The Quality Payment Program improves Medicare by helping providers focus on care quality and in making patients healthier. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment differences for 13 years. If a provider participates in Medicare Part B, s/he is part of the team that serves more than 55 million of the country’s most vulnerable Americans, and the Quality Payment Program (QPR) will provide new tools and resources to help patients get the best possible care. Doctors may choose how to participate based on practice size, specialty, location, or patient population.

The Quality Payment Program has two tracks:

  • Advanced Alternative Payment Models (APMs) or
  • The Merit-based Incentive Payment System (MIPS)

Participating in an Advanced APM, through Medicare Part B incentive payments are earned with an innovative payment model.

Participating in MIPS, a performance-based payment adjustment is earned.

Who’s included?

Providers in an Advanced APM or if Medicare is billed more than $30,000 a year and care is provided for more than 100 Medicare patients a year. If fewer patients or lower billing amounts, providers are not included in the program.

All physicians are required to comply with MACRA rules in 2017 to stop Medicare payment reductions.

Based on the data submitted, future reimbursement will be increased or decreased depending on performance using the quality and cost metrics.

The new guidelines are based on a complicated scoring system that requires just about every single practice to modify what and how they record their patient encounters. Basically, the metrics reported in 2017 will make a significant difference in future revenue.

As we have reported earlier on the MACRA rules, the problems involved to gear up and participate are difficult enough that it is predicted to speed the decline of small practices and force those providers to join forces with larger provider groups, e.g., those with less than 25 physicians would be penalized based on low performance with failure to provide data as the biggest culprit.  Solo practices they predicted will have penalties at 87%.  CMS estimated that 81% of physicians in a practice with 100 or more clinicians will earn a bonus.

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