Post on 15-Apr-2017
This event is live as of XYZ
MIPS Deep DiveAlexis Isabelle
Senior Manager Quality Performance
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Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at:http://downloads.cms.gov/files/TR2013.pdf;
Projected Medicare Fee-for-service Payment Cuts per the ACA
2014 2015 2016 2017 2018 2019 2020
Projected number of Medicare beneficiaries
54M 56M 57M 59M 61M 63M 64M
-14B -21B -25B -32B -42B -53B -64B
Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf
FFS versus FFV
Eliminates incentive to increase volume Eliminates incentive to provide high-cost services over equally effective low-cost servicesQuality-based incentives Shared risk Emphasizes the role of primary care providers Encourages coordination of care
Fees billed per units of serviceIncome maximized through volumeNo penalty for poor quality Providers lose money if they reduce unnecessary services
Volume
Driven Health
Care
Value-
BasedHealth
Care Co
stQualit
y
Fee-for-service Value-based payments
• Medicare Access and CHIP Reauthorization Act (MACRA) signed into law April 16th, 2015
• Repealed the flawed sustainable growth rate (SGR) formula
• Extends Children’s Health Insurance Program (CHIP) for two years
• New two-track Medicare physician payment system emphasizing value-based payment models
Landmark legislation alters howMedicare reimburses physicians
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APMACIAPM Entity
Eligible Clinician
MIPS
QPAdvanced APM
CPIAQPPPartial
QPCPS
PQRS
CPIA
MU
VM
MACRA
CHIP
ACI
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QPP
APMMIPS Merit-based Incentive
Payment Systemcombination of MU, PQRs, VM, and new CPIA
Alternative Payment Model
Quality Payment Programthe overarching name that covers MIPS and APM tracks
CPS MIPS composite performance score
MIPS Deep Dive
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MU PQRS VMMIPSMerit-Based Incentive Payment
System
Consolidates three existing programs, adds in additional performance category
APMAlternative Payment Models
Incentive payments available to qualified and eligible APM
1
2
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MIPS Eligibility – Years 1 and 2
• Physicians (MD/DO and DMD/DDS)• PAs• NPs• Clinical nurse specialists• CRNs• Anesthetists• Groups (defined by TIN) that include
such clinicians
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MIPS Eligibility – Years 3+
• Physical or occupational therapists• Speech-language pathologists,• Audiologists,• Nurse midwives• Clinical social workers• Clinical psychologists• Dietitians/Nutritional professionals
Everyone reports MIPS
in 2017.
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Three clinician groups not subject to MIPS
ExclusionsECs can volunteer to reporting but won’t receive any money
Has not submitted claims under any
group prior to performance
period
Qualifyingparticipants (QPs)
Partial qualifying participants who opt not to report
MIPS
<$10k in Medicare billing
AND≤ 100 Part B
enrolled beneficiaries
Newly enrolled Medicare clinicians
APM participantsLow threshold
NOTE: MIPS does not apply to hospitals or facilities
Four performance categories
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Category weight varies over time
2019 2020 2021+
25 25 25
15 15 1510 15 30
50 45 30
Four Categories That Determine MIPS Score Relative Weight Over Time
Quality
Resource UseClinical practice
improvement activities (CPIA)
Advancing Care Information (ACI)
Quality1
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Quality(currently PQRS)
1• 6 measure selection• 1 cross-cutting measure and 1 outcome
measure, or another high priority measure if outcome is unavailable
• Select from individual measures or a specialty measure set
• Population measures automatically calculated
• Providers and groups measured and graded against the performance of their peers
ACI(Advancing Care
Information) 2
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Advancing Care Information(currently EHR Incentive or MU)
2• Scoring based on key measures of patient
engagement and information exchange• Flexible scoring for all measures to promote
care coordination for better patient outcomes
• Points are awarded based on performance; only the highest performers will be able to earn full credit
CPIA(Clinical practice
improvement activities)3
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Clinical practiceimprovement activities
3New category
• Minimum selection of one CPIA activity (from 90+ proposed activities) with additional credit for more activities
• Full credit for patient-centered medical home (PCMH)
• Minimum of half credit for APM participation• Activities are weighted as High or Medium
weight with corresponding points
Resource Use4
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Resource Use(currently VM)
4• Medicare claims; no reporting• Minimum thresholds of 20 patients/cases• Adjusted for geographic payment, beneficiary risk factors
Total per capita cost measure (part A+B across VM chronic conditions for COPD, CHF, CAD, DM) as seen in VM with slight modification• Expanded list of primary care services to include TCM, CCM• Excluded SNF
MSPB measure as seen in VM with slight modifications
Episode-based measures (41 across specialties)*
1
2
3
MIPS has different set of “rules” and scoring going forward
Weighting of Cost & Quality categories will change over time with Quality declining and Cost increasing (from 10% to 30% by 2019)
Source: CMS
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Category Weight(Year 1) Scoring
Quality 50%
• Each measure 1-10 points compared to historical benchmark
• 0 points for a measure that is not reported• Bonus for reporting outcomes, patient experience,
appropriate use, patient safety and EHR reporting• Measures are averaged to get a score for the category
Advancing Care
Information (ACI)
25%
• Base score of 50 percentage points achieved by reporting at least one use case for each available measure
• Performance score of up to 80 percentage points• Public Health Reporting bonus point• Total cap of 100 percentage points available
Clinical practice
improvement activities
(CPIA)
15%• Each activity worth 10 points; double weight for “high”
value activities; sum of activity points compared to a target
Resource Use 10% • Similar to quality
Composite performance score calculation
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A single MIPS composite performance score will factor in performance in 4 weighted performance
categories on a 0-100 point scale
Quality Resource UseCPIAACI
MIPS Composite Performance Score (CPS)
Payment adjustment scale has more complexity, less middle ground
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Demonstrative onlyMIPS Budget-neutral program, 2019 payment based on 2017 performanceCPS Threshold has not yet been releasedCMS estimates only 0.3% of providers will have a score exactly equal to the CPS threshold
Provider payment adjustmentBased on distance from CPS Threshold score
(Example) CPS Threshold -
60Lowest
quartile or non
reporters get flat
4% downward adjustmen
t0 10 20 30 40 50 60 70 80 90 100
14
12
10
8
6
4
2
0
-2
-4
-6
All providers with <60 CPS receives
downward adjustment
All providers with
>60 CPS receive an upward adjustment
Payment Adjustment (%) Payment Adjustment (%) (high performers)
-1% +1%
Payment adjustment will increase over time
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30%
20%
10%
0%
-10%
Paym
ent A
djus
tmen
t
-4%4%
12%
2019
-5%
5%
15%
2020
-7%
7%
21%
2021
-9%
9%
27%
2022
High performers eligible
for additional incentive
Budget neutrality adjustment: Scaling factor up to 3x may be applied to upward adjustment to ensure payout pool equals penalty pool
Non-reporting
groups given lowest score
Preparing for 2017
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2019
Fast timeline for clinicians to follow
MACRA Implementation Timeline
2016 2017 20182019
TodayFinal Rule
Released
Providers may not be certain which track they
will fall into when reporting in 2017
Not much time for many
providers to get
involved in QPP
Performance period
Providers notified of track
assignmentPayment
adjustment
Based on
Merit Based Incentive Payment
System (MIPS)
Advanced Alternative Payment
Models (APM)
Preparing Performing Reporting Payment
StartsJanuary 1st, 2017
Source: CMS
Payment adjustments vary with differentsizes of clinician groups
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Solo 2-9 10-24 25-99 100 or more Overall0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
87.00%69.90%
59.40%44.90%
18.30%
45.50%
12.90%29.80%
40.30%54.50%
81.30%
54.10%
CMS Estimated Penalties and Bonuses in 2017,By Practice Size
Percent likely to be penalized Percent likely to receive bonus
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Historically, our clients perform better.
Meaningful Use Stage 2 attestation
% of HCPs avoidingPQRS penalties in 2015
NATIONAL AVERAGE
60%ATHENAHEALTH
CLIENTS
93.6%NATIONAL AVERAGE
33%ATHENAHEALTH
CLIENTS
98.2%MU and PQRS Client
Guarantee
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Currently estimating our clients’ performance in real-time
athenaNet provider performance on Meaningful Use Stage 2 measure: Use Secure Electronic Messaging
NETWORK WIDE CHANGES:1. NEW FUNCTION: Now easier for practices to
register patients to the patient portal.2. FUNCTION UPDATE: Now easier for providers
to send patients secure messages through the patient portal.
100%
90%
80%
70%
OCT. 2014 NOV. 2014 DEC. 2014
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We will take on your busy work
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We will make sense of the 200 measures and choose which are right for
you
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Thank You
Glossary of Terms
ACI
Advanced APM
APM
Advanced Care Information, formerly known as Meaningful Use
Alternative Payment Model
Alternative Payment Model which CMS has designated “eligible”
APM Entity
CPS
CPIA
EC
The TIN(s) participating in an APM or Advanced APM
Clinical Practice Improvement Activities
MIPS composite performance score
Eligible Clinician, the new definition of professionals who fall under this category under MACRA
MIPS
QPP
QP
Partial QP
Merit Based Incentive Payment System, the combination of MU, PQRS, VM and new CPIA
Qualifying APM Participant
Quality Payment Program, the overarching name that covers MIPS and APM tracks
Partial Qualifying APM participants