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

Section 5

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 providers 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 providers 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 providers, 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 providers have better information about their patients’ medical history — and stronger relationships with their patients’ other providers.

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 providers an incentive to coordinate care inside and outside the doctor’s office. Through coordinated care providers 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 a final rule implementing 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 providers who care for Medicare beneficiaries. These changes create a Quality Payment Program (QPP) that:

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

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

  • MIPS
  • 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 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.

Learn more about APMs and MIPS, including program fact sheets and where to find help, at the Quality Payment Program Education & Tools resource library. Plus, you’ll find downloadable quality-payment resources below.

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 providers affected, or potentially affected, by the new MACRA legislation

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 APM options under the new MACRA legislation

Who it’s for
All providers affected, or potentially affected, by the new MACRA legislation

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

Download Quality Payment Program Fact Sheet [PDF - 451 KB]

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 QPP’s policies, goals, and models

Who it’s for
All providers affected, or potentially affected, by the new MACRA legislation

When it’s used
To get an overview of the QPP 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
  • Value Modifier Program
  • Medicare Electronic Health Record (EHR) Incentive Program

Through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress improved and streamlined these programs into the new Merit-based Incentive Payment System (MIPS). Most Medicare clinicians will initially participate in the Quality Payment Program (QPP) 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 appropriate to the type of care they provide.

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

  • Cost
  • Quality
  • Clinical practice improvement activities
  • Advancing Care Information (ACI)

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
Potential or eligible providers that choose to participate in MIPS

When it’s used
To learn more about MIPS under the new MACRA legislation

Download Merit-Based Incentive Payment System (MIPS) [PDF - 2.4 MB]

A new approach to paying for medical care through Medicare, alternative payment models (APMs) incentivize quality and value. 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

As we discussed in Section 5.2, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established Advancing Care Information (ACI) as 1 of 4 performance categories that determines the new Merit-based Incentive Program (MIPS) score and payment for Medicare-eligible clinicians.

ACI 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 performance score. MACRA incorporates the payment adjustments for Medicare-eligible professionals from the EHR Incentive Program into the larger MIPS structure — along with other Centers for Medicare and Medicaid Services (CMS) quality-reporting programs.

Note: Beginning with the 2019 payment adjustment year, Medicare-eligible professionals 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 performance score for Meaningful Use of certified EHR technology and other quality-based reporting.

Advancing Care Information Fact Sheet

Advancing Care Information Fact Sheet

Overview
Principal changes from the Medicare EHR Incentive Program to ACI performance category

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

When it’s used
To learn more about the ACI performance category under MIPS

Download Advancing Care Information Fact Sheet [PDF - 1.9 MB]

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 (typically defined as 15 or fewer clinicians) and practices in rural or Health Professional Shortage Areas (HPSAs) play a vital role in caring for Medicare patients with diverse needs. The Centers for Medicare & Medicaid Services (CMS) appreciates the unique challenges that small practices face in different communities, and the Quality Payment Program (QPP) as proposed provides accommodations for various practice sizes and configurations.

CMS is also sensitive to the concerns expressed over the regulatory impact analysis; specifically, a perception that the QPP will negatively affect small practices. This regulatory impact analysis is based on 2014 data when many small and solo practice physicians did not report their performance. It also doesn’t reflect the accommodations intended to provide additional flexibility to 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 QPP implementation.

Flexibility for Small Practices

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
Small practices and practices in rural or health professional shortage areas

When it’s used
To find help for small practices — as it relates to the new MACRA legislation

Download Flexibility for Small Practices [PDF - 200 KB]

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 2 tracks for primary-care practices. It provides incrementally advanced care-delivery requirements and payment options to meet the diverse needs of primary-care practices in the U.S. 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 5 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 (ACI)
  • 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: May 31, 2017