MACRA: The Big - gcms.orggcms.org/Bulletins/2016_10_October_MACRA-The Big Picture.pdf · MACRA...
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Transcript of MACRA: The Big - gcms.orggcms.org/Bulletins/2016_10_October_MACRA-The Big Picture.pdf · MACRA...
MACRA: The Big Picture
MU
VBPM
PQRSACOs
Bundled Payments
MIPS
APMs
MSSPs
PGIP
OSCs
Why is Medicare changing?
HHS Vision
FFS Payments Payments for Quality & Value
Better Care
Smarter Spending
Healthier People
Trends
PQRI/PQRS
Medicare eRX
Meaningful Use
Value-Based Payment Modifier
MSSP
Pioneer ACOs
Bundled Payments
HHS Goals
Traditional Medicare payments tied to
quality/value
• 85% by end of 2016
• 90% by end of 2018
Traditional Medicare FFS payments tied to alternative
payment models
• 30% by end of 2016
• 50% by end of 2018
What is MACRA?
MACRA
• Medicare Access and CHIP Reauthorization Act
o Passed by Congress in April 2015
o Repealed the SGR
o Sunsets multiple downward payment adjustments in existing Medicare legacy initiatives
o New Quality Payment Program (QPP)
Two new payment tracks for physicians
Merit-based Incentive Payment System (MIPS)
Advanced Alternative Payment Models (APMs)
Quality Payment Program
MIPS
Performance-based payment adjustments
Modified FFS model that combines &
streamlines existing Medicare quality
programs
Most physicians and other eligible clinicians will initially follow this
path
APMs
Fixed Medicare bonus payment
Focus on reduced costs and high-value services
#s of participants expected to increase
over the years
• Eligible clinicians (ECs) in 2019 and 2020
o Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists
• In MIPs unless…
o Participating in Advanced APMs
o 1st year in Medicare
o Low patient volume
• ECs may be expanded by the HHS Secretary beginning in 2021 (e.g., dietitians, psychologists, nurse midwives, social workers, clinical psychologists, etc.)
QPP Participants
• Payment adjustment year – 2019
• Performance year – 2017
o Transition year
o “Pick Your Pace” (for 2017 only) or participate in Advanced APM pathway
o Start no later than October 2, 2017
o Report performance data by March 31, 2018
QPP Implementation Dates
Don’t Participate = -4% payment adjustment
Report at least one quality measure or improvement activity, or the advancing
care information base component = no payment
adjustment (-/+)
Submit at least 90 consecutive days of data = neutral or small positive
payment adjustment
Submit full year of data to Medicare = opportunity to
earn maximum positive payment adjustment
“Pick Your Pace”
“Pick Your Pace”
QPP Cycle
What are APMs?
• Alternative Payment Model
o Payment approach designed to incentivize high-quality and cost-efficient care
o Can apply to a specific clinical condition, a care episode, or a population
o As defined in the final rule…
CMS Innovation Center Model (other than a Health Care Innovation Award)
Medicare Shared Savings Program ACOs
Demonstrations under the Health Care Quality Demonstration Program
Demonstrations required by federal law
APMs
• Advanced APMs
o Subset of APMs
o Share rewards
o Share nominal financial risk
o Utilize electronic health record technology
o Base payment on quality measures comparable to MIPS QMs
o CMS designated
o Includes medical home models expanded under the CMS Innovation Center
Advanced APMs
• 2017 Advanced APMs
o Medicare Shared Savings Program (Tracks 2 and 3)
o Next Generation ACOs
o Comprehensive Primary Care Plus
o Comprehensive ESRD Care (LDO and non-LDO arrangements)
o Oncology Care Model (two-sided risk arrangement)
• 2018 and beyond
o TBD
o Could include a new MSSP ACO Track 1+, bundled paymentmodels, other payer ACOs, physician-focusedpayment models, etc.
Advanced APMs
• Qualified participants (QPs)
o Participate in an Advanced APM
o Receive a certain percentage of payments or see a certain percentage of patients through the Advanced APM s
o Eligible for 5% bonus payments from 2019-2024 on their FFS payments
o Exempt from MIPS
Advanced APM Path
• Partially qualified APM participants
o Medicare payment and patient thresholds less than those required for QP status
o Do not quality for 5% bonus, but have options
Assigned MIPS score and receive associated MIPS adjustment
No MIPS reporting and no payment adjustment (plus or minus)
Advanced APM Path
APM Path - QP Thresholds
• MIPS APMso Participate under an agreement with CMS
o Include one or more MIPS ECs on their APM participation list
o Base payment incentives on performance cost/utilization and quality measures
o Example - MSSP ACO (Track 1)
o Special rules regarding scoring and data submission
MIPS APMs
What is MIPS?
+ Improvement Activities = MIPS
VBPM
MUPQRS
MIPS
• Measures physicians and other eligible clinicians based on performance in four categories
o Quality
o Cost
o Advancing Care Information
o Improvement Activities
• 100-point composite performance final score
• Participation as an individual, group, or MIPS APM
MIPS
MIPS – Year 1 Weighted Scoring
Quality
60%
Advancing Care
Information
25%
Improvement Activities
15%
Cost
0%Final Score
MIPS – Future Weighted Scoring
2019 2020 2021+
Quality 60% 50% 30%
Cost 0% 10% 30%
Advancing Care Information*
25% 25% 25%
Improvement Activities
15% 15% 15%
*Potential to decrease weight to not less than 15% if proportion of physicians who are meaningful EHR users is determined to be 75% or greater.
• Other considerations
o Modified participation requirements for some MIPS ECs -non-patient facing, hospital-based, small practices, practices in rural or geographic health professional shortage areas
o Non-patient-facing MIPS ECs
Defined as an individual MIPS EC that bills 100 or fewer patient-facing encounters during a performance period, and a group provided that more than 75% of the NPIs billing under the group’s TIN meet the definition of a non-patient facing MIPS EC
Patient-facing encounter (list of face-to-face encounter codes will be made available on the CMS website)
o Performance data will be posted on Physician Compare
MIPS
• What is meant by quality, cost, advancing care information, and improvement activities?
• Final measures list to be published annually
• Select 6 measures or 1 specialty measure set
o At least 1 outcomes measure (or high priority measure)
o 50% scoring threshold in 2017; 60% in 2018
o Partial credit vs pass/fail
• Groups using the web interface – report 15 quality measures
• MIPS APMs (e.g., MSSP Track 1) – report through the APM
Quality
• Performance scoring
o Each measure earns up to 10 points
o Based upon the percentile-basis performance of the measure
o 3 points minimum for reporting a measure
o Zero points for measures not reported
o Opportunity to earn bonus points
o Maximum 60 points
Quality
• In 2017, weight is zero
• Score based on Medicare claims
o No reporting necessary
• Performance feedback will be given
o Total per capita costs for all attributed beneficiaries
o Medicare spending per beneficiary
o 10 episode-based measures
• Risk-adjusted
Cost
• Emphasis is on interoperability, secure information exchange, and patient engagement
• Scoring is comprised of a base score, optional performance score, and bonus points
o 5 measures comprise the base score (50 points)
Security risk analysis, e-Prescribing, patient access, sending summary of care, requesting/accepting summary of care
o 9 measures are optional (up to 90 points)
o Bonus for reporting to public health or clinical data registries and for utilizing CEHRT for improvement activities (up to 15 points)
o Earn 100 points or more for full credit
Advancing Care Information
• Focus is on care coordination, shared decision-making, beneficiary engagement, health equity, population management, and patient safety
• Credit given for engaging in clinical practice improvement activities
• 90+ activities weighted as “high” (20 points) or “medium” (10 points)
• Zero score if not engaged in at least one activity
• 40 points* for maximum score
• Full credit for PCMH designation
• Minimum half credit for APM participation
Bonus points for utilizing EHR technology
Improvement Activities
Improvement Activities Categories
Expanded Practice Access
Care Coordination
Population Management
Patient Safety & Practice
Assessment
Beneficiary Engagement
Achieving Health Equity
Emergency Response and Preparedness
Integrated Behavioral &
Mental Health
What happens now?
Strategies for Success
• Determine whether you qualify and where you fit in
Strategies for Success
• “Just breathe”
o Much of this will be familiar if you’re currently participating in PQRS, MU, specialty or other professional quality improvement activities
• Participate in PQRS in 2016
• Participate in MU in 2016
• Determine pathway that makes sense for your situation
o Estimate MIPS scores
o APM participation options
ROI
Strategies for Success
• Review Quality and Resource Use Reports (QRURs)
o Download at https://portal.cms.gov
o See directions on how to obtain your QRUR at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2014-QRUR.html#2014-annual-qrur
o QRURs with 2015 data recently released
o Request informal review if disagree with findings within 60 calendar days after the release of the QRURs
Strategies for Success• Identify gaps and areas of strength under current
federal quality programs
o Current PQRS measures that are meaningful
o Work on improving administrative processes and performance measurements under PQRS and VBPM
o Is patient data entered consistently and accurately
o HIT that works for you
Opportunities for efficiencies , patient engagement, analytics, etc.
• Compare quality measures already reporting via commercial insurers
o Identify alignment opportunities
Strategies for Success
• Emphasize need for accurate documentation and coding to ensure claims reflect complexity of patient population
o Ensure physicians and billers/coders are speaking the same language
o Co-morbidities that are considered for treatment or medical decision-making should be documented and included on the claim
• Examine where best to focus efforts
o Chronic disease management patients
o Referrals and transitions of care
o High treatment costs without sacrificing quality
Strategies for Success
• Identify current practice improvement activities
o What can be easily accomplished
o What future opportunities are there
E.g., Telehealth, expanded access, AMA Steps Forward modules, etc.
o Review internal workflow processes related to patient engagement and data exchange
• Evaluate staffing needs and resources
• Evaluate EHR and third-party vendor readiness
Strategies for Success
• Rely on MSMS, AMA, specialty societies, physician organizations, etc. for education opportunities and to help you sort through the details
The Big Picture
Medicare Quality Payment Program:
Alternative Payment Models (APMs)
Merit-based Incentive Payment System (MIPS)
VBPM
PQRS
MU/EHR
Medicare eRX
PQRS
Physician Compare MSSPPioneer ACOs
Comprehensive Primary Care InitiativeBundled Payments
Resources
• CMS MACRA QPP Web Site - https://qpp.cms.gov/
• CMS PQRS Web Site - http://cms.hhs.gov/PQRS
• CMS Value-based Payment Modifier –http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html
• QRURs - https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html
• FAQs – https://questions.cms.gov
• AMA - http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-physician-payment-reform.page
Resources• QualityNet Help Desk
o 1-866-288-8912 (TTY 1-877-715-6222)
• National Provider Calls
o http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/CMSSponsoredCalls.html
• FFS Provider Listserv
o https://list.nih.gov/cgi-bin/wa.exe?A0=PHYSICIANS-L
Stacey Hettiger
Director, Medical and Regulatory Policy
Michigan State Medical Society
(517) 336-5766
Thank You!
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