2025 MACRA Quality Payment Program

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 introduced the Quality Payment Program (QPP) to replace the sustainable growth rate. Congress passed MACRA with the intent to spur a transition towards rewarding physicians based on the quality and value of the care they provide. The QPP was first implemented in 2017 and offers two participation pathways—the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

The 2025 performance year marks the ninth year of the QPP.

Under MIPS, a participating clinician receives an overall score of 1–100 points based on performance in the four MIPS categories: Quality, Cost, Promoting Interoperability, and Improvement Activities. This final score is compared to the performance threshold that is determined yearly by the Centers for Medicare and Medicaid Services (CMS). CMS then applies a positive, neutral, or negative payment adjustment to the clinician’s Medicare Part B reimbursement based on how the clinician's MIPS score compares to the performance threshold. In 2025, the MIPS performance threshold remains at 75 points, and clinicians can receive a maximum negative payment adjustment of 9 percent for failure to comply with the program.

Surgeons can enter their National Provider Identifier (NPI) in the QPP Participation Lookup Tool to determine their QPP eligibility each year. In the Lookup Tool, clinicians can find their MIPS eligibility status for each Taxpayer Identification Numbers (TINs) that they are associated with. Note that clinicians may be required to participate in MIPS under each practice they are associated with (i.e., each of unique TIN/NPI). CMS also provides eligibility information at the group level.

Surgeons can participate in the QPP at the individual, group, and/or APM Entity level (if applicable). If a clinician participates at multiple levels and has multiple MIPS final scores, CMS will use the highest score for that unique TIN/NPI. Once eligibility is determined, surgeons should check with their employer or practice leadership to determine the most appropriate participation option for the 2025 performance year and associated reporting expectations.

Surgeons may also choose to participate through a MIPS Value Pathway (MVP)—a voluntary alternative reporting pathway to traditional MIPS that has been available since 2023. Whether surgeons participate via traditional MIPS or an MVP, their score will continue to be calculated based on the four performance categories. 

The APM track of the QPP was developed with a goal to improve quality and value of care, reduce growth in health care spending, or both. APMs can apply to a specific clinical condition, care episode, or whole population. Clinicians who receive a substantial portion of their Medicare reimbursement or see a substantial number of Medicare patients under what CMS designates as an Advanced APM are considered Qualifying Participants (QPs) and are exempt from MIPS. Advanced APMs bear a certain amount of risk determined by CMS, require reporting on quality measures similar to MIPS, and require the use of certified EHR technology (CEHRT).

QPs have historically received a lump sum Medicare incentive payment of 5 percent, which was considerably higher than positive adjustments available through MIPS. However, the APM incentive payment drops to 3.5 percent starting with the 2025 payment year, based on 2023 eligibility. For the 2026 payment year, based on 2024 eligibility, it drops further to 1.88 percent while at the same time, QPs will be eligible for a higher Medicare Physician Fee Schedule (MPFS) conversion factor update than non-QPs, including MIPS participants (0.75 percent vs. 0.25 percent). Barring Congressional action, the APM incentive payment goes away completely starting with the 2027 payment year, but the differential conversion factor update will remain.