2023 MACRA Quality Payment Program

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 introduced the Quality Payment Program (QPP) to replace the sustainable growth rate (SGR). Congress passed MACRA with the intent to spur a transition towards rewarding physicians based on the quality and value of the care they provide. The QPP was first implemented in 2017 and offers two participation pathways—the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

The 2023 performance year marks the seventh year of the QPP.

MIPS consolidated three legacy programs—the Physician Quality Reporting System (PQRS), Value-based Modifier (VBM), and Electronic Health Record (EHR) Incentive Program—and recast them as Quality, Cost, and Promoting Interoperability (PI). MIPS also introduced a new component—Improvement Activities (IA). Under MIPS, a participating clinician will receive an overall score of 1–100 points based on performance in the four MIPS performance categories, and the MIPS score will be compared to the performance threshold that is determined yearly by the Centers for Medicare and Medicaid Services (CMS). Beginning with the 2023 performance year, MIPS eligible clinicians can also choose to participate in a MIPS Value Pathway (MVP). Based on how the clinician's MIPS score compares to the performance threshold, CMS will then apply a positive, neutral, or negative payment adjustment to the clinicians Medicare Part B reimbursement for the corresponding payment year.

Surgeons can use their National Provider Identification (also known as NPI) numbers in the QPP Participation Lookup Tool to determine their QPP eligibility. To be eligible for MIPS, clinicians must exceed the low-volume threshold, which is defined by allowed charges, the number of Medicare patients served, and the number of covered professional services the clinician provides to Part B patients. A clinician who bills more than $90,000 for Medicare Part B-covered services, sees more than 200 Part B patients and provides more than 200 covered professional services to Part B patients will be required to participate in MIPS. In the Lookup Tool, clinicians can find their MIPS eligibility status for each Taxpayer Identification Numbers (TINs) that they are associated with and may be required to participate in MIPS under each of the unique TIN/NPIs. CMS also provides eligibility information at the group level.

Surgeons can participate in the QPP at the individual, group, subgroup, and/or APM Entity level (if applicable). If a clinician participates at multiple levels and has multiple MIPS final scores, CMS will use the highest for that unique TIN/NPI. Once eligibility is determined, surgeons should understand at what level their employer or group plans to participate in the QPP (for example, at the individual, group, subgroup, or even at the APM Entity level) and how this may have changed since previous years.

The APM track of the QPP was developed with a goal to improve quality and value of care and reduce growth in health care spending. APMs can apply to a specific clinical condition, care episode, or whole population. MACRA implemented a 3.5 percent Medicare incentive payment for clinicians who participate sufficiently in advanced APMs for the 2023 performance year.