Why this News Brief

We believe Medicare’s Quality Payment Program may offer unique opportunities to monetize your medical device, diagnostic test or digital health technology outside of traditional reimbursement pathways.  It takes time to determine the value of incorporating the Quality Payment Program into your product development, clinical trial, and sales efforts.


The Centers for Medicare and Medicaid Services (CMS) announced material changes to Medicare reimbursement for clinicians starting January 1, 2017. The changes are a direct result of the Medicare Access and CHIP Reauthorization Act of 2015 and codified under the Quality Payment Programs.  We believe that with a better understanding of these Programs, there could be an opportunity to create economic value for your medical technology in the absence of fee for service reimbursement.

In 2017, clinicians may choose from two tracks under the Quality Payment Program:

  • Advanced Alternative Payment Models (Advanced APMS) or
  • Merit-based Incentive Payment System (MIPS)

The MIPS track provides a performance-based payment adjustment to the clinician’s 2019 Medicare reimbursement based on 2017-performance data submission. The intention of the data submitted by the clinician to Medicare is to report the quality and efficiency of clinical care they provided to Medicare beneficiaries.  The performance data measures individual clinicians on three distinct categories: quality, improvement activity and advancing care information.  Based on the data submitted, the payment adjustment to the clinician’s Medicare reimbursement can be additive, punitive or have no impact.

Advanced APMS is the other track for clinicians that allow them to earn more from Medicare for sharing in the financial risk related to patients’ outcomes. Clinicians may earn a 5% lump sum bonus to their 2019 Medicare reimbursement based their 2017 performance data submission.  Clinicians who qualify for this track participate in Medicare population models like the Comprehensive ESRD Care Model or Oncology Care Bundled Payment Model.   Most clinicians who care for Medicare beneficiaries participate in at least one of Medicare’s population or bundled payment models.

While Medicare has set the standard for Quality Payment Programs, it is reasonable to conclude that commercial payers will soon emulate them.  Medicare is encouraging commercial payers and employer health plans to incorporate similar alternative reimbursement programs into their health plans and in doing so, help to create a national patient quality care standard.


About Rowinski Group

Founded in 2004, Rowinski Group LLC is a reimbursement and healthcare payer data analytics consulting firm for medical device, digital health, diagnostics, and imaging companies. Rowinski Group is based in Silicon Valley – San Francisco bay area with offices at selected client locations.

Rowinski Group has two core service offerings; securing codes and reimbursement on behalf of companies and applying healthcare payer data analytics to help solve companies’ complex business issues such as responding to questions from the FDA and U.S. Payers.

Through these service offerings Rowinski Group helps U.S. and international companies build their U.S. market share for the medical technology they are developing and selling. For more information visit www.rowinskigroup.com