Followup Review: CMS's Management of the Quality Payment Program

WHY WE DID THIS STUDY

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted clinician payment reforms designed to promote quality and value of care. These reforms, known as the Quality Payment Program (QPP), are a significant shift in how Medicare calculates compensation for clinicians and require CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care. The first performance year began on January 1, 2017.

In 2016, OIG conducted an early implementation review of CMS's management of the QPP. While we found that CMS had made significant progress in developing the QPP, we identified two vulnerabilities that were critical for CMS to address in 2017: (1) providing sufficient guidance and technical assistance to ensure that clinicians were ready to participate in the QPP, and (2) developing information technology (IT) systems to support data reporting, scoring, and payment adjustment. OIG conducted this followup review to assess CMS's progress in mitigating these potential vulnerabilities and to identify emerging risks.

HOW WE DID THIS STUDY

We interviewed CMS staff and reviewed internal CMS documents as well as publicly available information. We conducted qualitative analysis to identify key milestones (both those achieved and those yet to come), priorities, and challenges related to QPP implementation.

WHAT WE FOUND

During 2017, CMS made significant efforts to address the two vulnerabilities that OIG identified in its 2016 management review-developing IT systems and preparing clinicians to participate in the QPP. With regard to IT, CMS appears on track to deploy the systems needed for data submission by January 1, 2018. With regard to clinician readiness, CMS has conducted outreach, awarded technical assistance contracts, communicated eligibility information, issued subregulatory guidance, and established a Service Center to respond to questions. However, clinician feedback collected by CMS demonstrates widespread awareness of the QPP, but also uncertainty about eligibility, data submission, and other key elements of the program. With regard to emerging challenges, we found that CMS has not yet developed a comprehensive program integrity plan for the QPP.

WHAT WE CONCLUDE

CMS has made progress towards implementing the QPP, but challenges remain. CMS appears on track to deploy the IT systems needed for data submission by January 1, 2018. OIG has identified two vulnerabilities that are critical for CMS to address in 2018 because of their potential impact on the program's success:

1. If clinicians do not receive sufficient technical assistance, they may struggle to succeed under the QPP or choose not to participate.
2. If CMS does not develop and implement a comprehensive program integrity plan for the QPP, the program will be at greater risk of fraud and improper payments.