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Explaining Medicare’s Quality Payment Program For 2018

June 27, 2018 | Medicare Enrollment

As the payment model for healthcare services moves from a fee for service to a fee for value model, the Centers for Medicare and Medicaid Services (CMS) has rolled out a number of new metrics and tools to help track patient care for healthcare services providers.

Fee For Service vs. Value Added Model

A key incentive CMS has unveiled recently is the Merit-based Payment System (MIPS) that pays providers a more positive reimbursement rate based on measurable patient outcomes. To bring this vision to reality, the CMS also built the necessary tools to track key patient data that measures these quality outcomes by developing the Quality Payment Program (QPP).

To participate in the QPP, a healthcare provider must bill Medicare more than $30,000 per year with care provided to more than 100 Medicare patients per year. In addition, a person must either be a physician, a physician assistant, a nurse practitioner, a clinical nurse specialist or a certified registered nurse or nurse anesthetist.

The purpose of this overhaul of the reimbursement program is to help incentivize healthcare practitioners based on four key factors. These include the quality of care, the use of resources, clinical practice improvement activities and the meaningful use of certified electronic health record(HER) technology. Overall, MIPS will use the existing quality measures set by previous programs including the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM) and the Medicare HER Incentive Program for Eligible Professionals. Ultimately, the payment adjustments previously awarded under those programs will be phased out by the end of 2018 and replaced with the incentives outlined in the new MIPS beginning January 1, 2019.

The process to receive these positive payment adjustments requires a practitioner join the Advanced APM after meeting the above criteria then send in data about the care provided throughout the year and submit this data by a deadline of March 31, 2018 for care provided in 2017. Sending in this quality data through the Advanced APM can earn an additional five percent inventive payment. After Medicare gives feedback about the performance based on the data, the practitioner can earn a positive MIPS payment adjustment for 2019 if the data for 2017 was submitted by the deadline.

This quality incentive plan adjustments begin at four percent in 2019 and goes up gradually to nine percent in 2022, so this rewards healthcare practitioners for giving their patients high quality care over a period of time.

Entering all the necessary data to qualify for these incentive payments can be a daunting task. Given the move to electronic medical records, ensuring the data is entered and also protected under HIPAA privacy requirements can present a challenge.

Therefore, CMS launched an Advanced Program Interface (API) last month that allows developers to create interfaces for healthcare practitioners where they can more easily enter patient records in a secure manner to be reimbursed.

Kate Goodrich, MD and director of the CMS Centers for Clinical Standards and Quality cited that this new tool was based on the user experience. She also reiterated that the CMS remains committed to making this process easier while supporting efforts to improve quality care across the country.

The new API is publicly available here.

The American College of Physicians came out with a supportive statement of the new CMS API championing the CMS for designing and sharing an accessible interface that helps simplify the process for physician participation in the Quality Payment Program.

“These efforts are aligned with ACP’s ongoing efforts to help equip physicians with tools and support needed to transform from volume-based, to value-based, patient-centered care,” said the American College of Physicians President Nitin S. Damle.

The CMS also recognizes that paying for the necessary technology to participate in the QPP can be overwhelming for small practices that may only have a single physician. Therefore, the Department of Health and Human Services has made $100 million available to help small practices prepare for QPP. This funding will support training and education for Medicare clinicians in practices with 15 clinicians or fewer – specifically targeting rural communities and historically under resourced areas.

In a statement issued, the HHS shed light on the Department’s intentions with this funding.

“Providing these tools to help physicians and other clinicians in small practices navigate new programs is key to making sure they are able to focus on what is most important: the needs of their patients,” said B. Vindell Washington, principal deputy national coordinator of the Department of Health Office of the National Coordinator for Health Information Technology.

The CMS hopes that as the program grows, the possibility of being rewarded for providing better care also grows. With the new API tool, the burden of entering the necessary data to make this possible should be greatly alleviated, so caregivers can spend more time with patients and care for them in the way the practitioner feels will give them the best possible healthcare outcome.