What’s New for the Quality Payment Program in 2023

The Centers for Medicare & Medicaid Services (CMS) finalized several updates to meet 2023 participation requirements for year 7 of the Quality Payment Program (QPP). There are two ways to participate in the QPP—report via the Merit-Based Incentive Payment System (MIPS) or sufficient participation in an Advanced Alternative Payment Model (APM).

Beginning in 2023, clinicians eligible for MIPS may choose to participate through a MIPS Value Pathway (MVP), which is a new, alternative reporting pathway to traditional MIPS. Whether you participate via traditional MIPS or an MVP, your score will continue to be calculated based on the following MIPS performance categories:

Quality: Aims to measure the quality of the care delivered
Improvement Activities (IA): Includes an inventory of activities that assesses how clinicians improve care processes, enhances patient engagement in care, and increases access to care
Promoting Interoperability (PI): Focuses on the use of certified electronic health record (EHR) technology (CEHRT) to manage patient engagement and the electronic exchange of health information
Cost: Evaluates a clinician’s total cost of care during the year, a hospital stay, or a specific episode of care for attributed patients (CMS automatically calculates the cost category using Medicare claims.)

An MVP includes a subset of measures and activities across the quality, IA, and cost performance categories focused on specific specialties, conditions, or patient populations. The framework also incorporates PI measures and a foundational set of population health-focused administrative claims-based quality measures that are foundational elements of all MVPs. For the 2023 performance year, clinicians can choose from 12 MVPs (see Table 1).

The current MVP framework relies on siloed performance categories and other restrictive elements of MIPS. However, the College continues to work with CMS to develop MVPs that reflect a more comprehensive quality framework, much like the ACS Quality Programs that focus overarchingly on the care of the patient, including the goals and outcomes important to the patient, while also valuing the infrastructure, resources, and processes needed to deliver optimal care and improvement.

Figure 1: MVPs Available for Reporting in 2023

Advancing Cancer Care	Optimal Care for Kidney Health	Optimal Care for Patients with Episodic Neurological Conditions
Supportive Care for Neurodegenerative Conditions	Promoting Wellness	Patient Safety and Support of Positive Experiences with Anesthesia
Optimizing Chronic Disease Management	Adopting Best Practices and Promoting Patient Safety with Emergency Medicine	Advancing Care for Heart Disease
Improving Care for Lower Extremity Joint Repair	Advancing Rheumatology Patient Care	Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes

MVP Reporting Requirements

MVPs are constructed with quality measures, IAs, and cost measures that align across an episode of care or clinical condition. As described in Table 2, if a surgeon chooses to participate in an MVP, he or she must select quality and IAs from the MVP to report. The cost measures associated with the MVP will be calculated by CMS using administrative claims measures, if the clinician or group has attributed enough patients under the measure (like traditional MIPS).

MVPs also incorporate population health measures and the PI performance category as a foundational layer. Similar to the cost measures, clinicians and groups are scored only on population health measures if a sufficient number of patients has been attributed (see Table 3).

Figure 2. Reportable MVP Quality, IAs, and Cost

Quality Requirements	Improvement Activities Requirements	Cost Requirements
MVP participants should select four quality measures from the MVP measure inventory. One of the measures they select must be an outcome or high priority measure.	MVP participants must select: Two medium-weighted IAs OR One high-weighted IA OR Participate in a certified or recognized patient-centered medical home or comparable specialty practice	CMS calculates an MVP participant's cost score using the cost measures that are included in the MVP based on administrative claims data. Each MVP only includes cost measures relevant to the topic. There is no reporting requirement for the category and CMS will only calculate their cost scores based on the measures in the MVP.

Figure 3: Foundational Layer

Population Health Measures	PI Requirements
MVP participants must select one population health measure. The results of the population health measure are added to their quality performance score.	The PI requirements for MVPs are the same as traditional MIPS, unless the MVP participant qualified for automatic reweighting or has an approved hardship exception.

How MVPs Are Scored

MVP scoring largely aligns with traditional MIPS. The performance category weights will remain consistent with what has been finalized for MIPS in 2023. The same reweighting policies also will be applied to MVPs.

Subgroup Reporting

Beginning in 2023, subgroup reporting will be an option for those reporting MVPs. Through subgroup reporting, multispecialty groups will have the option to create subgroups to report performance information that is relevant to specific specialists or care teams within the larger group. Although subgroup reporting is initially voluntary for MVP participants, beginning in 2026, multispecialty groups will be required to form subgroups to report MVPs.

Some stakeholders are concerned about the potential classification of a group with a single clinical focus as a multispecialty group and have asked how this impacts the requirement for multispecialty groups to form subgroups.

The ACS has advocated for CMS to use subgroup reporting to recognize team-based care. However, the College has opposed making subgroup and MVP reporting mandatory until physicians have had enough time to re-engineer how they report quality, determine the necessary structures and processes, incorporate safety and outcome measures, and make the business case for participating in MVPs and as a subgroup.

At this time, CMS has not yet proposed any limits on the composition of a subgroup other than restricting an individual clinician to only one subgroup within a group. The agency is exploring options for allowing clinicians to participate in multiple subgroups in the future. CMS also will provide additional guidance as appropriate in the future and consider additional policies to ensure that subgroups best represent clinical coherence.

MIPS Scoring Policies for 2023

Many MIPS scoring policies—which apply to both traditional MIPS and the new MVP framework—will remain the same from the 2022 performance period to the 2023 performance period. For 2023, the performance threshold, or the number of overall MIPS points required to avoid a payment penalty for the 2025 payment year, remains set at 75 points. However, beginning with the 2023 performance year, the exceptional performance bonus is no longer available. The performance category weights also are unchanged. Quality and cost both contribute 30% to the MIPS overall score, PI contributes 25%, and IA remains at 15%. Surgeons should refer to the ACS QPP resources for more details about the 2023 MIPS policies.

Note that MIPS-eligible clinicians will receive the highest final score that can be attributed to their Taxpayer Identification Number (TIN)/National Provider Identifier combination from any reporting option (traditional MIPS, APM Performance Pathway, or MVP) and participation option (individual, group, subgroup, or APM Entity), with the exception of virtual groups. Clinicians who participate as a virtual group always will receive the virtual group’s final score.

All surgeons should use the QPP Participation Status Lookup tool (qpp.cms.gov/participation-lookup) to determine if they are required to participate in MIPS in 2023, and if they fall into any special status categories (qpp.cms.gov/mips/special-statuses) such as facility-based, which could alter their reporting requirements.

New Policies for the Quality Category

CMS previously finalized the following policies, which will go into effect with the 2023 performance period:

Removal of the three-point floor for quality measures with a benchmark. Measures with a benchmark (unless surgeons are in their first 2 years of the MIPS program) will be worth between one and 10 points.
Measures without a benchmark will no longer be eligible for three points. If surgeons report a measure without a benchmark, they will receive zero points, unless the measure is new to the program or the surgeon is part of a small practice.
Measures that do not meet the case minimum (at least 20 patients) will no longer be eligible for three points. If surgeons report a measure that does not meet the case minimum, they will receive zero points, unless the measure is new to the program or the surgeon is part of a small practice.

CEHRT Changes for the PI Category

The PI category focuses on how clinicians use CEHRT to manage patient engagement and the electronic exchange of health information. To receive a score in this category, use of technology that is certified under the Office of the National Coordinator for Health IT’s certification program is required.

Beginning this year, MIPS-eligible clinicians and groups must use EHR technology to report PI that is updated to meet the requirements of the 2015 Edition Cures Update (healthit.gov/topic/certification-ehrs/2015-edition-cures-update-test-method). To find out if your EHR is federally certified in compliance with this update, search the Certified Health IT Product List (chpl.healthit.gov/#/search).

Maximum Payment Adjustments

As determined by the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA), the maximum negative payment adjustment for the 2025 payment year based on 2023 performance is -9%. Because MIPS is a budget-neutral program, the total amount of funding available for positive payment adjustments cannot be determined until CMS knows the total amount of negative payment adjustments in any given year. It is important to keep in mind that the maximum positive payment adjustments to date have not exceeded 2.5% (payment adjustments were 1.88% in 2019, 1.68% in 2020, 1.79% in 2021, and 2.33% in 2022).

Advanced APMs

Clinicians who receive a substantial portion of their reimbursement or see a substantial number of patients under what CMS designates as an advanced APM are considered qualifying participants (QPs).

Advanced APMs bear more than nominal risk and must have a certain percentage of their participating clinicians using CEHRT. For 2022, QPs are exempt from MIPS and instead qualify for a lump sum bonus payment in 2024, based on 5% of their Part B allowable charges for covered professional services in 2023 (across all TINs they may practice under, which can result in a substantial bonus).

However, under MACRA, the 5% incentive payment ends after the 2022 performance year (2024 payment year). Going forward, QPs instead will be eligible for a larger annual base conversion factor update under the Medicare Physician Fee Schedule (0.75%) compared to non-QPs (0.25%), who also may be eligible for MIPS payment adjustments.

Starting in 2023, the payment and patient thresholds to qualify as a QP also increase, which will make it more challenging for clinicians to qualify for this track of the QPP. The ACS continues to push Congress for an extension of the 5% APM incentive payment and to maintain the current thresholds.

Haley Jeffcoat is a Quality Affairs Associate and Jill Sage is a Quality Affairs Manager in the ACS Division of Advocacy and Health Policy in Washington, DC.