QPP Made Simple(r)

TMA Helps Physicians Advocacy Institute Launch Vast MACRA Resource Center

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Quality Feature — October 2017

Tex Med. 2017;113(10):31-36. 

By Joey Berlin
Associate Editor

Less than a year into its existence, the Quality Payment Program (QPP) already has been a bear for many physicians to navigate and comprehend. And it isn't likely to get any easier on its own.

Dallas public health physician John Carlo, MD, chair of the Texas Medical Association Council on Socioeconomics, says he's heard widely varying physician reactions to QPP, a product of the Medicare and CHIP Reauthorization Act (MACRA) of 2015.

"We've heard some groups have become early adopters. Some are ignoring it," Dr. Carlo said. "In fact, even some I've heard have quit their practice or used it as the final straw to end or sell their private practice."

Obviously, physicians need help ― lots of it ― understanding the QPP as they drown in confusing language and more acronyms than incentive payment dollars. That's why the Physicians Advocacy Institute (PAI), composed of several state medical societies including TMA, is doing its best to make the program clearer.

PAI, with the help of Washington, DC-based consulting firm Healthsperien, has completed phase one of an ongoing effort both to improve MACRA and to make it easier to understand. The major product of that first phase is an online MACRA QPP Resource Center, which offers a wealth of knowledge through guides, video tutorials, frequently asked questions, and more. (See "Valuable Resources.")

The website is free to use, designed for all levels of physician knowledge on MACRA, and complements TMA's MACRA Resource Center. And with TMA's help, PAI continues its work for medicine on all things MACRA. 

"We believe that we have achieved our goal of establishing the most comprehensive set of educational resources available to physicians," said Kelly Kenney, chief executive officer of PAI.

Working With PAI

Dr. Carlo, the chief executive officer of Prism Health North Texas, believes some physicians misperceived QPP as an entirely new reporting program, when actually programs such as the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier program, and meaningful use were folded into it. Under MACRA, those three programs were replaced with the Merit-Based Incentive Payment System (MIPS), one of two QPP tracks physicians can choose.

"The elements were all there prior to MACRA. It's just that it all got put together under a single system. We were doing PQRS and meaningful use and all the other stuff already, so this really wasn't that new," Dr. Carlo said. "It's just I think the messaging and how it came across, it appeared to be new, but it really wasn't anything different."

However, Dr. Carlo's office has experienced some of the frustrations of QPP firsthand. He says the biggest challenge was to obtain an electronic health record (EHR) system that could handle the necessary reporting, and "a lot of our work" involves backtracking to double-check whether staff entered the EHR reporting data correctly.

"It's very onerous," he said. "We've had quite a few people taking time to do it. The difficult part is, when you make the change, it takes somewhere [around] 24 to 48 hours for your system to update. So you might put a new set of information in, then you have to go back the next day [and] see if it made a difference."

Questions about EHR requirements are among the issues PAI tackles on the online resource. PAI, which works to "advance fair and transparent payment policies and contractual practices by payers and others," was formed out of the ashes of an early 2000s class-action lawsuit against several for-profit HMOs. As PAI's website explains, the suit alleged the health plans had "systematically denied and/or reduced payment to physicians who had delivered services to covered patients."

The case resulted in a number of settlements, including one with Prudential Insurance Company of America that directed settlement funds to be used "to address issues relating to abuses of managed care." Under the terms of that settlement, PAI was formed "to continue the momentum to restore fairness" in the business practices of managed care.

TMA is a charter member of PAI, and its board contains members of nine state medical societies, including TMA Executive Vice President Louis J. Goodman, PhD, the PAI treasurer.

Dr. Goodman says the PAI/Healthsperien's QPP project was geared toward doing four things for physicians:   

  • Help them make a decision on how to participate, such as determining their initial participation level for 2017, which featured several options for data reporting;
  • Help them decide how they are going to prepare, such as by introducing an EHR system into their practice; 
  • Provide a roadmap to a seamless transition to MIPS participation; and
  • Provide a pathway for physicians and groups that want to use the other QPP track: an advanced alternative payment model (APM).   

"I think at this point, there's so much red tape and regulation and burden on our doctors that our challenge was to make it as understandable and simple as possible," Dr. Goodman said.

Gary Bacher, a founding member of Healthsperien, says the group worked "very, very closely" with physicians. "We wanted to make sure as we did this that it didn't become a set of materials that would, so to speak, sit on the shelf ― that they'd be much more accessible to people," he said

"And we also realized in doing that … that the physician community is not monolithic," he added. "There are many different kinds of physicians and different types of practices." Mr. Bacher pointed out that the guide must address the different challenges QPP presents to employed physicians, those in small and large groups, and multispecialty practices.

Another consideration was building the website for any level of QPP expertise ― including none at all. Each state medical society brought input from its member physicians on what their questions and issues with QPP were or could be.  

"While it's available to all physicians in the country, TMA's involvement reflects the specific nature of Texas physicians. It was really important to have that kind of local input," Ms. Kenney said.

Looking Ahead to MACRA's Future

Ray Quintero, a principal for Healthsperien, says phase two of the project will involve expanding the site's QPP resources.

"Much of phase two will continue to be listening to physicians in the field, and so much of that is reliant upon what TMA and the other state associations are hearing and PAI is hearing directly," he said. "As physicians are starting to become more active in the QPP, they're starting to have more questions overall, as well as more elaborate questions."

Ms. Kenney says PAI will update the QPP resource center as needed to reflect any changes to MACRA. And updates likely will be needed before too long: The Centers for Medicare & Medicaid Services (CMS) released its 2018 proposed rule to revise the QPP in June.

CMS said in a release its goal was to "simplify the program, especially for small, independent, and rural practices, while ensuring financial sustainability and high-quality care within Medicare."

"We've heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient," CMS Administrator Seema Verma said in the release. "That's why we're taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork."

In August, TMA and PAI both submitted formal comments on the proposed rule. "We continue to be concerned that the compliance, documentation, and reporting necessary to score well in the Quality Payment Program are prohibitively costly for many physicians," TMA wrote. "CMS should continue efforts to streamline and simplify all reporting and compliance requirements."

PAI's comments emphasized how important it will be to "give physicians an opportunity to [have] continued flexibility to participate in the program more incrementally without being penalized," Ms. Kenney said. 

The comments also stressed allowing physicians to organize into collaborative arrangements that can qualify for the advanced payment model track, she says.

Mr. Quintero said it's often difficult for Healthsperien to get the kind of feedback it needs, but the voices of TMA staff and physicians "have really been instrumental in the work that we've been doing." 

"I think this collaboration underscores how much expertise exists out in the state medical associations," Ms. Kenney said. "And when you bring that all together with a good process, a lot of positive things can come of it."

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email


The 11 Steps

The Physicians Advocacy Institute's MACRA QPP Resource Center covers 11 steps to navigate the Quality Payment Program (QPP), with details to help physicians achieve each step:  

  1. QPP introduction
  2. Determining your eligibility and exemption status
  3. Medicare payment under the QPP
  4. Understanding MIPS basics
  5. Avoiding the 2019 penalty ― the minimum you need to do in 2017
  6. Participating in the QPP without an electronic health record
  7. Reporting individually or as a group
  8. Getting credit in the QPP for already being part of an alternative payment model (APM)
  9. Two pathways ― MIPS and advanced APMs: Which pathway is best for you?
  10. Differences between a MIPS APM and an advanced APM
  11. Where to go for more QPP resources  



TMA Practice Consulting can help prepare physician practices for the transition under the Medicare Access and CHIP Reauthorization Act (MACRA). TMA's practice management consultants can conduct a MACRA readiness assessment of your practice and provide customized on-site assistance to help you with your practice's specific needs. The assessment will focus on clinical processes, electronic health record optimization, and workflow improvement opportunities to help increase your Merit-Based Incentive Payment System (MIPS) scoring. TMA is dedicated to working with you and your practice to earn an incentive payment, not just to avoid the penalty. To learn more, email TMA Practice Consulting  or call (800) 523-8776.

TMA PracticeEdge can help physicians form accountable care organizations, which would allow them to pool resources and participate in the Quality Payment Program (QPP). For more information, visit www.tmapracticeedge.com.


Valuable Resources

Tthe Physician Advocacy Institute's (PAI's) resource center on the Quality Payment Program (QPP) reflects that all-encompassing, big-tent effort.

The website's front page has seven sections: 

  • Background Resources: Provides an overview of MACRA, the QPP's two participation pathways, and more; explains how QPP affects fee-for-service payments for Medicare Part B; and includes a glossary of QPP-related acronyms ― so, so many acronyms ― that cause physicians twisted synapses and letter overload.
  • Navigating the QPP: Features an 11-step guide to familiarizing yourself with the program (see "The 11 Steps" above).
  • MIPS Pathway: Presents an overview of MIPS, including guidance on its four performance categories for 2017 and an overview of scoring across each category
  • Advanced APM Pathway: Focuses on the rules for participating in the QPP through an advanced alternative payment models (APMs), with specific guidance for different types of payment models and a side-by-side comparison of advanced APMs.
  • Video Library: Contains five video tutorials, which collectively provide a high-level overview of MACRA, as well as information on the four 2017 performance categories for MIPS; advanced APMs; and MIPS APMs.
  • FAQs: Provides a searchable frequently-asked-questions section.
  • QPP Updates: Contains a paper listing five guiding principles PAI has identified to reform and improve the QPP. 
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