What is the Quality Payment Program (QPP)?

Definition

The Quality Payment Program (QPP) is the umbrella value-based payment program governing Medicare Part B clinicians, established by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. QPP has two pathways: the Merit-based Incentive Payment System (MIPS), a pay-for-performance program that adjusts baseline Physician Fee Schedule payment up or down based on clinician performance, and Advanced Alternative Payment Models (Advanced APMs), which exempt qualifying participants from MIPS in exchange for participation in risk-bearing payment models.

Why QPP exists

MACRA replaced the Sustainable Growth Rate formula — the prior statutory mechanism that had repeatedly threatened large reductions in Physician Fee Schedule payment rates — with a structured value-based payment framework. QPP was the operational mechanism MACRA established. The dual-track design reflected a policy intent: clinicians who participate in qualifying risk-bearing APMs are recognized for that participation through MIPS exemption and a separate APM incentive payment, while clinicians who do not are subject to MIPS performance evaluation.

The MIPS pathway

MIPS is a pay-for-performance program. Each performance year, eligible clinicians earn a composite MIPS Final Score (0-100) based on four performance categories, each contributing a weighted portion of the score:

• Quality — Performance on a set of selected quality measures. The Quality category historically carried the largest single weight, though CMS has rebalanced category weights over time. Measures span clinical effectiveness, patient safety, care coordination, and patient experience.
• Promoting Interoperability — Adoption and use of certified electronic health record technology, with measures covering electronic prescribing, health information exchange, public health reporting, and patient access to records.
• Improvement Activities — Attestation to participation in CMS-defined practice-improvement activities — care coordination, beneficiary engagement, expanded practice access, and others.
• Cost — Risk-adjusted total-cost-of-care and episode-based cost measures, calculated by CMS from claims data with no clinician reporting burden.

The MIPS Final Score determines a payment adjustment applied two years later to the clinician’s Physician Fee Schedule payments. Adjustments can be positive or negative. The program is statutorily budget-neutral — bonuses to high performers are funded by penalties on low performers — though additional bonus pools have been periodically available.

The Advanced APM pathway

Clinicians who meet thresholds for participation in a CMS-designated Advanced APM — for example, an MSSP ACO in a two-sided risk track, or ACO REACH — qualify as Qualifying APM Participants (QPs) for the year. QPs are excluded from MIPS reporting and adjustment for that year, and historically received a separate APM incentive payment, the level of which has changed over time. The Advanced APM pathway is the mechanism through which QPP rewards participation in two-sided-risk payment arrangements relative to MIPS.

Connection to APCM

APCM-billing primary-care practices benefit on the MIPS pathway in several specific ways:

• Quality category measure performance — Several MIPS quality measures used by primary-care clinicians overlap directly with HEDIS-style measures (e.g., controlling high blood pressure, A1c control, depression screening and follow-up) — the same measures APCM care-management activities improve. APCM panel-management and chronic-disease workflows produce the documented activity these measures capture.
• Behavioral health measure performance — The CY2026 APCM-aligned BH add-on codes (G0568-G0570) drive integrated behavioral health workflows that produce documented activity on MIPS measures including depression screening, antidepressant medication management, and follow-up after behavioral health acute care.
• Improvement Activities — Several Improvement Activities in the CMS-approved inventory align directly with the care-coordination, beneficiary engagement, and integrated behavioral health work APCM reimburses. Attestation to those activities is supported by the underlying APCM documentation.
• Cost category — APCM care-management activity that reduces avoidable utilization — emergency department visits, readmissions, fragmented specialty referrals — improves performance on the MIPS Cost category episode-based measures.

For practices on the Advanced APM pathway through an MSSP two-sided-risk track or ACO REACH, APCM still applies. APM-participating clinicians are exempted from MIPS but continue to bill the Physician Fee Schedule for services not folded into capitation arrangements, including APCM where the ACO arrangement preserves Physician Fee Schedule billing for those codes.

Practical positioning

For a primary-care practice evaluating APCM in the context of QPP participation:

• The care-management documentation produced by APCM is directly useful for MIPS Quality and Improvement Activities reporting.
• Integrated behavioral health under the CY2026 BH add-on codes produces additional documented activity on behavioral health quality measures, an increasingly weighted area in MIPS.
• Adoption of APCM does not affect Advanced APM status — participation thresholds for the Advanced APM pathway are determined by APM participation, not by which Physician Fee Schedule codes the practice bills.

Primary sources

• Centers for Medicare & Medicaid Services. Quality Payment Program annual final rules — performance category weights, measure inventory, and APM thresholds for the current and prior performance years.
• Medicare Access and CHIP Reauthorization Act of 2015. Public Law 114-10. Title I.
• CMS QPP Resource Library — MIPS measure specifications and Improvement Activities inventory.
• National Association of ACOs (NAACOS) and Medical Group Management Association policy resources on the MIPS / Advanced APM split.

Related concepts

For the largest ACO program and Advanced APM pathway, see What is the MSSP?. For the full-risk ACO model that also qualifies as an Advanced APM, see What is ACO REACH?. For the broader payment shift, see What is value-based care?. For the quality measurement framework that overlaps with MIPS quality measures, see What is HEDIS?. For APCM and its behavioral health extension, see What is APCM? and What is BHI?. For strategic context, see The APCM Opportunity.