May 15, 2024

From Fee for Service to Value-Based Care

The United States health care system is transitioning away from a fee-for-service payment model towards a value-based care model. This new model is intended to ensure clinicians can focus on quality and value of care rather than volume of services performed. This change was designed to allow practitioners to focus on meaningful measures and reporting quality of care.

The Centers for Medicare and Medicaid Services (CMS) is promoting high quality health care by tying Medicare reimbursement to the value of care provided. CMS uses the Merit-based Incentive Payment System (MIPS) to determine payment adjustments using a composite performance score.

Understanding MIPS

MIPS is a consolidated and streamlined version of Medicare’s legacy quality reporting programs. MIPS reduces the level of financial penalties clinicians face, but also provides a greater potential for bonus payments.

Under this payment system, physicians no longer face the threat of double-digit cuts each year as they did under the now repealed sustainable growth rate. This results in greater predictability in annual payment updates.

The Medicare Access and CHIP Reauthorization Act of 2015

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 formula.
• Changes the way that Medicare rewards clinicians.
• Streamlines multiple quality programs under MIPS.
• Gives bonus payments for participation in eligible alternative payment models (APMs).

MIPS components are weighted as follows:

• Quality (30%)
• Cost (30%)
• Promoting interoperability (25%)
• Improvement activities (15%)

Improving Practice Capacity for HIV Prevention

CMS has introduced a new MIPS Improvement Activity (IA) that is designed to incentivize improvement of practice capacity for HIV prevention. This IA is designed to further the goal of promoting HIV prevention care. It encourages clinicians to establish policies and procedures to improve practice capacity to increase HIV prevention screening and linkage to appropriate prevention resources through one or more of the following activities:

• Implement EHR prompts or clinical decision support tools to increase appropriate HIV prevention screening.
• Require that providers and staff take part in an educational program on key topics like HIV prevention screening and PrEP initiation.
• Assess and refine current HIV prevention screening policies, like integrated HIV/STI testing and PrEP initiation.

Under the new MIPS, physicians are now free to develop EHR policies in ways that blend with their workflows and improve care.

Targeted Review Requests

Each year around July, CMS notifies MIPS-eligible clinicians about their MIPS score from the previous year and corresponding payment adjustment for the following year. Clinicians who believe there was an error in calculating their payment adjustment have 60 days to submit an appeal to CMS, known as a targeted review request.

CMS makes a determination about targeted review requests on a case-by-case basis. However, some examples of targeted review circumstances include the following:

• Errors or data quality issues for the measures and activities submitted.
• Eligibility and special status issues (e.g., you fall below the low-value threshold and should not have received a payment adjustment).
• Being erroneously excluded from the APM participation list and not being scored under the APM Scoring Standard.
• Performance categories were not automatically reweighted even though you qualify for automatic reweighting due to extreme and uncontrollable circumstances.

Leveraging Academy Expertise

The Academy wants to help our members advance quality measures that:

• Minimize burdens on clinicians.
• Improve outcomes for patient.
• Increase value in care.

We want to help you leverage your expertise to help CMS continue to develop measures that contribute to building a truly value-based health care system. We look forward to partnering with you in this regard. Please feel free to reach out to our Public Policy Director at chauncey@aahivm.org with any challenges you have.