Medicare Quality Payment Programs

The Medicare Accessibility and CHIP Reauthorization Act (MACRA) introduced several changes to the physician reimbursement framework. MACRA replaced the Sustainable Growth Rate formula with the Quality Payment Program (QPP) to provide incentives that emphasize value and quality of care over volume. The QPP is comprised of four performance categories: Quality, Improvement Activities, Cost and Promoting Interoperability.

Under the QPP, clinicians can participate in either the Merit-Based Incentive Payment System (MIPS) or in Advanced Alternative Payment Models (APMs) to avoid downward payment adjustments and potentially receive upward adjustments. CMS estimates that for the first few performance years most clinicians will follow the MIPS track.

MIPS allows Medicare clinicians to be paid for providing high-quality, efficient care through success in four performance categories as shown below. Each category is weighted and added into a final MIPS performance score:

1. Quality (30%): To complete this requirement, radiologists will need to report up to six quality measures, including an outcome measure, with 12 months of data. Quality improvement will be calculated based on performance, with up to 10 percentage points available. If there is not sufficiently complete data, zero percentage points will be given.
2. Promoting Interoperability (25%): Most ACR members will be reweighted to zero in this category as non-patient-facing clinicians or hospital-based eligible clinicians, but data may be submitted if clinicians would like to receive credit. For non-patient-facing clinicians, these 25 percentage points will be reweighted to the Quality category.
3. Improvement Activities (15%): Radiologists will be required to attest completion to up to four improvement activities. Small, rural and shortage-area practices or non-patient-facing MIPS physicians need two medium-weighted improvement activities or one high-weighted improvement activity to meet full performance score.
4. Cost (30%): The cost category will measure Medicare Spending per Beneficiary (MSPB) and Total Per Capita Cost (TPCC). Cost will be calculated using claims and will not require data submission.

Payment adjustment for the 2026 payment year (based on 2024 reporting) ranges from -9% to +9%. CMS has approved the ACR National Radiology Data Registry (NRDR) as a Qualified Clinical Data Registry (QCDR) for 2024. Radiology group practices can continue to use the ACR NRDR QCDR to satisfy 2024 MIPS requirements.

Other highlights:

• The performance threshold remains at 75 points.
• Exceptional performance bonus and high priority bonuses no longer available.
• Three-point scoring floor for measures has been removed; measures are now eligible for one to 10 points.
• Non-benchmarked measures more than two years old will now default to zero points.
• No changes to the policies for small and rural or non-patient facing practices.
• No changes to category weights.

For more details, please view the ACR summary of the QPP Final Rule impact on Radiology.

These are the quality measures specific to Diagnostic Radiology, Interventional Radiology and Radiation Oncology. Additionally, CMS recognizes that small and rural practices may experience additional burdens while participating in the QPP. Please see the CMS webpage for Small, Underserved and Rural Practices for information about their monthly newsletter and other types of support available.

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We have resources that can help.

The Hospital Inpatient Quality Reporting (IQR) Program was developed as a result of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. Section 5001(a) of Public Law 109-171 of the Deficit Reduction Act of 2005 provided new requirements for the Hospital IQR program, which built on the voluntary Hospital Quality Initiative.

The Hospital IQR Program is intended to equip consumers with quality-of-care information to make more informed decisions about healthcare options. It is also intended to encourage hospitals and clinicians to improve the quality of inpatient care provided to patients. The hospital quality-of-care information gathered through the program is available to consumers on the Hospital Compare website.

The Hospital Outpatient Quality Reporting (OQR) quality data reporting program was implemented by CMS for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate. The OQR program is modeled on the current quality data reporting program for inpatient services, the Hospital Inpatient Quality Reporting Program.

To meet hospital OQR requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission and data validation requirements. The current measure set for the Hospital OQR Program includes measures that assess processes of care, imaging efficiency patterns, care transitions, ED throughput efficiency, the use of health information technology, care coordination, patient safety and volume. Participating hospitals agree that they will allow CMS to publicly report data for the quality measures (as stated in the current OPPS Final Rule).

Hospitals that meet data reporting requirements during a given calendar year (CY) receive their full OPPS payment update for the upcoming CY; hospitals that do not participate or fail to meet these requirements may receive a two percent reduction of their payment update.