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Medicare Quality Payment Program (QPP)

Policies for 2020 & 2021 performance year

The Medicare program has transformed how it reimburses psychiatrists and other clinicians for providing services, under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The new Quality Payment Program (QPP) is designed to reward physicians for demonstrating a high level of quality of care or participating in new models of care that reward quality and efficiency. The Centers for Medicare and Medicaid Services (CMS) has issued annual rules and regulations for the 2020 and 2021 performance years. These programs may impact many psychiatrists, even those who do not participate in Medicare, since other payers are looking to these as a model for their own initiatives.

How Did the MACRA Stabilize Medicare Payments to Psychiatrists?

MACRA repealed the flawed sustainable growth rate (SGR) formula that triggered deep cuts in payments for physician services, year after year. In its place, the law requires annual, across-the-board "updates" (increases) in Medicare Part B payments of: 0.5% per year from July 2015 through 2018; 0.25% for 2019; 0% (a "freeze") from 2020 through 2025; and starting in 2026, 0.75% for "qualifying participants" in "advanced" alternative payment models (Advanced APMs), and 0.25% for all others. The Medicare Payment Advisory Commission reports to Congress each year on whether the update scheduled for the next year is sufficient. Then Congress decides whether to legislate any changes.

What are the Two Pathways Under the Quality Payment Program?

There are two pathways under the QPP for psychiatrists to earn substantial rewards. First, the Merit-Based Incentive Payment System (MIPS) replaced several Medicare quality programs and offers the first real opportunity for clinicians to receive sizable rewards for meeting quality metrics and achieving a high level of performance. Second, clinicians who participate in "Advanced APMs" can earn a 5% bonus for each year they meet the qualifying criteria.

The Merit-Based Incentive Payment System (MIPS)

Under the MIPS program, eligible clinicians or clinician groups have their performance assessed using a set of measures across several categories (see below). Based on those performance results, clinicians or clinician groups then have their payment rates adjusted for a future year; payments may be increased or decreased depending on how an eligible provider has performed against national benchmarks. The MIPS program consolidates aspects of three Medicare quality programs: the Physician Quality Reporting System (PQRS), Electronic Health Records Incentive Program/Meaningful Use (MU), and Value-Based Payment Modifier (VM). There are four MIPS performance categories: quality, promoting interoperability (formerly advancing care information), cost, and improvement activities. CMS has made a commitment to ease physicians' administrative burden and maintain flexibility in this program.

Who are MIPS "Eligible Clinicians"?

Initially, the MIPS program limited "eligible clinicians" to physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists. Starting with performance year 2019, CMS added other types of non-physician practitioners, including clinical psychologists and clinical social workers.

The MIPS program applies only to psychiatrists (and other eligible clinicians) who either participate in Medicare or have "non-participating" status in Medicare. It does not apply to psychiatrists who formally "opt out" of Medicare and are paid directly by Medicare beneficiaries under private contract.

The program covers only Medicare Part B payments for "physician services" covered by the Medicare Physician Fee Schedule. This includes payments to psychiatrists for seeing patients in Federally Qualified Health Centers and Rural Health Clinics, if those payments are separate from the federal bundled payment. The MIPS program does not apply to services or payments covered by Medicare Part A (hospitals, etc.); Part C (Medicare Advantage); Part D (prescription drug plans); Medicaid; or private payers.

What if I Have Few Medicare Patients, Just Enrolled in Medicare, Or Participate in an Advanced APM?

Many psychiatrists will be exempt from MIPS reporting requirements and payment adjustments, because they fall below the "low-volume threshold." For the 2020 performance year, CMS defined this threshold to exclude any individual psychiatrist or group practice which either: (a) billed less than $90,000 for Part B covered professional services; (b) saw fewer than 200 Part B patients; and (c) provided fewer than 200 covered professional services to Part B patients. So only those psychiatrists or practices with over $90,000 in Medicare Part B covered charges AND over 200 Medicare Part B patients –per year– will be subject to 2020 MIPS reporting requirements and 2022 payment adjustments.

Psychiatrists and other MIPS-eligible clinicians are also excluded from MIPS if they just enrolled in Medicare that year. In addition, psychiatrists who are "qualifying participants" in an Advanced APM are exempt from MIPS reporting and payment adjustments. Those who are "partially qualifying participants" can choose whether to participate in MIPS. If they choose to report, they will receive a MIPS payment adjustment. If they choose not to report, there will be no MIPS adjustment.

How Will I Know if I'm Excluded from MIPS?

CMS has created a MIPS Lookup Tool that allows psychiatrists to check their MIPS participation status. Just enter your National Provider Identifier (NPI) number to see if you are excluded. CMS reviews past claims to see who falls under the low-volume threshold. For each MIPS performance year, psychiatrists will have two 12-month time periods in which to qualify. They can be excluded if their Medicare Part B allowed charges or beneficiaries are within the low-volume threshold in either (or both) of these periods.

The low-volume analysis will be calculated separately at the individual NPI level, and then also at the group TIN (Tax Identification Number) level, depending on how each psychiatrist is paid. Those who are paid through both their NPI and one or more TINs may be excluded with respect to their NPI billings, but not with respect to the TIN(s). This may be true for many psychiatrists, as group practices are subject to the same low-volume threshold as individual practices.

Eligible clinicians who are not subject to MIPS requirements may still submit MIPS data and receive a MIPS composite score. However, they will not receive a MIPS payment adjustment.

MIPS Reporting, Scouring and Adjustments

For the 2020 and 2021 performance periods, the maximum negative payment adjustment is -9%, and positive payment adjustments can be up to 9%. Overall payment adjustments must be budget-neutral, so individual upward adjustments will be "scaled" so the annual totals of all bonuses and penalties are roughly equal. The negative adjustments cannot go above the annual ceiling for that year. There is an additional, separate bonus from 2019 through 2024 for "exceptional performers" who score in the top 30%. This bonus can be up to an extra 10%. The exceptional performance bonuses have separate funding, of up to $500 million per year.

What Goes Into My MIPS Composite Score?

Each eligible clinician or group receives a MIPS composite score that will determine their future MIPS payment adjustment. They will be compared to a "performance threshold" for that year, which is based on the median performance of all eligible clinicians from a prior period. Scoring above the performance threshold results in a positive adjustment (addition); scoring below it yields a negative adjustment (reduction). There is no adjustment if you score at the threshold. Adjustments apply to all Medicare Part B payments during the second year after the performance year. So 2020 performance determines 2022 adjustments, 2021 performance determines 2023 adjustments, etc.

The composite score is made up of individual scores for four different performance categories. There is some flexibility in how these are weighted, but they generally count as described below:

MIPS Quality Performance Category

Quality counts for 60% of the composite score for the 2020 performance year and 40% for 2021 reporting. This category builds on the Physician Quality Reporting System (PQRS) but has more reasonable reporting standards. PQRS required the reporting of nine quality measures across three National Quality Strategy "domains." The MIPS requirement is to report six quality measures, including one outcome measure if one is available — or one measure of appropriate use, patient safety, efficiency, patient experience, or care coordination. The MIPS continued most valid PQRS quality measures and added measures used by private payers and for different settings. There is a "Mental/Behavioral Health" measure set with 22 measures relevant to psychiatrists. The MACRA also included $75 million to fund development of new quality measures.

MIPS Cost Performance Category

For the 2021 performance period, the Cost category will count for 20% of your MIPS score. There is no specific reporting for this category, as it will be calculated by CMS. The Cost category replaces the Value-Based Payment Modifier (VM). Future Medicare claims will need to include special codes indicating the correct 1) care episode, 2) patient condition, and 3) physician's relationship to the patient. These codes will help link patients to the right clinicians for measuring the MIPS Cost score.

MIPS Promoting Interoperability (PI) Performance Category

For the 2021 performance period, this category (formerly known as Advancing Care Information) will count for 25% of your MIPS score. In order to pass this category, a psychiatrist must either use certified electronic health record technology (CEHRT) or qualify for a hardship exception. The hardship exceptions include:

  1. MIPS eligible clinician in a small practice
  2. MIPS eligible clinician using decertified EHR technology
  3. Insufficient Internet connectivity
  4. Extreme and uncontrollable circumstances
  5. Lack of control over the availability of CEHRT

Psychiatrists must report five measures to achieve a Base Score. Then they can earn points for reporting up to eight measures for their Performance Score. Bonus points are also given for certain MIPS Improvement Activities.

MIPS Improvement Activities (IA) Performance Category

This category counts for 15% of your score. There are 105 activities for 2021, including nine "Integrated Behavioral and Mental Health" activities, such as collaborative care. All but a few of these activities must be done for at least 90 consecutive days to receive credit. Psychiatrists may already be doing several of these activities on a regular basis. Improvement Activities are assigned 'high,' 'medium,' or 'low' weights; to achieve full credit, clinicians must submit one of the following combinations of activities:

  • 2 high-weighted activities;
  • 1 high-weighted activity and 2 medium-weighted activities; or
  • 4 medium-weighted activities.

The requirements are lower for small and rural practices and those in health professional shortage areas (HPSAs). Participants in recognized or certified patient-centered medical homes or comparable specialty practices earn the maximum Improvement Activity performance category score simply by attesting to this during the submission period.

Special Statuses

Clinicians or groups that meet certain requirements, including small practices and those serving health professional shortage areas (HPSAs), may qualify for automatic re-weighting of some QPP performance categories or other special statuses. For example, clinicians practicing in HPSAs earn double the points for each improvement activity.

What are the MIPS Reporting Methods and Options?

The MIPS program preserves most reporting methods of the previous Medicare quality programs. These include qualified clinical data registries (QCDRs), qualified registries, electronic health records, claims (for Quality) and administrative claims/no submission required (for Quality and Cost). Attestation is another method, for the IA and PI categories. Groups of 25 or more may also use the CMS Web Interface. Vendors approved by CMS can report the "CAHPS for MIPS" patient surveys. CMS has also created an online portal for direct submission of all MIPS data. However, beginning with the 2022 performance period, the CMS Web Interface will sunset as a collection/submission type. Starting with the 2018 performance year, CMS began to allow small and solo practitioners to form "virtual groups" to report and be assessed together.

Reporting Through QCDR (such as PsychPRO)

The MIPS program encourages and rewards reporting via QCDRs by individuals and group practices. This is the easiest way to do MIPS reporting, as the QCDR does the actual data capture and reporting. In addition to being less burdensome, QCDR reporting can earn credit under the PI and IA categories, potentially leading to higher MIPS scores and higher bonuses. QCDR measures can also be directly approved by CMS, which avoids the lengthy, complex review process for approval by the National Quality Forum. PsychPRO, the APA mental health registry, is an approved QCDR and can assist psychiatrists (and other mental health professionals) in MIPS reporting. Visit the PsychPRO Registry page for more information.

"Virtual Group" Reporting

Starting with the 2018 performance year, solo practitioners and small practices (of up to 10 MIPS eligible clinicians) can form a voluntary "virtual group" for the purposes of MIPS reporting and assessment. Each participant must exceed the MIPS low-volume threshold. The virtual group can submit their MIPS data together, and their performance will be assessed as a group. This can allow small practices to pool resources and potentially streamline their MIPS reporting. The deadline to sign up as a virtual group for performance year 2021 was December 31, 2020.

Incentives for "Advanced" Alternative Payment Models

Psychiatrists, other physicians, and non-physician practitioners may qualify for Medicare payment incentives for participating in new models of care and delivery that improve quality, lower health care spending, or both.

Some may be eligible for 5% incentive payments, from 2019 through 2024, if they have sufficient revenue or patients tied to these new models of care to be considered a "qualifying participant" in an "Advanced" Alternative Payment Model (APM). They are also exempt from the MIPS program and will receive slightly higher annual payment increases starting in 2026.

Those with slightly lower levels of revenue or patients tied to Advanced APMs may be considered "partially qualifying participants." They can elect not to do MIPS reporting, and not incur a penalty.

To be considered an Advanced APM, a model must be approved by CMS and meet the following criteria:

  1. Requires participants to use certified EHR technology;
  2. Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and
  3. Either:
    1. is a Medical Home Model expanded under CMS Innovation Center authority, or
    2. requires participants to bear a significant financial risk.

CMS has approved the following models as Advanced APMs for the 2020 performance year:

  • Bundled Payments for Care Improvement (BPCI) Advanced
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Accountable Care Organization (ACO) Track 1+ Model
  • Medicare Shared Savings Program – Track 2, Track 3, Level E of the BASIC track, the ENHANCED track
  • Next Generation ACO Model
  • Oncology Care Model (OCM) – Two-Sided Risk
  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1-CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
  • Comprehensive ESRD Care (CEC) Model (LDO arrangement and Non LDO Two Sided Risk Arrangement)
  • Maryland Total Cost of Care Model (Care Redesign Program and Primary Care Program)

There is currently no Advanced APM strictly for mental health or substance use disorders.

The Physician-Focused Payment Model Technical Advisory Panel (PTAC) reviews proposals for new APMs. But current policies make it very difficult to develop Advanced APMs for mental health. Psychiatrists who are currently underpaid would have to risk up to an 8% payment reduction if the APM fails to produce cost savings. Meeting the CEHRT requirements is also a challenge. Unless these policies improve, psychiatrists will probably continue to see few options for participating in Advanced APMs.

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