Rhonda Luetkenhaus | Manager Quality Programs and Research

Praesidio Healthcare Consulting LLC


How does a Patient-Centered Medical Home fit in the Quality Payment Program (QPP) of MACRA?

Every now and then we get a question through our Quality Programs Help Desk that bears sharing with everyone. This is one of those questions and we hope that if you are considering becoming a PCMH, or already are one, this post will help clarify how PCMH can fit within the MACRA Quality Payment Program.

So how does it fit? Well, that depends on the financial structure and program design of the medical home and whether it meets criteria that CMS has laid out in the QPP final rule. Before I jump into the technical language of what does or doesn’t meet the requirements for the QPP, as far as a medical home, I’ll point out that there are two paths in the QPP and several types of medical home models. The “fit” now becomes a little more complex.

First, let’s look at the two paths in the QPP, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). The MIPS path scores a provider’s (or practice’s) performance in four categories:  Quality, Advancing Care Information (ACI), Improvement Activities, and Cost. These categories measure a provider’s performance in patient outcomes, safety, use of certified EHR technology (CEHRT), team-based care, and costs of care. The final MIPS score determines if a positive or negative payment adjustment will be applied to the provider’s (individual) NPI two years down the road.

The second path, Advanced APM, assigns a status of Qualifying Participant (QP) or Partial Qualifying Participant (Partial QP) to the provider – determined by the percentage of Medicare payments or patients in the Advanced APM – for a five percent incentive applied two years later. An Advanced APM is an alternative to the traditional Medicare fee-for-service payment model. Depending on the financial risk arrangement, providers may share the difference between the dollars estimated for cost of care and actual expenditures.

In other words, the Advanced APM must take on more financial responsibility for managing patient outcomes and costs of care and be exposed to a revenue loss. Both paths share the same basic elements such as, reporting quality measures, utilizing CEHRT, and implementing activities that improve patient outcomes and care coordination, the difference is the Advanced APM path requires a model to bear a certain amount of financial risk.

Now that I’ve briefly explained the two paths in the QPP, let’s review the types of medical home models. The most commonly thought of medical home model is the Patient-Centered Medical Home or PCMH – which is a medical home that is certified by a national organization like the National Committee for Quality Assurance (NCQA) or The Joint Commission and follows standards and guidelines to transform a practice as being “patient-centered.” Medical home models include those designed by commercial insurance, Medicaid, and other payers. Basically, a medical home model is an approach to the design of care delivered and generally has at its core, comprehensive, team-based, coordinated, and accessible care focused on quality and safety.

Since medical home models vary, how they fit in the QPP will depend on their model type, payment approach, and the percentage of Medicare payments and patients it has. For example, if the medical home model is a certified PCMH it would fit in the MIPS path; providers there would submit data to the four categories of MIPS:  Quality, ACI, Improvement Activities, and Cost. A PCMH, in and of itself, does not receive the overall 100 percent score for MIPS but will achieve the full score in the Improvement Activities category which is 15 percent of the overall MIPS score.

Providers in the PCMH must then meet all or part of the other three MIPS categories, Quality, ACI, and Cost. Medical home models that are not certified as PCMH will receive one-half of the Improvement Activities category score in the MIPS path and must choose additional Improvement Activities to obtain the full category score. Like PCMHs, non-certified medical home models must meet all or part of the other three MIPS categories –  Quality, ACI, and Cost – to receive the highest overall MIPS score.

At this writing, only one medical home model, the Comprehensive Primary Care Plus Model (CPC+), meets the criteria for an Advanced APM; providers practicing in a CPC+ could meet the QP status and receive a 5 percent incentive two years later.

Back to the initial question:  How does a patient-centered medical home fit into the Quality Payment Program (QPP) of MACRA? It will depend on its payment approach, whether it is a Medicare Fee-For-Service model or an alternative payment model. For models that are based on Medicare Fee-For-Service, they will take the MIPS path; for models that meet the financial risk criteria, they will take the path of Advanced APMs.

In summary:

  • A certified “PCMH” will fit the MIPS path and capture the full Improvement Activities category score which is 15 percent of the overall MIPS score.
  • Likewise, a medical home model (non-certified) will be scored in the MIPS path and capture one-half of the Improvement Activities category score which is 7.5 percent of the MIPS overall score.
  • Providers in the CPC+ Model will fit the Advanced APM path.
  • If the model is an APM, but does not meet the Advanced APM criteria, it would receive special scoring under the MIPS path.

If you have any questions about medical home models and the QPP, or any questions about QPP, please reach out to us, we’d enjoy hearing from you.

Rhonda Luetkenhaus, CAHIMS