The final rules for the Quality Payment Program are out and while there are still some lose ends, the real face of the program is beginning to emerge.  The Quality Payment Program (QPP) replaces the previous system of Medicare Sustainable Growth Rate reimbursement method and rewards quality care with two more consistent systems – Advanced Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS.)  The QPP is expected to evolve over several years in stages and parts of the program are not implemented in the first, or “transition” year of 2017.  The transition (first) year reporting will be a 90-day period in 2017.  The payment system will go into effect in 2019.

What are APMs?

APMs are special group payment approach models developed by clinicians to deliver high-quality and low-cost are to a population, condition, or episode.  For a group or provider to be eligible for a 5% bonus through APMs, 25% of their Medicare Part B payments or 20% of their Medicare patients must come through an Advanced APM.

What is MIPS?

MIPS is a payment approach that assesses quality in four parts and rewards Medicare providers with higher reimbursement when meeting mandated criteria.   MIPS eligible physicians are Medicare providers.   Most optometrists will be paid under the MIPS system.  Small practices with less than $30,000 in allowable Medicare charges a year and less than or equal to 100 Medicare patients seen are exempt.  Most optometry practices are above that threshold and will be required to participate.

What are the 4 areas that MIPS uses?

Providers will get a cumulative grade on:

  1. Quality Measures will be published by November 1st of each year to be used in the following year.  This program is an adaption of the PQRS  system in which providers will report on at least six measures, including an outcome measure, unless there are not six measures that apply to that particular group or physician.  We have seen over the years that many of the PQRS and CQM measures did not apply to optometry.  The old standbys are back though including patient management of POAG, diabetic eye disease, and AMD.
  2. Improvement Activities support efforts to improve care coordination, beneficiary (patient) engagement, and population  management.  We have seen those measures included in Meaningful Use (MU) in the past with patient education, recall, and transition of care.  Activities will be weighted based on difficulty and in 2017 MIPS eligible providers will need to meet four medium-weighted or two high-weighted activities to get full credit in this area.  There will be adjustments for practices in shortage areas and small practices.  Small groups (fewer than 15 providers) will need to report on two measures.  Examples include using the AOA More’s Qualified Clinical Data Registry (QCDR), surveying patients on their experience, improvements to the patient portal, and tobacco use assessment.
  3. Advancing Care Information focusing on utilization of certified electronic health record technology with a minimum of five measures with up to 9 submitted for “Bonus Points.”  These measures closely resemble the Meaningful Use measures:

    Security Risk Analysis
    Provide Patient Access
    Send Summary of Care
    Request/Accept Summary of Care
    For bonus credit, you can:
    Report Public Health and Clinical Data Registry Reporting measures
    Use certified EHR technology to complete certain improvement activities in the improvement activities performance category

  4. Cost performance is not used in 2017 but will address cost-effective utilization of the Medicare system and provide feedback used for future measures that will be graded.

Scoring under MIPS

Similar to the previous PQRS and MU programs, the minimum score to avoid reimbursement reductions will be low but providers with high scores will be rewarded with positive adjustments to their payments.  Over time, the program will become harder with higher scores and longer compliance periods required to avoid lower payments.

Review process

A review process is being finalized where providers can request that their score be reviewed and adjusted if valid.

Reporting Methods

Measures will be reported through web interface, claims, EHR, or registries – depending on the measure.  Requirements for third party data submitters are being finalized and registries, EHR vendors, and CMS-approved vendors will have the ability to file the QPP data on behalf of providers.  The AOA More program has plans to be an active participant in conjunction with EHR vendors for reporting on behalf of Optometrists.  Their QCDR will also help providers meet many of the Improvement Activities measures.  Measures are being “previewed” now by EHR vendors with the final measures being determined by December 31.  Participation in data collection and reporting will require the use of certified EHR software.