An alternative payment model (APM) that has been certified by CMS to meet the following criteria:
- Requires participants to use certified electronic health record technology (CEHRT);
- Provides payment for covered professional services based on quality measures comparable to those used in the Quality performance category of the Merit-Based Incentive Payment System (MIPS); and
- Is either a Medical Home Model expanded under CMS Innovation Center authority OR requires participating APM entities to bear more than a nominal amount of financial risk for monetary losses.
An APM is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. Advanced APMs are a subset of APMs that entail a minimum level of risk tied to cost and quality. Under the Quality Payment Program (QPP), clinicians who provide a sufficient volume of Medicare services through an Advanced APM in any given year are eligible for a 5% Medicare incentive payment.
Federal certification of health IT assures purchasers and other users that an electronic health record (EHR) system or other relevant technology offers the technological capability, functionality, and security to help a clinician meet the standards of federal reporting mandates, including the Promoting Interoperability category of MIPS.
CMS defines MIPS eligible clinicians as physicians (as defined in section 1861(r) of the Social Security Act), physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who bill under Medicare Part B. As of 2019, the following professionals are also included under this definition: clinical social workers, physical and occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals.
Exclusions. Clinicians expressly excluded from MIPS include:
- Qualifying Participants in Advanced APMs
- Low-volume clinicians, defined as group practices and clinicians who:
- Have ≤ $90K in Part B allowed charges for covered professional services;
- Provide care to ≤ 200 Part B-enrolled beneficiaries; OR
- Provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS)
- Clinicians who newly enroll in Medicare during the performance period and have not previously submitted Medicare claims as an individual, part of a group, or under a different tax identifier.
For the 2017 performance period, CMS estimates that about 20% of MIPS eligible cardiothoracic surgeons will not be eligible for MIPS due to these exclusions. CMS has not released additional specialty specific data since that time.
Under MIPS, CMS defines “hospital-based” clinicians as individuals who furnish 75% or more of their covered professional services in sites of service identified by inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), off=campus outpatient hospital (POS-19) or emergency room (POS 23) setting. To qualify as a hospital-based group in 2021, more than 75% of the NPIs in the group must meet the definition of a hospital-based MIPS individual eligible clinician. Although these clinicians and groups are not explicitly excluded from MIPS, they are not required to comply with the Promoting Interoperability (PI) category of MIPS. If a hospital-based clinician or group opts not to participate in the PI category of MIPS, CMS will generally redistribute the weight of this category to the Quality category.
MACRA ended the Sustainable Growth Rate formula and makes changes to how CMS calculates updates to physician payments under the Medicare Physician Fee Schedule (PFS). It also authorizes the Quality Payment Program (QPP), which began in 2017, where physicians and other eligible clinicians are paid based on the quality and effectiveness of the care they provide.
MIPS consolidates elements of legacy Medicare physician quality programs (Physician Quality Reporting System or PQRS, the Value Modifier, and the EHR Incentive Program) into a single value-based payment program. Under MACRA, CMS is required to evaluate clinician performance based on the following four categories:
MIPS eligible clinicians will receive a MIPS Final Score based on a scale of 0–100 points, which represents performance across all four MIPS categories and is used to determine Medicare payment adjustments. Clinicians may earn up to a certain number of points within each MIPS performance category based on performance. The score from each category is then weighted according to percentages prescribes in MACRA and through rulemaking. The category scores are then combined to arrive at a final MIPS composite score.
A qualified clinical data registry (QCDR) is a CMS-approved entity with clinical expertise in medicine and in quality measurement development that collects medical or clinical data on behalf of a MIPS eligible clinician for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. To be considered a QCDR, an entity must self-nominate and successfully complete a qualification process.
A QCDR will complete the collection and submission of quality measures data on behalf of MIPS eligible clinicians. The STS National Database is a QCDR but will not submit MIPS data for the 2021 program year.
An eligible clinician may become a QP or a Partial QP each year by participating in an Advanced APM at a sufficient enough level determined by payment or patient thresholds. Clinicians in an Advanced APM who are Partial QPs may choose whether or not to submit data on MIPS measures and activities. If Partial QPs do not choose to participate in MIPS, they are not required to participate in MIPS data submission and will not receive a MIPS payment adjustment.
QP/Partial QP status determinations are generally made collectively for all eligible clinicians participating in each Advanced APM Entity. If the collective calculations demonstrate that the APM Entity meets the payment amount or patient count threshold, all of the eligible clinicians would achieve QP or Partial QP status.
The QP and Partial QP determination thresholds change over time. STS members may contact advocacy@sts.org for an additional resource guide.
The QPP was authorized under MACRA to reward physicians and other Medicare Part B clinicians who proved high-value, high-quality care. The program also reduces Medicare payments to those clinicians who do not meet performance standards. The Quality Payment Program has two tracks:
More information about the QPP is available here.
Specialty measure sets are suggested subsets of MIPS measures that CMS believes are most applicable to a specific specialty. They are intended to help clinicians navigate the large inventory of measures available under MIPS.