Changes to Medicare’s Quality Payment Program

Providers will soon see changes to Medicare’s Quality Payment Program, which will have impacts on their payment for many years to come. Learn more about the specifics below.
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In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) changed the reimbursement structure for clinicians treating Medicare patients. The program, known as the Quality Payment Program (QPP) initially created two paths for providers to be paid by the federal government – Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Overall, the goal of the QPP is to create a framework allowing Medicare to pay providers based on performance, not on services rendered. Every year new Final Rules are released, which govern the QPP for the coming fiscal year.

Significant changes ahead

Accordingly, change is coming soon to the QPP, affecting clinicians and healthcare organizations participating in the MIPS program in 2022. These changes are multifaceted and driven by statutory requirements in MACRA – the CMS initiative to streamline program requirements proposed in 2019 for the MIPS Value Pathways (MVPs) framework – and the latest iteration of CMS’ quality measure strategic plan, the March 2021 CMS Quality Measurement Action Plan.

While clinicians are probably aware of proposals in the 2022 Physician Fee Schedule (PFS) that have direct impact on reimbursement – such as adjusted performance thresholds; category reweighting; and fundamental change to measures – these proposals are the harbinger of significant change in CMS’ flagship quality reporting program that will extend to 2025 and beyond.

MIPS to MIPS Value Pathways

In the FY 2020 PFS, CMS initially proposed a transition from MIPS to MVPs beginning with the 2020 reporting year. These proposals outlined goals for MVPs to provide a more streamlined and cohesive reporting experience, with measures organized around clinical specialty or health condition and aligned with reporting categories for quality, promoting interoperability, improvement activities and cost, and more consistency with the quality requirements for Alternative Payment Models (APMs). 

Responses to MVPs were mixed, with some respondents indicating that reporting would become overly complex, and others concerned that the interoperability requirements of the 21st Century Cures Act that would be critical to the success of MVPs would not be implemented prior to the 2020 reporting year. When CMS finalized the FY 2020 PFS in November, they indicated they would be moving forward with MVPs, but in a future program year. Faced with the COVID-19 public health emergency, CMS further delayed the implementation of MVPs in the FY 2021 PFS. However, CMS did include proposals in the FY 2022 PFS to transition to MVPs beginning in 2023, and the Final Rule should include more definitive information this fall.

CMS’ Quality Measurement Action Plan

CMS introduced the Quality Measure Action Plan at the March 2021 CMS Quality Conference, with goals to:

  • Implement Meaningful Measures that align quality measurement with clinical practice
  • Leverage measured results through transparent public reporting and payment programs
  • Engage and empower patients in quality measurement
  • Transition to digital measures and incorporate healthcare data analytics to drive quality improvement
  • Focus measures on health equity and gaps in care

CMS is soliciting input from stakeholders on this plan through Requests for Information on proposed MVPs and the transition to HL7 FHIR-based digital measurement by 2025. 

Interoperability in healthcare

Critical to the success of future CMS quality initiatives is to not only measure the quality of care, but to also utilize measures to improve quality – without making the process burdensome to clinicians and healthcare organizations. Systems and data must be interoperable between care environments and clinicians while also being capable of integrating input from the patient to achieve that goal. The solution lies in interoperability established by the 21st Century Cures Act, facilitating information exchange between systems and engaging and empowering patients in their care.

For more on how this legislation impacts payments in healthcare, download our white paper: The 21st Century Cures Act: A payer’s perspective.
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