Evolving Payer Models: CMS Quality Payment Program

What is the Quality Payment Program?

In April 2015, Congress repealed the SGR (sustainable growth rate) formula that determined Medicare physician fees, replacing it with legislation called MACRA (Medicare Access and CHIP Reauthorization Act of 2015).

This landmark bipartisan legislation advances a forward-looking, coordinated framework for healthcare providers to successfully take part in the CMS Quality Payment Program (QPP) that rewards value and outcomes in one of two ways:

  • Alternative Payment Model (APM)
  • The Merit-Based Incentive Payment System (MIPS)

Who is in the Quality Payment Program?


Find our MACRA Readiness Assessment and more detailed information on MIPS categories for payment adjustments at Provider Resources.

The QPP 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 healthcare delivery system.

You can choose how you want to participate in the QPP based on your practice size, specialty, location or patient population. You’re a part of the QPP if you bill Medicare more than $30,000 a year AND provide care for more than 100 Medicare patients a year AND are a:

  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetist

APM | Alternative Payment Models

A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care. CMS is constantly developing new payment and service delivery models to encourage this mindset. One of those models is the Medicare Shared Savings Program (MSSP).

aAPM | Advanced Alternative Payment Models

For the 2017 performance year, you may qualify as an aAPM if you meet all 3 requirements below:
  • Use a certified Electronic Health Record (EHR)
  • Currently report quality measures comparable to those used in MIPS
  • You are in a medical home model OR bear more than a nominal amount of financial risk
For the 2017 performance year, the following models are Advanced APMs:
  • Comprehensive End-State Renal Diesease Care Model (Two-Sided Risk Arrangements)
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program Track 2
  • Shared Saviings Program Track 3
  • Oncology Care Model (Two-Sided Risk Arrangement)
Additional aAPM models for 2018:
  • ACO Track 1+ (*Our ACO model.)
  • New Voluntary Bundled Paymnet Model
  • Comprehensive Care for Joint Replacement Payment Model
  • Advancing Care Coordination through Episode Payment Models Track 1

MIPS Merit-Based Incentive Payment System

In MIPS, you can earn a payment adjustment based on evidence-based and practice-specific quality data. MIPS is the category that will apply to most physicians:

  • Moves Medicare Part B clinicians to a performance-based payment system
  • Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice
  • Reporting standards align with Advanced APMs wherever possible

Key Takeaway

Positive adjustments are based on the performance data of the performance information submitted, not the amount of information or length-of-time submitted. You can submit 90 days of information with great quality and receive a higher percentage than someone who submitted all year with acceptable quality.

Potential Financial Rewards

Although MACRA creates separate paths for payments under the Medicare Physician Fee Schedule (PFS), these paths are in addition to, not in replacement of, the PFS.

MACRA replaced SGR with a schedule that will increase baseline Medicare Part B payments by 0.5% per year until 2019. The first payment adjustments will be based on performance year 2017 and will reflect in your 2019 Medicare payments.

If you participate in an Advanced APM, you will receive a + payment adjustment of 5% every year, beginning in 2019. 

PQRS Payment Reminder: PQRS will be referred to as a “legacy program.” The last performance year of this program was 2016. If you participated this last year, your payment adjustment will take place in 2018. As a reminder, this is not associated with your 2018 MIPS performance.

How to Prepare for QPP

Conduct a general practice assessment to determine how prepared your practice is for this change.
  • Is your EMR updated? Ask your EMR vendor about MACRA additions.
  • Are you attesting for Meaningful Use? Stage 2 has the same measures that are in the ACI category.
  •  Have you reported PQRS measures? If not, make sure your EMR is updated for reporting purposes.
  •  Have you achieved NCQA Certification? NCQA-certified physicians already report on measures that overlap with MIPS.
  •  If you submitted quality data during the last calendar year, you should have access to your Quality and Resource Use Report (QRUR). This report will help you understand your performance in terms of cost and quality so you can prioritize potential areas for improvement.
  •  The first performance period begins on January 1, 2017 and closes December 31, 2017. You can choose to start anytime between January 1 and October 2, 2017.
  • No matter when you choose to report, it must be submitted by March 31, 2018.

MACRA Support

For more information please contact your UC San Diego Health Physician Network representative.