CMS Quality Payment Program Update

  • The MACRA final rule was released October 14, 2016.
  • The rule establishes the Quality Payment Program (QPP) under which providers will be classified by CMS into two reporting tracks: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).
  • QPP is designed to encourage eligible clinicians to participate in Advanced Alternative Payment Models (APMs).

Highlights of the final rule:

  • 2017 will be a “transition year” with modified reporting requirements with full participation required in 2018 and beyond.
  • Under the MIPS track, providers receive payment adjustments based on their performance against other providers on evidence-based and practice-specific metrics related to cost, improvement activity, quality, and advancing care information.
  •  “Pick your pace” options:
    • Test: report on 1 quality or 1 improvement activity, or 4-5 required advancing care information measures
      • Avoids negative payment adjustment
    • Partial: submit for 90 consecutive days
      • May earn a neutral or small positive adjustment
    • Full: report a full year of data
      • May earn a moderate positive adjustment
    • No Participation: providers who qualify for the QPP but do not participate in the MIPS or APM path will receive a 4% negative payment adjustment in 2019.
    • The only way to receive a negative adjustment is to do nothing and fail to report on any metrics.
quality update chart

The size of your positive adjustments will depend both on how much data you submit and on your performance results on the data submitted

MIPS Track:

Four performance categories linked by their connection to quality and value of patient care.


Improvement Activities

Advancing Care Information


Replaces PQRS

New Category

Replaces Meaningful Use Program

Replaces Value-Based Modifier

2017 Weight:


2017 Weight


2017 Weight


2017 Weight


Report up to 6 quality measures including one outcome measure for a minimum of 90 days

Attest completion of up to 4 improvement activities for a minimum of 90 days

Fulfill the required measures for a minimum of 90 days: -Security Risk Analysis - e-Prescribing -Provide Patient Access -Send Summary of Care - Request/Accept Summary of Care

Choose to submit up to 9 measures for a minimum of 90 days for additional credit

No data submission is required. Calculated form adjudicated claims.

Groups in APMs qualifying for special scoring under MIPS, such as MSSP Track 1 or the Oncology Care Model: Report quality measures through your APM, no additional reporting.

Groups in APMs qualifying for special scoring under MIPS, such as MSSP Track 1 or the Oncology Care Model: Will receive full credit.



McLaren Physician Partners will report quality measures on behalf of its ACO providers

Participants certified by BCBSM as patient-centered medical homes or who participate in the McLaren ACO: Will automatically earn full credit for this category and avoid negative penalty in 2019




APM Track:

  • A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care.
  • APMs can apply to a specific condition, a care episode, or a population.
  • Advanced APMs are a subset of APMs and let practices earn more for taking on some risk related to patient outcomes.
    • Advanced APM Criteria:
      1. Certified EHR technology-at least 50% providers use certified EHR technology.    
      2. Must evaluate quality of care using evidence-based measures, comparable to those used in MIPSMu
      3. st require that entities incur more than a nominal amount of financial risk for spending above a set benchmark
    • May earn a 5% Medicare incentive payment during 2019-2024 and be exempt from MIPS track reporting requirements and payment adjustments if you have sufficient participation in an Advanced APM.
      1. Must receive a certain percentage of payments for covered professional services or see a certain percentage of patients through the Advance APM during the associated performance year.

Increasing Advanced APM Opportunities:

  • CMS is considering testing a new ACO (Accountable Care Organization) Track 1+ model that would be a new Advanced APM in 2018 with lower risk then currently available in Medicare ACOs.

MIPS APM scoring adjustment:

  • Applies to APMs that do not qualify as Advanced APMs but gives scoring advantage in MIPS performance categories.
  • PCMH designation by a regional plan, like the one instituted by BCBSM, qualifies for full credit given in the Improvement Activities category.
  • Cost is excluded if in an ACO, including MSSP Track 1 (only Tracks 2 and 3 count as Advanced APMs), with redistribution of cost to the advancing care information and improvement activity categories.
  • Full points are achieved in the improvement activity category if in a MIPS APM.

For more information please go to the QPP website @

If you have questions, please contact Dr. Michael Ziccardi, Medical Director at (248) 484-4923 or