MACRA Quality Payment Program: Key Things to Know and ... · • New payment models that reduce...

MACRA Quality Payment Program: Key

Things to Know and Strategies for

Success

November 17, 2016

2:00 – 3:00 pm ET

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http://www.ehealthinitiative.org/

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About eHealth Initiative

Since 2001, eHealth Initiative has been advocating the value of technology and innovation in healthcare through research and education.

eHI convenes its multi-stakeholder members, from across the healthcare ecosystem, to discuss how to transform healthcare through information and technology.

eHI members released The 2020 Roadmap. The primary objective is enable coordinated efforts by the public and private sector to transform healthcare by the year 2020.

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Multi-Stakeholder Leaders in Every Sector of Healthcare

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The 2020 RoadmapKey Focus Areas in 2016

Interoperability

Privacy & Security

Business & Clinical Motivators

Health IT Policy

Data & Analytics

Innovation

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Upcoming Webinars

November 21:

– Re-imagining Care Delivery: The Power of

Technology

November 30:

– The State of Federal Funding for HIEs today

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MACRA Quality Payment Program: Key Things

to Know and Strategies for Success

Speakers

• Jesse M. Ehrenfeld, MD, MPH, Associate Professor

of Anesthesiology, Surgery, Biomedical Informatics,

and Health Policy, Vanderbilt University School of

Medicine; American Medical Association Board of

Trustees

• Joe P. Price – Research Strategist, Cerner

• Amanda Adams, Senior Strategist, Cerner

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Upcoming Webinars

November 17:

– MACRA Quality Payment Program: Key

Things to Know and Strategies for Success

November 21:

– Re-imagining Care Delivery: The Power of

Technology

November 30:

– The State of Federal Funding for HIEs today

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This webinar was made possible through the generosity and

support of Cerner!

November 2016

Medicare Quality Payment Program Overview

(MACRA)

Rev. 11/1/16

© 2016 American Medical Association. All rights reserved.

Some general observations

• MACRA is complex

– More than a “replacement for the SGR”

– Law reflects the diversity of the profession

• Many of the new requirements are revisions of current requirements

• One goal of MACRA was to simplify administrative processes for

physicians

– Compared to recent past framework, there are significant improvements

– More improvements will be sought

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MACRA established two Medicare paths for physicians

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• MACRA was designed to offer

physicians two payment model

pathways:

• A modified fee-for-service model

(MIPS)

• New payment models that reduce

costs of care and/or support high-value

services not typically covered under

the Medicare fee schedule (APMs)

• In the beginning, most are expected to

participate in MIPS

• CMS named the physician payment

system created by MACRA the Quality

Payment Program (QPP)

MIPS

APMs


Timeline on payment adjustments

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2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

on

Fee

Schedule

Updates

MIPS

QPs in

Adv.

APMs

0.5% annual baseline updates No annual baseline updates

4% 5% 7% 9%Max Adjustment(additional bonuses

possible)

0.25%

or

0.75%

9% 9% 9%

5% bonus


MIPS components

Quality Reporting (was

PQRS)

Cost (was Value-based

Modifier)

Advancing Care Information (was MU)

Improvement Activities

MIPS

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MIPS aims:• Align 3 current independent programs

• Add 4th component to promote improvement

and innovation

• Provide more flexibility and choice of

measures

• Retain a fee-for-service payment option

Clinicians exempt from MIPS:• First year of Part B participation

• Medicare allowed charges < $30K or < 100

patients

• Non-patient facing with < 100 patients

• Advanced APM participants


Low-volume threshold exemption

• Eligibility for low-volume exclusion to be calculated by CMS

– Notification should occur in December

– Based on 12-month historical data (September-August)

– Includes Part B drug costs, but not Part D

• Info provided by TIN/ NPI for clinicians and by TIN for groups

– Something to factor in when group members decide whether to report as

individuals or as a group

• Qualifying individuals may volunteer to report, but they will not be

eligible for pay adjustments

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MIPS component weights (when fully transitioned)

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30%

25%15%

30%

Component Weights

Quality

ACI

Imp. Activities

Cost

Component Scoring• Quality:

– 60 points groups <15

– 70 points for larger groups

• Advancing Care Information:

– 50 points base score

– 90 points performance score

• Improvement Activities:

– 40 points (2-4 activities; 1-2 activities for practices < 15 clinicians, rural practices, and non-patient facing physicians)

• Cost:

– 10 points per measure

– Score is average of attributable measures

For 2017:

• Quality = 60%

• ACI = 25%

• IA = 15%

• Cost = 0%


Pick Your Pace: 2017 transitional performance reporting options

• Report some data at any point in CY 2017 to demonstrate capability

• 1 quality measure, or 1 improvement activity, or 4/ 5 required ACI measures

• No minimum reporting period

• No negative adjustment in 2019

MIPS Testing

• Submit partial MIPS data for at least 90 consecutive days

• 1+ quality measure, or 1+ improvement activities, or 4/ 5 required ACI measures


• Potential for some positive adjustment ( < 4%) in 2019

Partial MIPS reporting

• Meet all reporting requirements for at least 90 consecutive days


• Maximum opportunity for positive 2019 adjustment ( < 4%)

• Exceptional performers eligible for additional positive adjustment (up to 10%)

Full MIPS reporting

• No MIPS reporting requirements (APMs have their own reporting requirements)

• Eligible for 5% advanced APM participation incentive in 2019

Advanced APM

participation

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The only physicians who will experience negative payment adjustments

(-4%) in 2019 are those who report no data in 2017


Other transition elements

2017

• 90-day reporting for all MIPS elements

• Quality reporting threshold maintained at 50%

• ACI required measures reduced to 4/5 (depending on whether using 2014 or 2015 certified technology)

• Cost component of MIPS weighted 0%; quality component raised to 60% (for 2019 adjustments)

2018 (subject to rulemaking)

• 90-day reporting likely maintained for ACI and Improvement Activities only

• Quality threshold likely increased to 60%

• ACI required measures is 5 (must use 2015 certified technology)

• Cost component weight increased to 10%; quality component reduced to 50% (for 2020 adjustments)

Future years

• Full-year reporting for ACI?

• Quality threshold anticipated to increase over time

• Cost component weight will increase to 30% (for 2021 adjustments and beyond)

• Quality component weight will decrease to 30% (for 2021 adjustments and beyond)

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Calculating payment adjustments

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Quality score

weighted

Cost score

weighted

ACI score

weighted

Improvement

Activity score

weighted

Final Performance

Score

Final score at threshold (tied

to average performance) = 0%

Final score above threshold = 0%

to +X%

Final score below threshold = 0%

to -X%

Depending on final score distribution,

upward adjustments only could increase up

to 3x to maintain budget neutrality

Physicians with final scores

< 25% of threshold receive

maximum reduction

Up to $500 million available

2019-2024 to provide 10%

extra bonus for exceptional

performance (> top 25% of

those above the threshold)

Maximum adjustment ranges = +/-4% in 2019, +/- 5% in 2020,

+/- 7% in 2021, +/- 9% in 2022 onward


2019 payment adjustments (based on 2017 transition)

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Quality score

weighted (60%)

Cost score

weighted (0%)

ACI score

weighted (25%)

Improvement

Activity score

weighted (15%)

Final Performance

Score

Final score at 2017 threshold

of 3 points (one data element

reported) = 0%

Final score above threshold (up

to 70 points) = up to 0 to +4%

No data reported = - 4%

Up to $500 million available to

provide 10% extra bonus for those

who meet or exceed a 70 point

threshold

Adjustment amounts depend on:

• choice of 90-day or full-year

reporting

• whether some or all data

elements are reported

• performance under each

reported measure

• whether bonus points are

earned

• budget neutrality calculations


2019 (first year) penalty risks compared

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Prior Law 2019

adjustments

PQRS -2%

MU -5%

VBM -4% or more*

Total penalty risk -11% or more*

Bonus potential (VBM

only)

Unknown (budget

neutral)*

MIPS factors 2019 scoring

Quality measurement 60% of score

Advancing Care Info. 25% of score

Resource use 0% of score

Improvement

Activities

15% of score

Total penalty risk Max of -4%

Bonus potential Max of 4%, plus

potential 10% for high

performers*VBM was in effect for 3 years before MACRA passed, and

penalty risk was increased in each of these years; there

were no ceilings or floors on penalties and bonuses, only a

budget neutrality requirement.

Merit-based

Incentive Payment

System (MIPS)

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Quality reporting in MIPS

Key Things to Know

• Weighted score of 60% in 2017

• Decreases to 30% in later years

• 6 measures (or 1 specialty set)

• Over 250 quality measures available

• Flexibility in measure choice

• No domains, no cross cutting measures

• One outcome measure or high priority measure

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How do I approach

selecting and

submitting quality

measures?

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Advancing Care Information (ACI)

Key Things to Know


• Use of CEHRT required to get maximum of 100 points to receive full 25% credit

• No required thresholds for objectives

• Must have at least 1 in the numerator of ‘required’ measures and a “yes” to the “yes/no” objectives to receive credit

• CMS is retiring CPOE and Clinical Decision Support

• Objective exclusions do not apply to Stage 3 MU

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Advancing Care Information (ACI)

Advancing Care Information (ACI) MIPSExample

ReportingPerformance Score

1. Protect Patient Health Information N/ASecurity Risk Assessment Yes

2. ePrescribe N/AePrescribe 9%

3. Electronic Access to Health Info. 10 pointsPatient Electronic Access 88% 9.0 points

Patient-Specific Education 10% 1.0 point4. Coordination of Care 9 points

View, Download or Transmit (VDT) 20% 2.0 pointsSecure Messaging 2% 1.0 point

Patient Generated Health Information 53% 6.0 points5. Health Information Exchange 15 points

Send Transition of Care Electronically 20% 2.0 pointsRequest/Accept Patient Care Record 40% 4.0 pointsClinical Information Reconciliation 90% 9.0 points

6. Public Health & Clinical Registry Reporting 15 points

Immunization Registry (Bi-Directional) Yes 10 points(Optional) Syndromic Surveillance Yes 5 bonus points

(Optional) Case Reporting (Optional) Public Health Registry(Optional) Clinical Data Registry

Base Score Performance Score

50 49Total Score 99.0 Points

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How do I ensure I

receive full credit

for the ACI

category?

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Improvement Activities (IAs)


• 93 IAs weighted ‘medium’ or ‘high’

• 40 points required to receive full 15% credit

• ACI bonus points awarded for 19 IAs requiring CEHRT

• ECs in practice improvement models receive credit for IA category

• PCMH= 40 points (full credit)

• MIPS APM= 20 points (half credit)

Key Things to Know:

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Which

Improvement

Activities should I

focus on for

reporting?

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Cost Category

• Not included in Composite Performance Score (CPS) in 2017

• 2018- 10% of CPS

• 2019 and beyond- 30% of CPS

• Evaluated based on effective management of medical resources

• 10 total clinical condition and treatment episode-based measures

Key Things to Know:

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Episode Based Measures

Episode Name Included in the 2015 sQRUR

Mastectomy Yes

Aortic/Mitral Valve Surgery Yes

Coronary Artery Bypass Graft (CABG) Yes

Hip/Femur Fracture or Dislocation Treatment, Inpatient (IP)-Based Yes

Cholecystectomy and Common Duct Exploration Yes

Colonoscopy and Biopsy Yes

Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Yes

Lens and Cataract Procedures Yes

Hip Replacement or Repair Yes

Knee Arthroplasty (Replacement) Yes

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What should I do in the

short term to ensure I

am effectively using

medical resources in

the long run?

Alternative

Payment Models

(APMs)

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APMs participation options as outlined by CMS

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Advanced APMs

Qualified Medical Homes

MIPS APMs

• “Advanced” APMs--term

established by CMS; these

have greatest risks and offer

potential for greatest

rewards

• Qualified Medical Homes

have different risk structure

but otherwise treated as

Advanced APMs

• MIPS APMs receive

favorable MIPS scoring

• Physician-focused APMs

are under development

Physician-

focused

APMs TBD


CMS criteria for Advanced APMs

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Advanced APMs

EHR use

Quality Reporting

Financial

Risk

• 50% of participants must use certified EHR

technology

• Must report and at least partially base clinician

payments on quality measures comparable to

MIPS

• Bear “more than nominal risk” for monetary

losses

• Defined as the lesser of 8% of total Medicare

revenues or 3% of total Medicare expenditures

• Primary Care Medical Home models with < 50

clinicians have different standards (2.5%-5% total

Medicare revenues)

• Physicians may be Qualified Participants (QPs)

or Partially Qualified Participants (PQPs) based

on revenue and patient thresholds, with

differential rewards


MACRA incentives for Advanced APM participation

Model design

• APMs have shared savings, flexible payment bundles and other desirable features

Bonuses

• In 2019-2024, 5% bonus payments made to physicians participating in Advanced APMs

Higher updates

• Annual baseline payment updates will be higher (0.75%) for Advanced APM participants than for MIPS participants (0.25%) starting 2026

MIPS exemption

• Advanced APM participants do not have to participate in MIPS (models include their own EHR use and quality reporting requirements)

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Current Advanced APMs

Comprehensive ESRD Care Model

(13 ESCOs)

Comprehensive Primary Care Plus

(14 states, practice applications closed

9/15/16)

Medicare Shared Savings Track 2

(6 ACOs, 1% of total)

Medicare Shared Savings Track 3

(16 ACOs, 4% of total)

Next Generation ACO Model

(currently 18)

Oncology Care Model Track 2

(A portion of 196 practices will qualify)

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New Advanced APMs for 2018 (subject to rulemaking)

ACO Track 1+Voluntary bundled payment models

Comprehensive Care for Joint Replacement

Payment Model (CEHRT Track)

Advancing care coordination

through episode payment models Track 1 (CEHRT)

Vermont Medicare ACO Initiative (all payer ACO model)

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MIPS APMs

Criteria

•APM entity participates in a model under an agreement with CMS

•Entity includes at least one MIPS eligible clinician on a participant list

•Payment incentives based on performance on cost and quality measures (either on entity or individual clinician level)

2017 qualified models

•MSSP Track 1 counts

Advanced APM benefits do not apply

•Must participate in MIPS to receive any favorable payment adjustments

•Do not qualify for 5% APM bonus payments 2019-2024

•Not eligible for higher baseline annual updates beginning 2026

Other benefits

•2017 MIPS APMs receive full Improvement Activities credit

•ACOs: must report quality (50%), IA (20%) and ACI (30%)

•Non-ACO MIPS: quality score reweighted to zero and IA/ ACI reweighted to 25%/ 75%

•APM-specific rewards (e.g., shared savings)

•Eligible for annual MIPS bonuses, which continue indefinitely (vs. 6 years for 5% APM bonuses)

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Requirements and payments for APM participants

Qualified

Participant in

Advanced APM

Partially Qualified

Participant in

Advanced APM

MIPS APM

participant

Patient and revenue

thresholds required

>25% revenues or >20%

patients in 2019, rising to

75% or 50%, respectively

by 2023

>20% revenues or >10%

patients in 2019, rising to

50% and 35%,

respectively, by 2023

None

Eligible for APM bonus,

higher updates

Yes No No

Must participate in MIPS No Optional (but no

performance adjustments

without MIPS)

Yes

MIPS scoring and

adjustments

N/A Favorable weighting and

scoring

Favorable weighting and

scoring

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How can I join an

advanced APM?

Questions?

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Questions and Answers!

Please use the chat feature to ask questions

Today’s slides will be available for download on our

homepage at www.ehidc.org

If you have any questions, please contact Claudia

Ellison, [email protected]

http://www.ehidc.org/

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This webinar was made possible through the generosity and

support of Cerner!

MACRA Quality Payment Program: Key Things to Know and ... · • New payment models that reduce...

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