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

Value-Based Care

Health care payments should encourage improvements in care delivery and ensure patient centered care including care coordination, integration, and prevention and wellness is compensated appropriately.

Reconfiguring payments for health care services to incentivize value will allow providers to invest in practice improvements that optimize the provision of care that is more focused on patient needs.

Shifting from traditional fee for service (FFS) payments to person focused payments (in which all or much of a person’s overall care or care for related conditions is encompassed within a single payment) is a particularly promising approach to creating and sustaining delivery systems that value quality, cost effectiveness, and patient engagement. Such payments can include accountability for the quality of care at the population level, rather than for the volume of particular services. Population-based payments give providers more flexibility to coordinate and manage care for individuals and populations. In combination with substantially reduced incentives to increase volume and increased incentives to provide services that are currently undervalued in FFS, there is a consensus that this flexibility will expedite innovations in care delivery, particularly for individuals with chronic, complex, or costly illnesses.

All alternative payment models (APM) and payment reforms that seek to deliver better care at lower cost share a common pathway for success: providers, payers, and others in the health care system must make fundamental changes in their day-to-day operations that improve quality and reduce the cost of health care. Making operational changes will be viable and attractive only if new alternative payment models and payment reforms are broadly adopted by a critical mass of payers.

Medicare beneficiaries in alternative payment models, such as ACOs, have better control over their health care, and providers have better information about their patients’ medical history and better relationships with their patients’ other providers. Doctors and other clinicians can focus on care coordination to ensure patients, especially those with chronic conditions, get the right care at the right time while avoiding medical errors and duplication. Under alternative payment models, providers have an incentive to coordinate care inside and outside the doctor’s office, by helping patients with their medications, communicating about upcoming appointments and expectations, and talking with the other members of the patient’s care team.

Today, there are 477 Medicare ACOs participating in the Shared Savings Program and the Pioneer ACO Model combined. In 2014, these programs generated a total net savings of $411 million. ACOs represent about three quarters of progress toward the goal announced today. And these gains will continue to increase over the course of the year, with the start of the Comprehensive Care for Joint Replacement model and the Oncology Care Model in 2016.

What resources are available on value-based care and quality payment programs?

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 Alternative Payment Models and the Merit-Based Incentive Payment System, including program fact sheets and where to find help, at the Quality Payment Program Education & Tools resource library.

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

On April 27, 2016, the Department of Health and Human Services issued a Notice Executive of Proposed Rulemaking to implement key provisions of the Medicare Access and Summary CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide. The MACRA makes 3 important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):

  • Repeals the Sustainable Growth Rate (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 proposed changes replace a patchwork system of Medicare reporting programs with a flexible system that allows you to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

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

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 impacted or potentially impacted by the new MACRA legislation

When it’s used
When seeking information on 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 APMs options under the new MACRA legislation

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

When it’s used
When seeking abbreviated information about the CMS Quality Payment Program

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

Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs, including the Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program. Through the law, Congress streamlined and improved these programs into one new 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, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide. MIPS allows Medicare clinicians to be paid for providing high quality, efficient care through success in four performance categories: Cost, Quality, Clinical Practice Improvement Activities and Advancing Care Information.

Merit-Based Incentive Payment System (MIPS)

Merit-Based Incentive Payment System (MIPS)

Overview
A training slide deck that describes the major provisions of the MIPS

Who it’s for
Potential or eligible providers that choose to participate in MIPS

When it’s used
When seeking to understand more information about the Merit-Based Incentive Payment System under the new MACRA legislation

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

APMs are new approaches to paying for medical care through Medicare that incentivize quality and value. As defined by MACRA (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf), APMs include:

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

Advancing Care Information (ACI) is the proposed name for one of the four performance categories which the Medicare Access and Chip Reinvestment Act (MACRA) established for the new Merit-based Incentive Program (MIPS) to determine the score and payment for Medicare eligible clinicians. In MACRA this category would require participants to report on measures related to the meaningful use of certified EHR technology in order to earn up to 25% of their performance score. In this way, MACRA incorporates the payment adjustments for Medicare EPs from the EHR Incentive Program into the larger MIPS structure along with other CMS quality reporting program. This means that Medicare EPs will no longer receive a payment adjustment based on participation in the EHR Incentive Program beginning with the 2019 payment adjustment year. Instead, these providers may participate in the MIPS program and receive a positive or negative performance score for meaningful use of certified EHR technology and other quality reporting. The specific requirements for the program will be updated upon publication of a final rule.

Advancing Care Information Fact Sheet

Advancing Care Information Fact Sheet

Overview
Principal Changes from the Medicare EHR Incentive Program to 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 proposed Advancing Care Information Performance Category under MIPS

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

2016 EHR Incentive Programs Spec Sheets for Stage 2 EP

2016 EHR Incentive Programs Spec Sheets for Stage 2 EP

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

Who it’s for
Eligible Professionals

When it’s used
To determine specific objective and measure criteria

Download 2016 EHR Incentive Programs Spec Sheets for Stage 2 EP [PDF - 85 KB]

2016 EHR Incentive Programs Spec Sheets for Stage 2 EH/CAH

2016 EHR Incentive Programs Spec Sheets for Stage 2 EH/CAH

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

Who it’s for
Eligible Hospitals, Critical Access Hospitals

When it’s used
To determine specific objective and measure criteria

Download 2016 EHR Incentive Programs Spec Sheets for Stage 2 EH/CAH [PDF - 284 KB]

Small practices (typically defined as 15 or fewer clinicians) and practices in rural or health professional shortage areas play a vital role in the care of Medicare patients with diverse needs. The Centers for Medicare & Medicaid Services (CMS) is sensitive to the unique challenges that small practices face in different types of communities, and the Quality Payment Program as proposed would provide accommodations for various practice sizes and configurations. In addition, CMS is sensitive to the concerns expressed by the proposed rule’s regulatory impact analysis, which was perceived to show that the Quality Payment Program would negatively impact 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 does not reflect the accommodations in the proposed rule that are intended to provide additional flexibility to small practices. This paper details the flexibility and support available to small practices and practices in rural or health professional shortage areas in the proposed rule. CMS is committed to a continued dialogue regarding the obstacles and challenges these practices encounter, both during the rulemaking period and throughout the implementation of the Quality Payment Program.

Flexibility for Small Practices

Flexibility for Small Practices

Overview
A summary of flexibility and support available to small practices impacted by the new MACRA legislation

Who it’s for
Small practices and practices in rural or health professional shortage areas

When it’s used
When seeking guidance 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+ will include 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. The care delivery redesign ensures practices in each track have the infrastructure to deliver better care to result in a healthier patient population. The multi-payer payment redesign will give practices greater financial resources and flexibility to make appropriate investments to improve the quality and efficiency of care, and reduce unnecessary health care utilization. CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data feedback to guide their decision making. CPC+ is a five-year model that will begin in January 2017.

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