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Quality Reporting in 2016 and Beyond: PQRS Giving Way to MIPS and APMs

April 4, 2016

One of the core functions of CMS has always been to drive quality improvement through the use of voluntary reporting programs, such as the Physician Quality Reporting System (PQRS). Originally established under the Tax Relief and Health Care Act of 2006 (TRHCA), the program provides financial incentives to eligible providers who successfully report quality data related to the services provided to Medicare beneficiaries. Providers have been participating in this program since 2007, but that participation will be changing as a result of recently passed legislature that takes aim at addressing CMS’s reimbursement methodologies.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law on April 16, 2015. MACRA addresses Medicare payment reform by focusing on three changes to the current reimbursement methodology: ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments, creating new framework for delivering incentive payments to providers for better care, and combining the current quality reporting programs/systems into one, new system. The implementation of MACRA requirements will occur over a timeline through 2021, but changes in the quality program portion of the law will begin with encounters beginning January 2017. In an effort to help CMS move towards their goal of paying for quality health care services, providers will be able to participate in quality programs in one of two new ways.

The Merit-Based Incentive Payment System, or MIPS, is the new system that combines parts of PQRS, the Value-Based Modifier (VBM), and the Medical Electronic Health Record (EHR) programs into one new system. The MIPS program is based on four parts: quality, resource use, clinical practice management, and the meaningful use of certified EHR technology. Beginning in 2019, eligible providers will receive a single MIPS composite performance score based on the information submitted through the MIPS program. Based on the composite performance score, eligible providers will receive positive, negative, or neutral adjustments beginning at 4% in 2019 and topping out at 9% in 2022. MIPS adjustments are budget neutral, so scaling factors may be applied to positive adjustments to offset the downward adjustment. The national bonus pool that has been established for each year of the program is set at $500 million dollars.

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