Wednesday, June 21, 2017

Changes to 2018 Quality Payment Program aim to help participation

The Centers for Medicare & Medicaid Services (CMS) has proposed a series of changes in the second year of the Quality Payment Program (QPP) that attempts to address some of the complaints from physicians that the original rules make participation in QPP difficult. As a reminder, the Medicare Access and CHIP Reauthorization Act of 2015 created the QPP with two payment tracks:  the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Under MIPS, some of the proposed changes in 2018 include:
•    Offering a Virtual Groups participation option.
•    Increasing the low-volume threshold so that more small practices and eligible clinicians in rural and Health Professional Shortage Areas are exempt from MIPS participation.
•    Allowing physicians to continue using 2014 Edition Certified Electronic Health Record Technology (CEHRT).
•    Awarding bonus points in the scoring methodology to physicians who care for complex patients and only use 2015 Edition CEHRT.

For the APM track, some of the proposed changes include:
•    Extending for two performance years (to 2020) the revenue-based nominal amount standard, which CMS previously finalized through performance year 2018. This standard would allow an APM to qualify as an Advanced APM under the financial risk criterion if the group’s physicians bore total risk of at least 8 percent of their Medicare Parts A and B revenue.
•    Altering the nominal amount standard for Medical Home Models so that the minimum required amount of total risk increases more slowly.

Both the full rule and an abbreviated fact sheet are available. CMS is accepting comments on its proposals through Aug. 21.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, May 25, 2017

Deadline approaches to join new MACRA payment model

Next week is the deadline to notify Medicare if your practice intends to participate in a new payment model aimed at helping practices, particularly smaller ones, meet the Quality Payment Program requirements under MACRA.

The Centers for Medicare & Medicaid Services (CMS) created a new Advanced Alternative Payment Model in December called the Medicare Accountable Care Organization Track 1+. This model limits some of the downside risks that practices face in Track 2 and Track 3 under Medicare’s Shared Savings program as CMS tries to encourage more practices to participate in risk-sharing agreements.

Accountable Care Organizations (ACOs) in Track 1+ will be eligible for shared savings up to 50 percent, based on quality performance. There is a fixed 30 percent loss sharing rate. The maximum level of downside risk depends on the composition of the participating ACOs. Track 1+ is largely based on Track 1 and incorporates aspects of Track 3, such as prospective beneficiary assignment and a three-day rule waiver for skilled nursing facilities. Track 1+ qualifies as an Advanced Alternative Payment Model (AAPM) under Medicare’s Quality Payment Program beginning in 2018. Qualifying AAPM participants are eligible to receive a 5 percent bonus payment.  

Track 1+ is open to current and renewing ACO Track 1 participants as well as new participants. Those already participating in Track 2 or Track 3 cannot apply.

If your practice would like to participate in Track 1+, you must first submit to Medicare a notice of intent to apply (NOIA). The deadline for filing a NOIA is noon ET on May 31. The Centers for Medicare and Medicaid Services (CMS) has published a user guide to help physicians through the NOIA process. After submitting an NOIA, physicians must complete the Track 1+ application July 1-31. Sample 2018 applications will be made available in June.

– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Wednesday, May 10, 2017

CMS provides tool to determine physicians’ MIPS participation status

The Centers for Medicare & Medicaid Services (CMS) is mailing letters alerting physicians and other health care professionals of their 2017 participation status for the Merit-based Incentive Payment System (MIPS). The agency is also offering an interactive tool on its Quality Payment Program website to determine if you should participate in 2017.

To determine your status, type your national provider identifier in the entry field of the tool. CMS will then tell you if you should participate in MIPS this year and where to find resources.

As a reminder, you are required to participate in MIPS in 2017 if you bill Medicare Part B more than $30,000 a year and see more than 100 Medicare patients a year. You must also be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse practitioner.

If you are new to Medicare in 2017, you do not have to participate in MIPS. You may also be exempt if you qualify for one of the special rules for certain types of clinicians or are participating in an Advanced Alternative Payment Model. To learn more, review the MIPS participation fact sheet.

If you are not required to participate in the program in 2017, you can still participate voluntarily. This can give you good experience for when you are required to participate,  and you will not be subject to payment adjustments.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, April 27, 2017

Are you participating in MIPS this year? Watch your mailbox

The Centers for Medicare & Medicaid Services (CMS) has begun mailing letters alerting physicians and other health care professionals of their 2017 participation status for the Merit-based Incentive Payment System (MIPS), one of the two reimbursement tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). Practices will receive letters from their local Medicare Administrative Contractor (MAC) through the end of May. The mailings will include three documents: a general information letter, participation information, and list of frequently asked questions.

The letters inform physicians as to whether the group and the individuals within the group are exempt from the MIPS reporting requirements based on their clinician type in 2017 or if they fall below the low-volume threshold. Eligible clinician types include: MD, DO, NP, PA, CNS, and CRNA. Clinicians are considered below the low-volume threshold if during the determination timeframe they billed less than $30,000 in Medicare allowed charges or provided care to fewer than 100 Medicare patients. CMS uses both historical claims data and data from the performance period to make this determination. The letters do not contain information on a clinician’s Advanced Alternative Payment Model (AAPM) status or hospital-based determinations.

Letters are distributed at the practice level, but will contain information on each individual associated with the tax identification number (TIN). If a practice has decided to report as a group, all clinicians within the TIN will be included in the reporting, even if a clinician falls below the threshold as an individual. Practices should review the letters and determine if they will report as individuals or as a group. Clinicians practicing in multiple TINs will need to verify their participation status with each practice.

Participation in MIPS requires clinicians and groups to report data in four performance categories in 2017 in order to avoid a negative payment adjustment in 2019.

– Erin Solis, Regulatory Compliance Strategist at the American Academy of Family Physicians

Tuesday, February 21, 2017

CMS awards millions to help small practices succeed in the QPP

The Centers for Medicare & Medicaid Services (CMS) is rolling out a new effort to give clinicians in solo and small group practices on-the-ground training and education about the Quality Payment Program (QPP). CMS has announced $20 million in grants to 11 organizations to provide the services for the first year of a five-year program. Working through the Medicare Access and CHIP Reauthorization Act (MACRA), CMS plans to invest up to an additional $80 million over the remaining four years.

CMS awarded contracts to the following organizations:

• Altarum

• Georgia Medical Care Foundation (GMCF)

• HealthCentric

• Health Services Advisory Group (HSAG)


• Network for Regional Healthcare Improvement (NRHI)

• QSource

• Qualis

• Quality Insights (West Virginia Medical Institute)

• Telligen

• TMF Health Quality Institute

These groups will provide hands-on training to help thousands of small practices, especially those in historically under-resourced areas, including those that are rural, have a shortage of health professionals, or are medically underserved. For example, clinicians will receive help choosing and reporting on quality measures, as well as guidance with all aspects of the program, including supporting change management and strategic planning and assessing and optimizing health information technology. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices.

To find out if your practice is eligible for this assistance, you can call 1-866-288-8292 from 8 a.m. to 8 p.m. (EST) or email

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, January 25, 2017

MIPS help offered for practices in rural and underserved areas

The Centers for Medicare & Medicaid Services (CMS) is inviting small practices that work in rural and medically underserved areas to join a webinar on Wednesday, Feb. 1, at 1:00 p.m. (Eastern Time) to learn more about participation in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program.

During the webinar, CMS will provide information about eligibility, how to participate in MIPS in 2017, methods for submitting data to CMS, performance categories, how practices are scored, and other resources for these types of practices.

Participants will also have the opportunity to ask questions during a Q&A session.

Registration is available online:

Space for this webinar is limited, so you are encouraged to register as soon as possible to secure your spot. After you register, you will receive an email message with a webinar link.

For more information on MIPS and the Quality Payment Plan in general, read this article in the latest issue of FPM.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, January 6, 2017

Medicare’s Quality Payment Program is coming; two opportunities to get ready

The new year has begun, which means the Medicare’s Quality Payment Program (QPP) becomes even more important as what you do (or don’t do) in 2017 may affect your Medicare payments in 2019. The Centers for Medicare & Medicaid Services (CMS) is offering two opportunities this month to get a leg up now on the new QPP.

First, CMS is conducting a Clinical Practice Improvement Activities Study and will accept applications for the study through Jan. 31. CMS says it is leading this study to examine clinical workflows and data collection methods using different submission systems and to understand the challenges facing physicians and other clinicians when collecting and reporting quality data. The agency says it will use this information to recommend ways to eliminate burdens, improve collection and reporting of quality data, and enhance clinical care.

Study participants must meet the following requirements between January and December of this year:

•    Complete at least three survey questionnaires.
•    Participate in at least three focus groups.
•    Submit at least three clinician quality performance measures to CMS.

If you or your physicians group is eligible for the Merit-based Incentive Payment System (MIPS) and successfully participates in the study, CMS will award you full credit for the Improvement Activities performance category of MIPS. Participants will also get direct feedback from other study participants and CMS during the study on how to reduce problems with data collection and submission.

For more information and to apply to participate in the study, please visit the CMS website. You should submit your completed applications to by Jan. 31.

CMS will also host a call titled “Medicare Quality Programs: Transitioning from PQRS to MIPS” on Tuesday, Jan. 24, from 2:00 p.m. to 3:30 p.m. (EST). During this call, you can find out how to complete the final reporting period for the legacy Medicare quality reporting programs and transition to MIPS.

To register, please visit MLN Connects Event Registration. CMS is evaluating this call for continuing medical education credit. Please refer to the call detail page for more information.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, October 21, 2016

Some tips on MIPS included in the final MACRA rule

By now, you may have seen that the Centers for Medicare & Medicaid Services (CMS) has released a final rule that implements the Medicare Quality Payment Program (QPP) called for in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Most of this regulation is final and effective Jan. 1, but CMS seeks comments on some sections.

Meanwhile, here are some highlights for the Merit-based Incentive Payment System (MIPS) portion of the rule:

•    Eligible clinicians only need to score three points and report as little as one measure to avoid a negative payment adjustment in 2019. Eligible clinicians who achieve a final score of 70 or higher will be eligible for the exceptional performance adjustment, funded from a pool of $500 million.
•    Eligible clinicians only need to report for a minimum of 90 consecutive days in 2017 to be potentially eligible for a small upward payment adjustment in 2019, which means you can start reporting as late as Oct. 2, 2017.
•    CMS is decreasing the number of measures eligible clinicians must report.
•    CMS estimates that more than 90 percent of eligible clinicians will receive a positive or neutral payment adjustment in 2019.

Although CMS is still not offering small practices a “virtual group” option under MIPS, there was good news for these physicians. For instance, CMS is excluding more small practices from being subject to MIPS by raising the “low-volume threshold” for exclusion to be $30,000 or less in Medicare Part B allowed charges and 100 or fewer Medicare patients. CMS also estimates that at least 80 percent of solo practices and groups with nine or fewer clinicians will receive either a positive or no MIPS payment adjustment in 2019.

To accompany the final rule and provide more information, CMS also launched a new QPP website and issued an executive summary, press release, blog post from Acting CMS Administrator Andy Slavitt, and fact sheet about the regulation. A family medicine perspective on the final rule is also available.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, March 10, 2016

Study: Practices spend $15.4 billion a year to measure quality

Physicians often complain about the time they have to spend filling out documentation and other forms to report quality measure information.

A new study published in Health Affairs attempted to quantify the problem and found that practices in primary care and three other common specialties spend an average of 785 hours per physician annually on entering quality information into computers, reviewing quality reports generated by external entities, tracking quality measure specifications, implementing processes for collecting data, and transmitting that information to third parties for quality measurement.

Multiplied by the average compensation for each type of physician and staff member, the study estimated U.S. practices spend more than $15.4 billion a year to report these quality measures.

Of the four specialties – which included primary care (family medicine and internal medicine), cardiology, orthopedics, and multispecialty practices that included primary care – the primary care physicians spent the most time and money on quality measures.

The study said those practices spent an average of 19.1 hours per physician per week on quality measurement with the physicians alone spending 3.9 hours. Annually, those practices spent an average of $50,468 per physician.

By comparison, cardiology practices said they spent 10.4 hours a week (1.7 hours for physician only) and $34,924 a year while orthopedic practices said they spent 11.3 hours a week (1.1 hours for physician) and $31,471 a year.

Multispecialty practices said they spent 17.6 hours a week. Researchers did not include financial information for multispecialty practices because the practices include specialties outside the study’s scope.

The study, paid for by The Physicians Foundation, was based on surveys of more than 300 practices contacted through the Medical Group Management Association database.

Researchers said 81 percent of respondents reported spending more time and money meeting quality measurement requirements now than three years ago and only 27 percent said they believed the measures actually represented quality care.

In addition, the report found that federal programs, state and regional agencies, and health insurers often use hundreds of quality measures that share very little in common with one another, compounding the work practices must perform to comply with all their requirements.

“There is much to gain from quality measurement,” the study authors write, "but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures.”

Wednesday, March 9, 2016

Majority of physician groups see no change under Value Modifier program

The Centers for Medicare & Medicaid Services (CMS) has released the results of the 2016 Value Modifier (VM). The VM lowers or raises a physician’s Medicare payments based on his or her performance on quality and cost measures. The 2016 results, which apply to physician groups of 10 or more eligible professionals (EPs), are based on data reported in 2014.

Of the 13,813 physician groups with 10 or more EPs, only 128 groups exceeded the program’s quality and cost benchmarks. These groups will receive an increase of either 15.92 percent or 31.84 percent in their payments under the Medicare Physician Fee Schedule. Physicians in 59 groups will see their payments reduced by 1 percent or 2 percent based on their performance on quality and cost measures. There were 5,418 groups who failed to meet the reporting requirements and will face an automatic 2 percent cut. The remaining 8,208 groups will not face any adjustment because of their performance or because there was insufficient data to calculate their VM.

Medicare Administrative Contractors will process claims based on the updated adjustment amounts beginning March 14. Claims with a date of service prior to this will automatically be reprocessed. Groups should see the adjustments on their claims within the next six weeks.

Beginning in 2017, the VM will apply to solo physicians as well as those in groups of two or more physicians. To avoid an automatic payment decrease, physicians should report to the Physician Quality Reporting System (PQRS). Physicians can pull their annual Quality Resource and Use Report (QRUR) to review their performance on quality and cost measures and see how they will fare under the VM.

--Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Friday, August 7, 2015

Studies show differing opinions on enforcing patient care quality

A pair of recent studies demonstrate that the medical community is far from unified on the subject of rewarding or penalizing physicians based on the quality of patient care.

The American Association of Physician Leadership and the Navigant Center for Healthcare Research and Policy Analysis jointly polled almost 2,400 physician leaders and medical executives and reported that 69 percent of them agreed or strongly agreed that physicians should be held accountable for both the cost and quality of care they provide to patients.

Sixty-three percent of those surveyed disagreed or strongly disagreed that the ongoing shift from fee-for-service reimbursement to payments based on value will hurt the quality of patient care.

In a released statement, Paul Keckley, Navigant’s managing director, said the leaders' support for greater accountability would likely cause “tension at home,” given that many physicians object to being held accountable when they have little or no control over the costs of tests, procedures, and medical devices.

“If leaders think their rank-and-file members need to be held accountable for costs,” Keckley said, “we had better quickly come to some consistent methodology for determining how a clinician is to know what costs are, and then a methodology for incenting them for lower cost and protecting them from frivolous lawsuits (if they deny care to control costs).”

Partially echoing Keckley’s comments, a new study by The Commonwealth Fund and the Kaiser Family Foundation found that half of the 1,624 primary care physicians who participated said the increased use of quality measures to evaluate provider performance was hurting the quality of care. Interestingly, that percentage was the same whether the physician was currently receiving quality-based incentive payments or not.

Only 22 percent of physicians said they felt the use of quality performance measures was improving care (the number was slightly higher, 28 percent, among physicians currently paid based on quality).

In total, 55 percent of the physicians reported receiving some sort of financial incentive based on quality or efficiency.

Fifty-two percent of physicians also said financial penalties for unnecessary hospital admission or readmissions were hurting care quality. Only one in six said programs with those types of penalties were helping.

Thursday, May 7, 2015

Mid-year quality reports from CMS provide a glimpse of the real thing

This fall, the Centers for Medicare & Medicaid Services (CMS) will release the 2014 Annual Quality and Resource Use Reports (QRURs) for all solo physicians and medical groups who submitted claims to Medicare during calendar year 2014.

These reports examine patient outcomes and cost information, which in turn will be used to calculate the 2016 Value Modifier.

In the meantime, CMS last month released the 2014 mid-year QRUR to physicians and medical groups. It measures performance on care provided between July 1, 2013, and June 30, 2014, meaning it contains only part of the information that will be in the annual report – and count toward the value modifier.

Still, CMS sees the mid-year report as a good resource for physicians and groups to identify areas where they need to improve their quality and efficiency. In fact, CMS has provided a guide on how to use your mid-year QRUR.

If you haven’t looked at your own mid-year report, you can find information to do so on the How to Obtain a QRUR web page.

Tuesday, March 31, 2015

HHS launches network to encourage value physician payments

Last week, the U.S. Department of Health and Human Services (HHS) launched the Health Care Payment Learning and Action Network. HHS intends for the network to work with private payers, employers, consumers, providers, state Medicaid programs, and others to expand the use of alternative payment models.

According to HHS, the network will:

•    Facilitate the joint implementation and expansion of new payment and care delivery models,
•    Identify ways to implement and report on these new payment models,
•    Collaborate to generate evidence, share approaches, and remove barriers,
•    Develop common approaches to such core issues as beneficiary attribution, financial models, benchmarking, quality and performance measurement, and risk adjustment, and
•    Create implementation guides for payers, purchasers, providers, and consumers.

HHS believes the network is key to the agency’s initiative to move the Medicare program, and the health care system at large, toward paying providers based on the quality of care they give patients, rather than the quantity. HHS highlighted that initiative in January when HHS Secretary Sylvia Burwell announced the goal of moving 30 percent of Medicare payments into alternative payment models by the end of 2016 and 50 percent into alternative payment models by the end of 2018. Alternative payment models include accountable care organizations, bundled payments, and advanced primary care medical homes. Overall, HHS seeks to have 85 percent of Medicare payments tied to quality or value by 2016 and 90 percent by 2018.

Anyone is welcome to join the network, and all interested individuals and organizations can register online. More information is available on the network’s web page.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, March 12, 2015

CMS reveals results of Value Modifier program's first year

The Center for Medicare & Medicaid Services (CMS) has gotten back the results of the first year of the Value-based Payment Modifier program and recently blogged about them.

The Value Modifier, included in the Affordable Care Act, is intended to encourage physicians and practice groups to provide high quality and cost-effective care. While it will eventually apply to all health care practitioners in the country, the Value Modifier is being phased in gradually and applied only to groups of 100 or more eligible professionals in 2015. Those groups that met at least minimum standards were given the option of electing “quality-tiering,” which boosts, cuts, or leaves stable those physicians’ Medicare payments based on how they performed against national quality and cost benchmarks in 2013. Those who met minimum standards but did not elect quality-tiering – 564 groups – were not subject to any adjustments this year based on their performance.

According to CMS, nearly 7,000 physicians in 14 group practices across the country are receiving an increase in their Medicare payments in 2015 as a result of this quality-tiering. The group practices receiving increases fell into two categories:

1.    Groups that produced high quality care at average cost (the majority of groups receiving increases).
2.    Groups that produced average quality care at lower-than-expected cost.

Physician groups getting increases had, on average, better hospital readmissions rates –14.3 per 100 admissions – than the national benchmark of 16.4. These groups also had, on average, lower hospital admissions rates for acute and chronic ambulatory care sensitive conditions. Another 102 groups electing quality-tiering will see no change either because they met the national benchmarks or there was insufficient data.

Meanwhile, 330 groups are slated to see their Medicare payments cut in 2015 because of the Value Modifier program. Eleven groups subjected themselves to quality-tiering but failed to meet national benchmarks for quality or cost. Another 319 failed to meet the minimum requirements of the program and didn't have an option to elect quality-tiering.

Beginning in 2016, the Value Modifier will apply to groups with at least 10 or more eligible professionals, and quality-tiering will automatically apply to all of them. In 2017, the Value Modifier will apply to all groups and to solo practitioners who are physicians. Beginning in 2018, CMS will apply the Value Modifier to non-physician eligible professionals as well.

Physician groups and physicians can find information about their quality and cost performance in their Quality Resource and Use Reports  that were made available last fall.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, January 26, 2015

Medicare sets goals for value-based reimbursement

Federal officials have set an ambitious timeline to speed up adoption of Medicare reimbursement models based on value, instead of strictly volume of services.

The U.S. Department of Health and Human Services (HHS) announced Monday a goal of having at least 85 percent of all traditional, fee-for-service Medicare payments tied to some sort of quality component by the end of 2016 and 90 percent by the end of 2018. As part of that effort, it aims to have at least 30 percent of all Medicare payments tied to quality or value through alternative payment models, such as accountable care organizations or bundled payment arrangements, by the end of 2016 and 50 percent by the end of 2018.

This is the first time HHS has set distinct targets for value-based payment models, which were included in the Affordable Care Act but not tied to specific goals. Proponents say changing from the current fee-for-service model will cut costs and encourage physicians to take greater responsibility for patient outcomes. HHS officials say about 20 percent of Medicare payments are now tied to alternative payment models, compared with none in 2011. Medicare fee-for-service payments last year totaled $362 billion.

HHS Secretary Sylvia Burwell announced the new goals after meeting with a group representing physicians, insurers, large corporations, and consumers. She also announced the creation of the Health Care Payment Learning and Action Network, which will work with all of these groups, plus individual states and Medicaid programs, to develop and encourage new alternative payment models.

For more information, Medicare has provided a fact sheet.

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