Evolution through Continuous Improvements

The core elements are realized with these strategic goals:

• Improve Beneficiary Outcomes
• Enhance Clinician Experience
• Increase Adoption of Advanced APMs
• Maximize Participation
• Improve Data and Information Sharing
• Ensure Operational Excellence in Program Implementation

By meeting these criteria, clinicians have a greater incentive to receive higher pay through Medicare. Asking how this may tie into a chronic care management program or (CCM) is a step in the right direction. By implementing a chronic care management program in an office, any practice can virtually meet all the criteria for a MIPs payment incentive. The performance categories measured are care quality, promoting interoperability, improvement activities, and cost.

Let’s take a closer look at the two ways a clinic or practice can participate in the Quality Payment Program in order to identify the best system for them. The Merit-based Incentive Payment System combines three legacy programs into a single, improved reporting program. The three programs being phased out are the Physician Quality Reporting System (PQRS), Positions Value Modifier (VM), and the Medicare EHR Incentive Program for Eligible Professionals. Note that The Medicare EHR Incentive Program for Eligible Hospitals and the Medicaid EHR Incentive Program for Eligible Professionals will continue and will not change. The last performance period was in 2016, and the previous payments issued under these legacy programs happened in 2018 with adjustments occurring in 2019.

The four MIPS performance categories are:

• Quality
• Cost
• Improvement Activities
• Advancing Care Information.

A clinician’s performance will be measured under these four categories and will get a final score. For a deeper dive into the specifics of the Merit-based Incentive Payment System make sure to signup for our newsletter to get the latest information on MIPS and everything related to Chronic Care Management. More information about this topic will be sent directly to you.

The second track under the Quality Payment Program is APM, or the Advanced Alternative Payment Models, which bring several new approaches to paying for medical care through Medicare that incentivizes quality and value. Through the Affordable Care Act and other legislation, Congress has defined many demonstrations that CMS conducts. With that said, an APM could include the CMS Innovation Center model, MSSP (Medicare Shared Savings Program), Demonstration under the Health Care Quality Demonstration Program, and Demonstration required by federal law. The next step up from these systems are the Advanced APMs, where greater rewards are available for any practice at the cost of taking on some additional risk. Three perks for participating in an Advanced APM are exclusion from MIPS reporting, receiving a 5% lump sum bonus, and receiving a higher Physician Fee Schedule update starting in 2026. If APMs and Advanced APMs are something your practice could benefit from, be sure to sign up for our email to get information and solutions sent straight to your inbox.

How Our CCM Program Solves These Problems

    Our CCM program helps to implement MIPs by meeting the four criteria set by CMS through these means:

• We integrate the quality measures that CMS has set for their quality standard in MIPs.
• We discuss and implement those measures into our monthly content during our calls.
• We help you build upon your improvement activities by enhancing patient engagement in care and increasing patient access to care.
• We help you meet the cost performance category by decreasing the number of hospital stays and cost associated with those stays.
• Our CCM program helps promote interoperability by helping the patients follow up on visits with other doctors as well as ensuring that they are scheduling their yearly exams.
• We also help doctors create a care plan for each patient and update those accordingly.
• We also make the doctor aware of any changes that might be occurring in the patients’ health, to ensure their current plans are continuously meeting those needs.
• Our CCM program also helps you stay compliant by enhancing improvement activities due to the regularity of calls with the patient. This builds a relationship of trust so they are more prone to share issues they may be having. For example, patients may share information about their mental health with our nurses that their doctor did not know beforehand. This gives you the ability to learn more information about your patients in order to give them better care, which results in happier patients.

    In conclusion, a Chronic Care Management program can provide all the measures you need in order to help you meet your MIPs criteria. It can change the way your practice is implemented in the daily lives of your patients and give you the opportunity to better meet the needs of your patients. Give us a call and let us implement these measures for you through our Chronic Care Management program.