The ABCs of Physician Quality

Reporting for Finance Professionals

HFMA South Carolina, June 2, 2016

Tom S. Lee, Ph.D.

CEO & Founder

SA Ignite

Learning Objectives

• Grasp key facets of quality reporting for

value-based programs such as MU, PQRS,

VBM and MIPS

• Understand how to balance the financial,

reputational and operational impacts of

quality reporting for value-based programs

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Agenda

• The “New Black” of Medicare Part B: MIPS

• The ABCs of Quality Reporting in Action:

PQRS Method and Measure Selection

• Q & A

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The “New Black” of Medicare Part B:

MIPS

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Rising Awareness of MIPS

“[MIPS] is the big regulation we're watching this entire year.”

- Washington counsel for the AMA (Feb 5, 2016)

“The implementation of the bipartisan MACRA legislation is a major item squarely

on our punch list that has everyone’s attention. At its most basic level it is a program

that brings pay for value into the mainstream through something called the Merit-

based Incentive Program.”

- Acting Administrator for CMS (Jan 12, 2016)

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The Medicare Access & CHIP

Reauthorization Act of 2015 (MACRA)

• “Doc fix” bill passed 92-8 by Senate

• Places each Medicare Part B provider into:

a) MIPS,

b) Alternative Payment Models (APMs) such as qualifying Medicare

ACOs,

c) both MIPS and APM, or

d) neither (small minority)

• “Planning for MACRA”, today 10:45A, Melinda Hancock

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How Many Medicare Part B Providers Will

Be Affected?

MIPS ~ 1.0M out of 1.25M Part B Providers

75% of APM participants ( ~30k providers) in ~500

Medicare ACOs (January 2016)

Hence, MIPS is the “new black” (default)

for Medicare Part B.

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MIPS Provider Eligibility • Who’s exempt

– Providers not exceeding minimum volume threshold of Part B patients or payments

– First-year Part B providers

– APM providers receiving 20%+ of their Part B payments through an APM tax ID

• Eligible as individuals or groups

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Plus:

MIPS Starts January 2017

• Leverages and augments PQRS, Value-Based Modifier

(VBM) and Meaningful Use rules

• Increases and consolidates financial impacts

• Ranks peers nationally and reports scores publicly

• MIPS is budget neutral: Incentives to winners funded by

penalties applied to losers

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Components of the

CY2017 MIPS Score

75% = MU + PQRS/VBM

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Financial Impacts of MIPS are Significant

• Under PQRS/VBM, the multiplier X is not capped; for Performance

Year 2014 it was 16 (with a 2% incentive bonus = 32% total bonus)

• Under MIPS, X is capped at 3.0 with an additional 10% bonus

awarded for “Exceptional Performance”

– For Performance Year 2020, up to a 9%*3.0 + 10% = 37% bonus

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MIPS Payment Adjustment Versus MIPS Points

PT = Performance Threshold

100 0

Exceptional Performance

Bonus Threshold

¼ PT

Max Incentive

Max Penalty

MIPS Points

Every MIPS point counts.

4-Year Annual Average Payment

Adjustment Versus MIPS Performance

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MIPS FINANCIAL CALCULATOR Assumptions:

•Budget-neutrality factor (x) = 2.0

•Average Exceptional Performance Bonus % = 5.0%

•Assume Exceptional Performance Threshold (EPT) corresponds to the 25th percentile of the range of possible scores above the Performance

Threshold (PT)

•Assume Maximum Exceptional Performance Bonus % is 2x the Average Exceptional Performance Bonus.

Free MIPS Financial Calculator: Google “mips calculator”, or go to

www.saignite.com/mips-solutions

http://www.saignite.com/mips-solutionshttp://www.saignite.com/mips-solutionshttp://www.saignite.com/mips-solutions

MIPS Rulemaking Timeline

• March 24: MACRA/MIPS draft rule submitted by CMS to OMB

• By ~June 2016: Release of draft rule

• By November 1, 2016: Release of final rule

• January 1, 2017: First performance year begins

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Free Resources to Help Educate

Your Organization

• 10 FAQs About MIPS:

http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips or

Google “merit-based incentive”

• Free MIPS Financial Calculator (Plus video and user guide):

http://www.saignite.com/mips-solutions or Google “mips calculator”

• Sign up at saignite.com for emails about 2016-2017 MIPS tools

• ABCs of MIPS monthly webinar videos and PDF presentations:

http://www.saignite.com/resources/hitech-abc-of-mips-webinar

– July 2015, The Financial Impact of MIPS

– December 2015, Planning for the 12 Months Before MIPS

– February 2016, MIPS for the C-Suite: How to Educate for Action

– March 2016, Tale of the Tape: MIPS versus Medicare ACOs

• LinkedIn Group “Merit-Based Incentive Payment System” (no ads)

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http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mipshttp://www.saignite.com/mips-solutionshttp://www.saignite.com/mips-solutionshttp://www.saignite.com/mips-solutionshttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinarhttp://www.saignite.com/resources/hitech-abc-of-mips-webinar

The ABCs of Quality Reporting in Action:

PQRS Method and Measure Selection

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PQRS and the VBM Quality Score

Key Considerations for Method Selection

• Within Method Selection what is the trade-off

among…

– Financial impacts and reputational implications?

– Administrative convenience versus:

• measure selection flexibility?

• ability to monitor performance?

– …and others

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PQRS Method Selection Complexity

PQRS Measure Selection Complexity

20 SA Ignite Proprietary and Confidential

To maximize VBM scores, measures must be selected from among…

…across Individual-Provider and GPRO PQRS reporting methods.

Also, for GPRO, should you opt-in to include the CAHPS patient

experience survey measures in the VBM Quality Score or not?

PQRS measures

~298 total

EHR Direct: 64 CQMs GPRO web interface: 17

measures Registry: ~280 measures

Individual

measures

Measures

groups

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Method Selection: Summary

PQRS Method Decision Tree (Example)

Cost

Multiple EHRs per TIN for

part of year?

If TIN 100+ docs, buying CAHPS for

PQRS?

GPRO

EHR vendor(s) support

2016 GPRO EHR direct?

Select own measures?

GPRO EHR

Direct

GPRO

Registry

GPRO Web

Interface

IP No

Yes or

N/A

No Yes

No No Yes

Yes

VBM Score

Comparison For each TIN,

analyze CQMs:

Which method gives

higher VBM $?

How do the data

extraction costs

compare?

What measures do

the method and my

EHR support?

Can data

be merged

in/ across

EHR(s)?

Q & A

Tom Lee

tom@saignite.com

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mailto:tom@saignite.com