What is QPP?
Overview of the Quality Payment Program (QPP)
Simply put, the Quality Payment Program is the United States Department of Health & Human Services’ (HHS) take on further
transitioning the healthcare industry from fee-for-service to value-based care.
On October 14, 2016, HHS issued its final rule with comment period implementing the Quality Payment Program (QPP) that is
part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Quality Payment Program improves Medicare
by helping you focus on care quality and the one thing that matters most — making patients healthier. MACRA ended the
Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for
13 years. The Quality Payment Program’s purpose is to provide new tools and resources to help you give your patients the
best possible, highest-value care.
The Quality Payment Program policy will reform Medicare payments for more than 600,000 clinicians across the country,
and is a major step in improving care across the entire health care delivery system. You can choose how you want to
participate in the Quality Payment Program based on your practice size, specialty, location, or patient population.
The Quality Payment Program is focused on moving the payment system to reward high-value, patient centered care. To be
successful in the long run, the Quality Payment Program must account for diversity in care delivery, giving clinicians
options that work for them and their patients. The Centers for Medicare and Medicaid Services (CMS) expects the Quality
Payment Program to evolve over multiple years and therefore, finalizes the rule with an additional 60-day comment period
to continue to solicit input from clinicians, patients, and others.
Who is in the Quality Payment Program?
You are eligible to participate in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment
Program if you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year, and you
are one of the following:
If 2017 is your first year participating in Medicare, then you are not required to participate in the Quality Payment Program in 2017.
When does the Quality Payment Program start?
If you’re ready, you can begin January 1, 2017 and start collecting your performance data. If you’re not ready on January 1,
you can choose to start anytime between January 1 and October 2, 2017.
Whenever you choose to start, you’ll need to send in your performance data by March 31, 2018.
The first payment adjustments based on performance go into effect on January 1, 2019.
How will the Quality Payment Program change my Medicare payments?
Depending on the track of the Quality Payment Program you choose and the data you submit by March 31, 2018, your 2019
Medicare payments will be adjusted up, down, or not at all. The information provided below is only relevant for the
2019 payment year. CMS will provide additional information on payment adjustments for 2020 and beyond beginning in 2018.
Test participation: Either 1 quality measure or 1 improvement activity or 4 or 5 required
advancing care information measures.
Note: Improvement activities and advancing care information measures are different from quality measures.
Groups using the web interface: Report 15 quality measures for a full year.
High-priority measure: Outcome measure, appropriate use measure, patient experience, patient
safety, efficiency measures, or care coordination.
For a list of high-priority measures, see files in MIPS Measures
Specialty-specific measure set: Not all measures in each specialty measure set will be applicable
to all clinicians in a given specialty. If the set includes fewer than six applicable measures, the eligible
clinician should only report the measures that are applicable.
For a list of measures for each specialty-specific measure set, see files in MIPS Measures
What is an Advanced Alternative Payment Model (APM)?
An Alternative Payment Model (APM) is a payment approach, developed in partnership with the clinician community,
that provides added incentives to clinicians to provide high-quality and cost-efficient care. APMs can apply to a
specific clinical condition, a care episode, or a population.
Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to patients’ outcomes.
You may earn a 5% Medicare incentive payment during 2019 through 2024 and be exempt from MIPS reporting requirements
and payment adjustments if you have sufficient participation in an Advanced APM. Earning an incentive payment in one
year does not guarantee receiving the incentive payment in future years.
Advanced APMs must meet the following requirements:
Be CMS Innovation Center models, Shared Savings Program tracks, or certain federal demonstration programs
Require participants to use certified EHR technology
Base payments for services on quality measures comparable to those in MIPS
Be a Medical Home Model expanded under Innovation Center authority or require participants to bear more than
nominal financial risk for losses. The final rule with comment period defined the risk requirement for an
Advanced APM to be in terms of either total Medicare expenditures or participating organizations’ Medicare
revenue (which may vary significantly). This enhanced flexibility allows for the creation of more Advanced
APMs tailored to physicians and other clinicians, such as advanced practice nurses, generally, and small
practice participation in particular.
In order to qualify for the 5% APM incentive payment for participating in an Advanced APM during a payment year,
you must receive a certain percentage of payments for covered professional services or see a certain percentage of
patients through the Advanced APM during the associated performance year.
For performance years 2017 and 2018, the participation requirements only apply to Medicare payments and patients.
Starting in performance year 2019, clinicians may also meet an alternative standard for Advanced APMs that will
include non-Medicare payments and patients.
What is the Merit-Based Incentive Payment System (MIPS)?
If you decide to participate in traditional Medicare, rather than an Advanced APM, then you will participate in MIPS
where you earn a performance-based payment adjustment to your Medicare payment. CMS estimates approximately 500,000
clinicians will be eligible to participate in MIPS in the first year of the program.
In MIPS, you earn a payment adjustment based on evidence-based and practice-specific quality data. Based on your
performance in 2017, you will see a positive, neutral, or negative adjustment of up to 4% to your Medicare payments
for covered professional services furnished in 2019. This adjustment percentage grows to a potential of 9% in 2022
and beyond. In addition, during the first six payment years of the program (2019-2024), MACRA allows for up to $500
million each year in additional positive adjustments for exceptional performance. In total, MACRA provides for up to
$3 billion in additional positive adjustments to successful clinicians over six years.
QPP replaced three Medicare reporting programs with MIPS (Medicare Meaningful Use, the Physician Quality Reporting
System, and the Value-Based Payment Modifier). Under the combination of the previous programs, you would have faced
a negative payment adjustment as high as 9% total in 2019, but the MACRA ended those programs, reduced the potential
negative payment adjustments in the early years, and streamlined the overall requirements. While these three programs
will end in 2018, if you have participated in these programs in the past, then you will have an advantage in MIPS
because many of the requirements should be familiar.
MIPS focuses on four categories of clinical care, assigning providers a composite score based on performance across
all four categories that serve as a modifier on their Medicare Part B reimbursements. However, the cost category
will not be assessed in 2017.
Quality (replaces PQRS)
Improvement Activities (a new measure of care coordination)
Advancing care information (replaces Meaningful Use)
Cost* (replaces Value-Based Modifier)
* The cost category will be calculated in 2017, but will not be used to determine your payment adjustment.
In 2018, the cost category will be used in your composite score.
For more information on the Quality Payment Program from CMS, click here.