The Office of the National Coordinator for Health Information Technology Health IT Playbook

Section 6

Value-Based Care

Health care payments should encourage improved care delivery and ensure appropriate compensation for patient-centered care — including care coordination, integration, and prevention and wellness.

Reconfiguring payments for health care services to incentivize value will allow clinicians to invest in practice improvements that optimize provision of care to focus more on patient needs as well as the needs of the provider.

A shift from traditional fee-for-service (FFS) payments to person-focused payments (where a single payment encompasses all or much of a person’s overall care) offers a promising way to create and sustain delivery systems that value:

  • Quality
  • Cost effectiveness
  • Patient engagement

These payments can include accountability for quality of care at the population level, rather than for the volume of specific services. Population-based payments give clinicians more flexibility to coordinate and manage care for individuals and populations.

Substantially reduced incentives to increase volume — combined with increased incentives to provide currently undervalued FFS — creates flexibility that will expedite innovations in care delivery, particularly for individuals with chronic, complex, or costly illnesses.

All alternative payment models (APMs) and payment reforms designed to deliver better care at lower costs share a common pathway to success. All clinicians, payers, and other players in the health care system must make fundamental changes in their day-to-day operations to improve quality and reduce health care costs.

However, a critical mass of payers must broadly adopt the new APMs and payment reforms before these operational changes can become viable and attractive.

Medicare beneficiaries in alternative payment models have more control over their health care, while clinicians have better information about their patients’ medical history — and stronger relationships with their patients’ other clinicians.

Doctors and other clinicians can focus on coordinating care to ensure their patients, especially those with chronic conditions, get the right care at the right time — while avoiding medical errors and duplication.

Alternative payment models give clinicians an incentive to coordinate care inside and outside the doctor’s office. Through coordinated care clinicians can, for example:

  • Help patients with their medications
  • Communicate upcoming appointments and expectations
  • Talk with other members of the patient’s care team

How does the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) reform Medicare payment?

On November 4, 2016, the Centers for Medicare and Medicaid Services (CMS) published the 2017 Final Rule implementing the Quality Payment Program as authorized under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

This bipartisan legislation replaced the flawed Sustainable Growth Rate (SGR) formula with a new approach to paying clinicians for the value and quality of care they provide. MACRA makes 3 important changes to how Medicare pays doctors and clinicians who care for Medicare beneficiaries. These changes create a Quality Payment Program (QPP) that:

  • Repeals the SGR formula
  • Streamlines multiple reporting programs into the new Merit-Based Incentive Payment System (MIPS)
  • Provides incentive payments for participation in Advanced Alternative Payment Models (APMs)

These changes replace a patchwork system of Medicare-reporting programs with a flexible system that lets clinicians choose from 2 paths that link quality to payments:

  • MIPS
  • Advanced APMs

MACRA also required CMS to develop and post a Quality Measure Development Plan that provides a framework for making clinician-quality measures that support MIPS and Advanced APMs.

Learn more: CMS offers in-depth information, webinars, and other resources for value-based programs at the Quality Payment Program: Delivery System Reform, Medicare Payment Reform, & MACRA website.

For more information on MIPS and Advanced APMs visit the Quality Payment Program website. Plus, you’ll find downloadable Quality Payment Program resources below.

Preparing Your Practice for Value-Based Care

In a value-based care model, physician payments are determined in part by patients’ health outcomes and their quality of care. This 5-step module will help you shift to a value-based care model that can help your practice provide higher-quality patient care while also reducing overall health care costs.

Go to the AMA STEPS Forward™ Preparing Your Practice for Value-Based Care module

CMS Path to Value

CMS Path to Value

Overview
A summary of how MACRA demonstrates a path towards transforming our health care system

Who it’s for
All clinicians affected, or potentially affected, by the Quality Payment Program

When it’s used
To learn how the new MACRA legislation demonstrates value

Download CMS Path to Value [PDF - 913 KB]

Quality Payment Program Fact Sheet

Quality Payment Program Fact Sheet

Overview
A summary of provisions related to MIPS and Advanced APM options under the Quality Payment Program

Who it’s for
All clinicians affected, or potentially affected, by the Quality Payment Program

When it’s used
To learn quick facts about the CMS Quality Payment Program

Download Quality Payment Program Fact Sheet [PDF - 2.7 MB]

Quality Payment Program Health IT Policy and Standards Committee Slides

Quality Payment Program Health IT Policy and Standards Committee Slides

Overview
A presentation about the policies, goals, and models of the Quality Payment Program

Who it’s for
All clinicians affected, or potentially affected, by the Quality Payment Program

When it’s used
To get an overview of the Quality Payment Program and the options within it

Download the Quality Payment Program Health IT Policy and Standards Committee Slides [PDF - 1.1 MB]

Medicare currently measures the value and quality of care — provided by doctors and other clinicians — through a patchwork of programs including the:

  • Physician Quality Reporting System (PQRS)
  • Value-based Payment Modifier Program (VM)
  • Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals

Did you know?

Completing the AMA STEPS Forward™ program counts toward CME credits and as a QPP Improvement Activity for your practice.

The Quality Payment Program streamlined these programs into a single, improved program known as the Merit-based Incentive Payment System (MIPS). Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS.

Consistent with the goals of the law, MIPS will improve the relevance and depth of Medicare’s value and quality-based payments. It will also increase flexibility by allowing clinicians to choose measures and activities that are best for their practice and patients.

MIPS provides a way for Medicare clinicians to get paid for providing high-quality, efficient care through success in 4 performance categories:

  • Cost
  • Quality
  • Improvement Activities
  • Advancing Care Information

Understanding Medicare Quality Reporting

In Medicare’s new Quality Payment Program, reporting on quality metrics affects how much Medicare will pay your practice. Learn how Qualified Clinical Data Registries (QCDRs) can help your practice accurately and successfully report quality data.

Go to the AMA STEPS Forward™ Quality Reporting module

Merit-Based Incentive Payment System (MIPS)

Merit-Based Incentive Payment System (MIPS)

Overview
A training slide deck that describes the major MIPS provisions

Who it’s for
MIPS eligible clinicians who are included in the program and need to actively participate

When it’s used
To learn more about MIPS under the Quality Payment Program

Download Merit-Based Incentive Payment System (MIPS) [PDF - 3.5 MB]

An Alternative Payment Model (APM) is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and cost-efficient care. As defined by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), APMs include:

  • CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)
  • Medicare Shared Savings Program (MSSP)
  • Demonstration under the Health Care Quality Demonstration Program
  • Demonstration required by federal law

To view a list of the APMs that CMS operates, download Alternative Payment Models in the Quality Payment Program [PDF - 263 KB]

APMs require providers to view and understand data from multiple health care settings. Practices that wish to implement APMs should assess their community’s existing data sharing capacity and may want to collaborate with other providers to develop a shared solution for sustainable APM adoption.

To learn more about strategies to support the adoption of APMs, download the Data Sharing Requirements Initiative: Collaborative Approaches to Advance Data Sharing [PDF – 2MB]

Advanced APMs

Advanced Alternative Payment Models (APMs) are a subset of APMs that allow practices to earn more for taking on additional risk related to their patient’s outcomes. Clinicians who participate to a sufficient extent in Advanced APMs can qualify for added incentives, such as a 5% lump sum incentive payment for their Medicare Part B professional services and exclusion from the Merit-based Incentive Payment System (MIPS).

Advanced APMs must meet the following criteria:

  • Require participants to use certified EHR technology
  • Require base payments for services on quality measures comparable to those in the Merit-based Incentive Payment System (MIPS)
  • Be a Medical Home Model expanded under CMS Innovation Center authority or require participants to bear more than nominal financial risk for losses

To be eligible for the Advanced APM incentives, clinicians must become Qualifying APM Participants (QPs) by having a certain percentage of their payments or patients through an Advanced APM.

As we discussed in Section 6.2, Advancing Care Information is 1 of 4 performance categories under the new Merit-based Incentive Payment System (MIPS).

Advancing Care Information will require participants to report on measures related to the Meaningful Use of certified electronic health record (EHR) technology. This will let them earn up to 25% of their MIPS final score.

Note: Beginning with the 2019 payment adjustment year, clinicians will no longer receive a payment adjustment based on participation in the EHR Incentive Program. Instead, they may participate in MIPS and receive a positive or negative payment adjustment based on their final score, which includes performance in the Advancing Care Information category.

Advancing Care Information Fact Sheet

Advancing Care Information Fact Sheet

Overview
Principal changes from the Medicare EHR Incentive Program to the Advancing Care Information performance category

Who it’s for
All physicians and other clinicians participating in MIPS

When it’s used
To learn more about the Advancing Care Information performance category under MIPS

Download Advancing Care Information Fact Sheet [PDF - 429 KB]

2017 Medicaid Eligible Professionals EHR Incentive Program Specification Sheet for Modified Stage 2

2017 Medicaid Eligible Professionals EHR Incentive Program Specification Sheet for Modified Stage 2

Overview
Detailed objectives and measures for modified Stage 2 of the CMS EHR Incentive Program

Who it’s for
Eligible professionals

When it’s used
To determine specific objectives and to measure criteria

Download 2017 Medicaid Eligible Professionals EHR Incentive Programs Specification Sheet for Stage 2 [PDF - 264 KB]

2017 Medicaid Eligible Hospital EHR Incentive Program Specification Sheet for Modified Stage 2

2017 Medicaid Eligible Hospital EHR Incentive Program Specification Sheet for Modified Stage 2

Overview
Detailed objectives and measures for modified Stage 2 of the CMS EHR Incentive Program

Who it’s for
Eligible hospitals, Critical Access Hospitals (CAH)

When it’s used
To determine specific objectives and to measure criteria

Download 2017 Medicaid Eligible Hospital EHR Incentive Programs Specification Sheet for Stage 2 [PDF - 264 KB]

Small practices (defined as 15 or fewer clinicians), especially those in rural or Health Professional Shortage Areas (HPSAs), play a vital role in caring for Medicare patients with diverse needs. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides support to help solo Merit-based Incentive Payment System (MIPS) eligible clinicians and small practices participate in the Quality Payment Program.

Additionally, the Centers for Medicare & Medicaid Services (CMS) appreciates the unique challenges that small practices face in different communities, and the Quality Payment Program provides options for clinicians in small practices.

The following paper details the flexibility and support available to small and rural practices, or HPSAs, as described in the legislation. CMS is committed to a continued dialogue regarding the obstacles and challenges these practices encounter, both during the rulemaking period and throughout the Quality Payment Program implementation.

Flexibility for Small Practices

Overview
A summary of flexibility and support available to small practices affected by the new Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation

Who it’s for
MIPS eligible clinicians in small practices, especially those in rural and Health Professional Shortage Areas

When it’s used
To find help for small practices — as it relates to the Quality Payment Program

Check out the Small Practice website

Comprehensive Primary Care Plus (CPC+) is a national, advanced primary-care medical home model that aims to strengthen primary care through a regionally-based, multi-payer payment reform and care-delivery transformation.

CPC+ includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States. Through a unique public-private partnership with 54 aligned payers in 14 regions, the CPC+ Round 1 and 7 payers in 4 regions in CPC+ Round 2, the CPC+ payment redesign gives practices the additional financial resources and flexibility they need to make investments that will improve quality of care and reduce the number of unnecessary services their patients receive. The care-delivery redesign ensures practices in each track have the infrastructure they need to deliver better care — for a healthier patient population.

The multi-payer payment redesign gives practices greater financial resources and flexibility in making appropriate investments to:

  • Improve care
  • Improve efficiency
  • Reduce unnecessary health care

CPC+ provides practices with a robust learning system, as well as actionable, patient-level cost-and-utilization data feedback to guide their decision making. Based on a 5-year model, CPC+ began in January 2017.

Section 6 Recap

Reconfigure payments to incentivize value.

  • Learn about the Quality Payment Program (QPP)
  • Stay on top of the Merit-Based Incentive Payment System (MIPS)
  • Understand Alternative Payment Models (APMs)
  • Explore Advancing Care Information
  • Find support for your small practice
  • Strengthen primary care with CPC+

Join the conversation.

Let us know how we can improve and expand on Value-Based Care.

Content last updated on: September 29, 2017