Value-Based Reimbursement and Quality Initiatives

What are value-based reimbursement and quality initiatives?

Value-based initiatives reward healthcare providers with incentive payments for the quality of care they provide to people with Medicare. These programs are part of the Centers for Medicare and Medicaid Services’ (CMS) quality strategy to reform how healthcare is delivered and paid for.

This resource page provides your practice with information about two key initiatives – the Quality Payment Program and Medicaid Promoting Interoperability – as well as electronic clinical quality measures (eCQMs) that help you measure and track the care you provide. It also includes information about health IT interoperability and how Practice Fusion supports that vision.

What is the Quality Payment Program?

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law, repealing the Sustainable Growth Rate (SGR) payment system which governed how physicians and other clinicians were paid under Medicare Part B. MACRA replaced the SGR, and its fee-for-service reimbursement model, with a new two-track value-based reimbursement system called the Quality Payment Program (QPP). This program is the latest in a series of steps the Centers for Medicare and Medicaid Services (CMS) has taken to incentivize high quality of care over service volume.

Clinicians have two tracks to choose from in the Quality Payment Program based on their practice size, specialty, location, or patient population:

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

Source: Centers for Medicare and Medicaid Services. Quality Payment Program.

MIPS Overview

The Merit-based Incentive Payment System (MIPS) is a program designed to tie payments to quality and cost-efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care. MIPS measures performance through the data clinicians report in four key areas: Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost.

Promoting Interoperability

Focuses on patient engagement and the electronic exchange of health information using certified electronic health record technology (CEHRT).

Quality

Covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups.

Improvement Activities

An inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care.

Cost

Measures that gauge the total cost of care during the year or during a hospital stay calculated by CMS based on your Medicare claims.

These four performance categories make up the MIPS final score which is used for determining payment adjustments. The MIPS Performance Year begins on January 1 and ends on December 31 each year. Program participants must typically report their data in the early part of the following calendar year to avoid a payment reduction.

MIPS resources

Alternate Payment Models (APMs) Overview

An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. There are five different types of APMs:

APMs	Meet the statutory definition of an APM. MIPS eligible clinicians participating in an APM are also subject to MIPS.
MIPS APMs	MIPS APMs have MIPS eligible clinicians participating in the APM on their CMS-approved participation list. Learn more about MIPS APMs
Advanced APMs	An Advanced APM is a track of the Quality Payment Program that offers a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you are excluded from the MIPS reporting requirements and payment adjustment. Learn more about Advanced APMs
Advanced & MIPS APMs	Most Advanced APMs are also MIPS APMs. MIPS Eligible clinicians participating in Advanced APMs are included in MIPS if they do not meet the threshold for payments or patients sufficient to become a Qualifying APM Participant (QP). The MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.
All-Payer/Other-Payer Option	To attain this Option, eligible clinicians must participate in a combination of Advanced APMs with Medicare and Other-Payer Advanced APMs. Other-Payer Advanced APMs are non-Medicare payment arrangements that meet criteria that are similar to Advanced APMs under Medicare. Learn more about All-Payer Advanced APMs

Source: Centers for Medicare and Medicaid Services. APMs Overview

APM resources

What is Medicaid Promoting Interoperability?

In 2011, CMS established the Medicare and Medicaid EHR Incentive Programs (now known as the Promoting Interoperability programs) to encourage clinicians, eligible hospitals, and CAHs to adopt, implement, upgrade (AIU), and demonstrate meaningful use of CEHRT.

Historically, the Promoting Interoperability Programs consisted of three stages:

Stage 1 established the foundation for Promoting Interoperability Programs by setting requirements for the electronic capture of clinical data, including providing patients with electronic copies of health information.
Stage 2 expanded upon the Stage 1 criteria with a focus on advancing clinical processes and ensuring that the meaningful use of EHRs supported the aims and priorities of the National Quality Strategy. Stage 2 criteria encouraged the use of CEHRT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible.
Stage 3 was initiated in 2017 and was created by a final rule released by CMS in October 2015. It focuses on using CEHRT to improve health outcomes. In addition, this rule modified Stage 2 to ease reporting requirements and align with other CMS programs.

To continue its commitment to promoting and prioritizing interoperability of healthcare data, CMS renamed the EHR Incentive Programs to the Promoting Interoperability Programs in April 2018. This change moved the programs beyond the existing requirements of meaningful use to a new phase of EHR measurement with an increased focus on interoperability and improving patient access to health information.

Source: Centers for Medicare and Medicaid Services. Promoting Interoperability (PI).

Medicaid Promoting Interoperability Resources

What are electronic clinical quality measures (eCQMs)?

Electronic clinical quality measures (CQMs) are tools that help measure and track the quality of healthcare services that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) provide, as generated by a provider’s electronic health record (EHR). Measuring and reporting eCQMs helps to ensure that our healthcare system is delivering effective, safe, efficient, patient-centered, equitable, and timely care. eCQMs measure many aspects of patient care, including:

Patient and Family Engagement
Patient Safety
Care Coordination
Population/Public Health
Efficient Use of Healthcare Resources
Clinical Process/Effectiveness

healthcare providers are required to electronically report eCQMs, which use data from EHRs and/or health information technology systems to measure healthcare quality. To report eCQMs successfully, healthcare providers must adhere to the requirements identified by the CMS quality program in which they intend to participate.

Source: Centers for Medicare and Medicaid Services. Clinical Quality Measure Basics.

eCQM Resources

How does Practice Fusion support interoperability?

According to HIMSS, interoperability is, “…the ability of different information systems, devices and applications (‘systems’) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organizational, regional and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally.”

In 2014, the Office of the National Coordinator (ONC) established a 10 year plan to advance interoperability of health IT, and developed a roadmap in three-, six-, and ten-year increments to guide focus and support private and public collaboration to achieve the vision. The ONC laid out three key goals in this effort that guide the strategic implementation of new features and functionality in health IT products:

Create a learning health system where individuals are at the center of their care and providers have a seamless ability to securely access and use health information from different sources.
Provide access to individual’s health information, which is stored in electronic health records (EHRs), but includes information from many different sources and portrays a longitudinal picture of their health.
Help public health agencies and researchers rapidly learn, develop, and deliver cutting edge treatments.

Source: The Office of the National Coordinator for Health Information Technology (ONC). Interoperability

Practice Fusion supports interoperability in a number of ways, particularly through advancements in patient API connections and integrations with health information exchanges (HIEs) across the country.

Interoperability Resources