Health Information Management

News: CMS' Proposed physician payment model consolidates, customizes quality initiatives

CDI Strategies, May 5, 2016

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Just as government healthcare reimbursement methods continue to evolve on the inpatient side, physicians also now face challenging healthcare reform initiatives for their own services. 

This week’s release of the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM) proposed rule outlines CMS’ specific plans for physician payments, pushing forward with its goal to increase value-based payments and unifying its varied quality, value, and EHR programs.
MIPS will be measured across four performance categories that each contribute a different percent to a provider’s overall score. Based on that score, CMS will calculate positive, negative, or neutral adjustments to Medicare payments.
In order to maintain budget neutrality, positive and negative adjustments will not exceed 4% in the first year, with additional bonuses granted to the highest performers. That number will continue to rise and reach 9% for 2022 and subsequent years.
The four proposed MIPS performance categories, in order of percent toward the total score in year one, are:
  • Quality
  • Advancing care information
  • Clinical practice improvement activities
  • Cost
The quality category would account for 50% of the total score and replace the Physician Quality Reporting System (PQRS) and the quality component of the Value Modifier Program. CMS proposes providers would choose to report six quality measures, with different options based on differences in specialty and practice. 
Advancing care information, which would account for 25% of the total score, is CMS’ replacement for the Medicare EHR Incentive Program and would spell the end of meaningful use reporting. The new program would remove the all-or-nothing measurements of previous EHR programs and focus on interoperability and information exchange.
Clinical practice improvement activities would make up 15% of the total score and reward providers for care coordination, beneficiary engagement, and patient safety. CMS proposes more than 90 options providers can choose from that match their specific practices’ goals. Participation in alternative payment models (APMs) will also add to providers’ scores in this category.
The cost would make up the final 10% of the total score and replace the cost component of the Value Modifier Program. It would require no additional reporting requirements for providers, relying instead on Medicare claims’ data. The category would include more than 40 episode-specific measures to account for differences among specialties.
CMS proposes evaluating performance for these measures beginning in January 2017 and basing payments off measures in 2019.
CMS also proposes that providers who participate in advanced APMs to be exempt from MIPS and also qualify for a 5% Part B incentive payment.
The MIPS exemption would be based on the volume of patients or payments received through advanced APMs, with the requirements increasing over time. For example, in 2019, providers would need to receive at least 25% of payments or see 20% of patients through an Advanced APM to qualify. In 2023 and beyond, those numbers would be 75% or 50%, respectively.
Examples of models that would qualify under the program include:
  • Comprehensive ESRD Care Model
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
CMS would review this list annually to include new models that would allow providers to bypass MIPS and qualify for the incentive payments. In the first year of availability, however, CMS would require all providers to report through MIPS.
For more information, see the rule and CMS’ associated fact sheet. CMS will accept comments on its proposals through June 27.


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