What are the value-based programs?
Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support our three-part aim:
- Better care for individuals
- Better health for populations
- Lower cost
Why are value-based programs important?
Our value-based programs are important because they’re helping us move toward paying providers based on the quality, rather than the quantity of care they give patients.
What are CMS’ original value-based programs?
There are 5 original value-based programs; their goal is to link provider performance of quality measures to provider payment:
- End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
- Hospital Value-Based Purchasing (VBP) Program
- Hospital Readmission Reduction Program (HRRP)
- Value Modifier (VM) Program (also called the Physician Value-Based Modifier or PVBM)
- Hospital Acquired Conditions (HAC) Reduction Program
Are there other value-based programs?
MACRA
What's MACRA?
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015.
MACRA created the Quality Payment Program that:
- Repeals the Sustainable Growth Rate (PDF) formula
- Changes the way that Medicare rewards clinicians for value over volume
- Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
- Gives bonus payments for participation in eligible alternative payment models (APMs)
- MACRA also required us to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019.
Quality Payment Program
You can learn more about the Quality Payment Program at qpp.cms.gov and on our CMS.gov pages. On 11/1/17, we moved the Quality Payment Program content you’re used to finding here to our new CMS.gov Quality Payment Program pages.
What's new?
Measure Development for the Quality Payment Program
On September 21, 2018, we selected 7 applicants to receive cooperative agreement awards through the “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity: Measure Development for the Quality Payment Program.”
The cooperative agreements give financial and limited technical support to:
- Develop
- Improve
- Update or Expand measures to use in the Quality Payment Program.
- Measures for consideration include.
- Outcome measures such as patient-reported outcome and functional status measures.
- Patient experience measures.
- Care coordination measures.
- Measures of appropriate use of services.
- We’re committed to advancing quality measures that.
- Minimize burden on clinicians.
- Improve outcomes for patients.
- Drive value in care.
It’s critical that we leverage the expertise and insight of those on the front lines to develop measures that make the most sense and contribute to building a truly value-based healthcare system. We look forward to partnering with these organizations.
Learn about the awardees and the measure(s) they’re developing (PDF) and read our frequently asked questions (PDF).
New Medicare cards
MACRA required us to remove Social Security Numbers (SSNs) from all Medicare cards. Replacing SSNs on all Medicare cards helps to better protect:
- Private health care and financial information
- Federal health care benefit and service payments
MIPS
What is MIPS?
CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program, which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.
Performance is measured through the data clinicians report in four areas – Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. We designed MIPS to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).
How it Works
There are four performance categories that make up your final score. Your final score determines what your payment adjustment will be. These categories are
Improvement Activities
This is a new performance category that includes an inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. The inventory allows you to choose the activities appropriate to your practice from categories such as, enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.
How it Works
This is a new performance category that includes an inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. The inventory allows you to choose the activities appropriate to your practice from categories such as, enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.
Quality
This performance category replaces PQRS. This category covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups. You pick the six measures of performance that best fit your practice.
Promoting Interoperability (PI)
CMS is re-naming the Advancing Care Information performance category to Promoting Interoperability (PI) to focus on patient engagement and the electronic exchange of health information using certified electronic health record technology (CEHRT). This performance category replaced the Medicare EHR Incentive Program for EPs, commonly known as Meaningful Use. This is done by proactively sharing information with other clinicians or the patient in a comprehensive manner. This may include: sharing test results, visit summaries, and therapeutic plans with the patient and other facilities to coordinate care.
Improvement Activities
This is a new performance category that includes an inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. The inventory allows you to choose the activities appropriate to your practice from categories such as, enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.
Cost
This performance category replaces the VBM. The cost of the care you provide will be calculated by CMS based on your Medicare claims. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. Beginning in 2018, this performance category will count towards your MIPS final score.
Why
MIPS was 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.
When
The MIPS Performance Year begins on January 1 and ends on December 31 each year. Program participants must report data collected during one calendar year by March 31 of the following calendar year. For example, program participants who collected data in 2017 must report their data by March 31, 2018 to be eligible for a payment increase and to avoid a payment reduction in 2019.