November 15, 2016
Quality-Based Payments in 2017: Four Ways to Join In

In the new year, there will be four ways to join in the Quality Payment Program. The Department of Health and Human Services (HHS), in conjunction with the Centers for Medicare and Medicaid Services (CMS), recently expanded value-based payments into an all-encompassing program that incorporates the alternative payment programs already in place with reformed reporting requirements and reimbursement assessment standards. A wider variety of healthcare providers will be able to get on board, with greater flexibility in adjusting and integrating this new system of Medicare payments.

Getting on board

Individuals and provider groups that want to join will be required to collect and report data for performance measures set by HHS and CMS. Participation in the program can start any time between January 1 and October 1, 2017, and performance data must be submitted to CMS by March 31, 2018, after which the data are assessed and adjusted to yield either upward, downward or neutral reimbursements, beginning in 2019.

Depending on how soon — and to what degree — you want to join, HHS and CMS have provided four routes, in an effort to ease the transition and help practices with the uptake of big changes by letting them decide the pace that fits them best.

1. Test the Quality Payment Program

Practices not ready to dive into the deep end just yet can choose to submit a minimum dataset for 2017. They’ll need to address at least one quality measure or define one activity that they use to improve their healthcare standards. This lets smaller practices (medical groups with fewer than 15 providers) or medical practices in rural, sparsely populated or socioeconomically-disadvantaged areas, to first test the waters — and then gradually develop the means, the resources, and the training to ultimately use this quality reporting system at a similar level to that of larger practices. Participating in this option avoids the negative payment adjustment that comes with not submitting any data at all.

2. Partial participation for part of the calendar year

Similar to the first option, healthcare providers also have the choice to submit partial performance data, but here, the option accounts for only 90 days within the 2017 year. This can result in either neutral financial standing (in other words, no negative penalties) or a small positive adjustment in payment. This option is designed for providers joining later in the eligibility period, so that they don’t miss out on the potential benefits of participation.

3. Full participation for the entire year

Participants that are already equipped with adequate resources and man-power, training, and familiarity with the methods of quality reporting, can submit a full year’s worth of performance data in order to receive a moderate positive payment adjustment.

These three routes are known as merit-based inventive payment systems (MIPS), which are lower-risk and, accordingly, present lower potential benefits. The fourth is advanced alternative payment models (APMs), which are higher risk and higher reward. Due to the difference in risk between the two models, CMS expects that most physicians will choose MIPS and, eventually, migrate towards APMs.

4. Participate in an Advanced Alternative Payment Model in 2017

Structured much like Accountable Care Organizations (ACOs) and bundled payment initiatives, APMs encourage teams of health professionals to provide coordinated care to improve patients’ health, and to form networks that improve quality and reduce spending. In order to join using this option, a provider or group must meet the following criteria:

  • Already be a part of a CMS payment model such as the Shared Savings Program or an ACO
  • Use certified EHR technology
  • Use the same quality measures as in the MIPS to structure payments for services
  • Be a Medical Home Model that is expanded by the CMS Innovation Center, or take on more than just nominal financial risk for losses by absorbing total Medicare expenses or the Medicare revenue from participating organizations.

Healthcare providers are encouraged to join Advanced APMs if they receive 25% of Medicare payments or see 20% of their Medicare patients via an Advanced APM. As an incentive to join, there is a 5% positive payment adjustment.

For more detailed information on the Quality Payment Program, HHS and CMS have launched a website that can help answer your questions and introduce you to the various performance measures you can choose to report.