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Provisions in the ACA tie provider payments to the quality of care they provide. Providers are expected to see their payments modified so that those who provide higher‐value care will receive higher payments than those who provide lower‐quality care. This provision took place in progressive stages. In FY 2013–2015, hospitals became accountable in both reporting and receipt of payment for specific domains of care that expanded to include an additional domain each year. These domains include the clinical process of care domain measures such as venous thromboembolism prophylaxis, appropriate surgical use of postoperative antibiotics, and urinary catheter removal postoperatively; the patient experience of care domain such as nurse communication, doctor communication, hospital staff responsiveness, pain management, medicine communication, and discharge information; the outcome domain measures such as acute myocardial infarction (AMI) 30‐day mortality rate, heart failure (HF) 30‐day mortality rate, pneumonia (PN) 30‐day mortality rate, central line–associated bloodstream infection (CLABSI); and in 2015 the efficiency domain, which focuses on Medicare spending per beneficiary. CMS assesses each hospital’s performance by comparing its scores on achievement and improvement related to each measure of performance (https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/Value‐Based‐Programs/HVBP/Hospital‐Value‐Based‐Purchasing). The following quality domains and weights are being applied for FY 2020: clinical outcomes (25%); person and community engagement (25%); safety (25%); and efficiency and cost reduction (25%).

The Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. MACRA required CMS to create the Quality Payment Program that repealed the Sustainable Growth Rate formula; changed the way that Medicare rewards clinicians for value over volume; streamlined multiple quality programs under the new Merit‐Based Incentive Payments System (MIPS); and gave bonus payments for participation in eligible alternative payment models (APMs).

MIPS was designed to tie payments to quality and cost‐efficient care, drive improvement in care processes and health outcomes, increase the use of health care information, and reduce the cost of care. Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Clinicians included in MIPS and APMs include nurse practitioners if they meet the thresholds required. These thresholds have been lowered over time to encourage greater participation. Performance in MIPS is measured through the data clinicians report in four areas: quality, improvement activities, promoting interoperability (formerly advancing care information), and cost. MIPS was designed to update and consolidate previous programs, including Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value‐Based Payment Modifier (https://qpp.cms.gov/mips/overview). The stated value of the MIPS is to incentivize providers, including APRNs, to practice by providing measurable high‐quality care that is also cost efficient. One of the criticisms of the program has been that it allows providers to choose measures that best reflect the patients served in that provider’s practice. While this makes sense in terms of each individual provider, there is such a wide array of options that it is difficult to aggregate data that will evaluate all providers on similar measures, thus making it difficult to ascertain the relative quality and cost savings.