9/20/2016
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Agenda
• The Last Mile
– The Physician Quality Reporting System (PQRS) 2016
– Value Based Modifier (VBM)
– Quality Tiering
• The First Glimpse
– Quality Payment Program (QPP)
– Merit-Based Incentive Payment System (MIPS)
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2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q2
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015
Submissions
Jan Feb Mar Apr May Jun
Full Year Data
Set
2016
Submissions
Providers: Provide Care | Document Care | Accumulate Data
Monitor Extractions, Data Exchange, and
Performance. Remediate Problems
PQRS EndsQPP Begins
Submission Portal
Opens
EHR & QCDR
QRDA Due
Registry & QCDR
XML Due
GPRO Web
Interface Due
GPRO 2016 Self
Nomination Due
2015
Feedback
Reports
and
QRUR
Available
Submission Portal
Opens
EHR & QCDR
QRDA Due
Registry & QCDR
XML Due
GPRO Web
Interface Due
2017 Penalty
Notices
2017 Q1
PQRS - QPP Timeline
Apply for
Informal
ReviewPQRS
Adjustments
Pay Out Thru
2018
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2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q2
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015
Submissions
Jan Feb Mar Apr May Jun
Full Year Data
Set
2016
Submissions
Providers: Provide Care | Document Care | Accumulate Data
Monitor Extractions, Data Exchange, and
Performance. Remediate Problems
PQRS EndsQPP Begins
Submission Portal
Opens
EHR & QCDR
QRDA Due
Registry & QCDR
XML Due
GPRO Web
Interface Due
GPRO 2016 Self
Nomination Due
2015
Feedback
Reports
and
QRUR
Available
Submission Portal
Opens
EHR & QCDR
QRDA Due
Registry & QCDR
XML Due
GPRO Web
Interface Due
2017 Penalty
Notices
2017 Q1
PQRS - QPP Timeline
Apply for
Informal
ReviewPQRS
Adjustments
Pay Out Thru
2018
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Healthcare System in Transition
Triple Aims related “chaos”• Patient Centeredness
• Accountable Care – Shared Savings Program
• Electronic Health Record Incentive Program
• Physician Quality Reporting System � Quality Payment Program
• Value-Based Modifier
• Physician Feedback Program
• Physician Compare Website
Fee For
Service
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Value Compass of Dartmouth’s Clinical Microsystem Group
Mingle’s Adaptation
9/20/2016Copyright 2012 Dan Mingle, MD
Cost
AccessQuality
&Safety
Practice
Vitality
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Triple AIMS of the Institute for Healthcare Improvement
Decrease the Cost of Care
Improve the
Experience of Care for Individuals
Improve the Health
of our Communities
Practice
Vitality
Accountable Care Patient Centered Care
New Payment Model
AccessQuality & Safety
Cost
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Revenue Cycle Opportunity
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Money i$ on the Line&
Performance Counts
The Healthcare Visit Value Stream
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Front
Office
Schedule
Appointment
Check
In
Check
Out
Patient
Care
Rooming Patient
Visit
Back
Office
Coding Billing Collection
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Errors Epidemic in the Value Stream
• Appointment Rules are Too Complex
• Unnecessary Waits and Delays
• Inadequate Capacity to Meet the Need
• Archaic Venues for Care Delivery
• Too Little Discipline to Track and Deliver Desirable
Interventions
• Too Much Attention to Opportunity for Profitable Procedures
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Avoid The dreaded Notice from CMS
in Late 2017
“You will be subject to a 2.0% downward payment adjustment
against all of your Medicare payments for 2018 services due to
failure to make a qualifying 2016 PQRS submission”
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“You will be subject to a 4.0% downward payment adjustment
against all of your Medicare payments for 2018 services due to
your Quality Tiering Adjustment for 2016”
Money to be Made – 2016 Reporting
• Quality Tiering under the Value Based Modifier
– 1-2% throughout 2018 for High Quality Care
– 1-2% throughout 2018 for Low Cost Care
• Maintenance of Certification (MOC)
– 0.5% Lump Sum Incentive in 2017
– When each are independently successful
• PQRS Submission
• Specialty Specific Maintenance of Certification Requirements
• 9% by 2022 MIPS Program Year
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Money to be Lost – 2016 Reporting
• 2% PQRS Adjustment throughout 2018 for failure to Submit
PQRS
• 2-4% Value Based Modifier Adjustment throughout 2018 for
failure to Submit PQRS
• Quality Tiering under the Value Based Modifier
– 1-2% throughout 2018 for Low Quality Care
– 1-2% throughout 2018 for High Cost Care
• 9% by 2022 MIPS Program Year
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At Risk 2016PQRS
Adjustment
(-2%)
VBM
Adjustment
(-2%)
VBM
Adjustment
(-4%)
Based On
Failure to make a
Qualifying PQRS Submission
Non-Physician Groups
and
Physician Groups < 10
Providers
Where ≥ half did not
submit PQRS
Physician Groups ≥ 10
Providers
Where ≥ half did not
submit PQRS
Average Range Average Average
MD/DO $2,000 $0 - $335,000 $2,000 / Provider $4,000 / Provider
Other
Provider$650 $0 - $40,000 $650 / Provider $1,300 / Provider
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Based on CMS 2013 PQRS Experience Report
3 Checkpoints
Checkpoints Judged as Submit as Adjustment
PQRS Practice-
Provider
Individual
or Group (GPRO)
0 or -2%
VBM Practice
Group
Group
or ≥ 50% Individuals
0 or -2% or -4%
Quality Tiering Practice
Group
Group -2% to +2% on Cost
-2% to +2% on Quality
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PQRS 2016
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Submit 9
Measures
3 Domains
1CC
No PQRS Adjustment
2%
PQRS
Adjustment
YES
NO FailMAV
Pass
You Pass or Fail in PQRS Individually
Unless you deliberately choose
Group Practice Reporting Option (GPRO)
Measure Applicability Validation Test
VBM 2016
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2%
VBM
Adjustment
4%
VBM
Adjustment
Group
Size
< 10
≥ 10
≥ 50% of
Group EPs
submitted
PQRS?
No VBM AdjustmentNOYES
Physician
in
Group?
NO
YES
You Pass or Fail in VBM as a Group
Then There’s Quality Tiering
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2%
VBM
Adjustment
4%
VBM
Adjustment
Group
Size
< 10
≥ 10
≥ 50% of
Group EPs
submitted
PQRS?
No VBM AdjustmentNOYES
Physician
in
Group?
NO
YES
VBM Quality Tiering
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Performance Countsin Quality Tiering under the Value Based Modifier
• If you have at least one Physician
– Physician = doctors of medicine, osteopathy, dental surgery, dental
medicine, podiatric medicine, optometry, and chiropracty
• And your total Medicare Provider Count is 1 - 9
» Low Composite Quality Performance Score � -1% Quality Tiering
Adjustment (Penalty)
» Low Composite Cost Performance Score � -1% Quality Tiering
Adjustment (Penalty)
• And your total Medicare Provider Count is ≥ 10
» Adjustments Double
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The Progressive Implementation of Quality Tiering
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Reporting
Year
First
Program
Year
First
Negative
QT Year
Who Size
2013 2015 2015 Physician Groups 100 or more
2014 2016 2017 Physician Groups 10 or more
2015 2017 2018 Physicians Solo and All Groups
2016 2018 MIPS Select Non-Physicians Solo and All Groups
2017 2019 2019 All of the above
Physicians = Doctors of Medicine, Osteopathy, Dental surgery, Dental
medicine, Podiatric medicine, Optometry, Chiropracty
Select Non-Physicians = Nurse Practitioner, Physician Assistant,
Certified Registered Nurse Anesthetist, Clinical Nurse Specialist
VBM 2016 (2018 Program Year)
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PQRS
Successful
for ≥ 50%
EP
YES
NO
-4% VBM
Adjustment
Group
Size
< 10 or
Non-Physician≥ 10
GPRO or
Individual
Submissions
-2% VBM
Adjustment
Mandatory Quality Tiering
Non-Physicians Group or Solo
Low
Quality
Avg
Quality
High
Quality
0 +1x% +2x%Low
Cost
0 0 +1x%Avg
Cost
0 0 0High
Cost
Physician Groups of 1 - 9
Low
Quality
Avg
Quality
High
Quality
0 +1x% +2x%Low
Cost
-1% 0 +1x%Avg
Cost
-2% -1% 0High
Cost
Physician Groups of 10 or More
Low
Quality
Avg
Quality
High
Quality
0 +2x% +4x%Low
Cost
-2% 0 +2x%Avg
Cost
-4% -2% 0High
Cost
10%
10%
Neg
80%
©2016 Mingle Analytics
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VBM 2016 (2018 Program Year)
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PQRS
Successful
for ≥ 50%
EP
YES
NO
-4% VBM
Adjustment
Group
Size
< 10 or
Non-Physician≥ 10
GPRO or
Individual
Submissions
-2% VBM
Adjustment
Mandatory Quality Tiering
Non-Physicians Group or Solo
Low
Quality
Avg
Quality
High
Quality
0 +1x% +2x%Low
Cost
0 0 +1x%Avg
Cost
0 0 0High
Cost
Physician Groups of 1 - 9
Low
Quality
Avg
Quality
High
Quality
0 +1x% +2x%Low
Cost
-1% 0 +1x%Avg
Cost
-2% -1% 0High
Cost
Physician Groups of 10 or More
Low
Quality
Avg
Quality
High
Quality
0 +2x% +4x%Low
Cost
-2% 0 +2x%Avg
Cost
-4% -2% 0High
Cost
10%
10%
Neg
80%
©2016 Mingle Analytics
For Payment Year 2016
X = 15.92
Who is Subject to PQRS?
• Essentially: Any Provider who Generates a Bill to Medicare Part B Covered by the Physician Fee Schedule
• Providers Employed by Critical Access Hospitals– NPI is now required in Type II billing
– Can submit PQRS if NPI is on the bill
– Will there be a penalty?
• Not Subject to PQRS:– FQHC
– Independent Diagnostic Testing Facilities
– Independent Laboratories
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Reporting Basics
• 9 Measures
• 3 Domains
• ≥ 50 % of Eligible Medicare Patients
• Any Measure with 0% Performance will not be Counted
• Submit 1 Cross-Cutting Measure
– If there is at least 1 face-to-face visit
– AND 15 Eligible instances for any Cross-Cutting Measure
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Individual Group
Claims
Registry
2016 Reporting Options
Qualified Clinical Data Registry
EHR
Measure Groups
Web Interface Tool
GPRO Registry
GPRO EHR
Certified Survey Vendor
Qualified Clinical Data Registry
New in the 2016 Reporting Year
MIPS?
2016 Supported Method-Measures
2014 2015 2016
Claims Measures 110 72 79
EHR (CQM) Measures 64 62 63
Registry Measures 201 175 198
Web Interface Measures 22 17 18
Measures Groups 24 22 25
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Beware: Inverse Measures, Stratified Measures, Annual re-
assignment of methods and domains
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Still the Best Mechanism
Cost-Effective and
Reliable
20162016
20162016
2016
We are adding
these
mechanisms in
2016
This is queued for
expansion. Complex
rules suggest value of
strategic partnerships
First mechanisms offered
after claims. Great
backup to GPRO Registry.
Highly Effective in our
hands
©2016 Mingle Analytics
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To Use the Group Practice Reporting Option
(GPRO)
• You must declare on the PQRS portal by June 30
– Your Intention to make a GPRO Submission
– Your Intended Method:
• Registry, Qualified Clinical Data Registry, EHR Direct, Data Submission Vendor, Web Interface Tool
– Intent to Use CAHPS for PQRS Survey
• Groups ≥ 100 must use the CAHPS Survey
• As of November 2015 You are no longer Trapped in your choices
– Change Method
– Make Individual Submissions
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Consumer Assessment of Healthcare Providers and Systems
CAHPS for PQRS
• Required for all Practices ≥ 100 Submitting GPRO
• Optional for all Group Practices ≥ 2
• Practice Bears the Expense
• Counts for 3 Measures, 1 Non-Specific Domain
• CAHPS is Based on 6 Months of Data, July 1 – December 31
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Not Enough Measures?
• Claims and Registry Reporting
– Measure Applicability Validation (MAV)
• EHR Reporting:
– Submit what you’ve got
• Web Interface
– Submit what you’ve got
• Qualified Clinical Data Registry
– No excuses
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To MAV or not to MAV(Measure Applicability Validation Test)
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PQRS 2016 (2018 Program Year)and the Measure Applicability Validation Test (MAV)
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Submit 9
Measures
3 Domains
1CC
No
Adjustment
-2%
PQRS
Adjustment
YES
NO
Other applicable Measures
not submitted
MAVCMS test for other
applicable measures
No other
Applicable measures
≥1 Measure Submitted
No Face to Face Visits
<15 Elig Instances for all
Cross Cutting Measures
≥1 CC Meas Submitted
≥50% Reporting Rate
Non-Zero Performance
YES
NO
©2016 Mingle Analytics
Don’t be Intimidated by Medicare“CMS fully expects individual eligible professionals
to report a full complement of 9 measures covering 3 domains”
(CMS 1/14/2016)
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CMS Qualifies that with:
“only use the MAV processes when reporting 9 measures covering 3 domains is
Simply not Appropriate or Possible” (CMS 1/14/2016)
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Physician Feedback Reports from the PQRS Portal
Report About Available
Feedback Report PQRS ± Third Quarter
Quality Resource and
Utilization Report
(QRUR)
Value Based Modifier and Quality
Tiering
± Third Quarter
QRUR Supplemental Episode of Care Cost Performance ± Fourth Quarter
QRUR Mid Year Split Year Last July – June Cost and
Administrative Claims Performance
± Second Quarter
QRUR Interim Report YTD Claims Performance Scattered sightings
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Informal Review
Program Timeframe
PQRS Must be Requested Within 60
Days Following Publication of the
PQRS Feedback Report
VBM Requests due 60 days after
Publication of QRUR
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About Claims Reporting
• High Failure Rate
• First Clue of Failure is Usually a
Penalty Notice
• Queued for Discontinuation
• Remains the Best way to Grade
and Communicate Performance
– For Some Measures
– For Some Practices
• Enduring Value to Claims
Performance Codes
– aka Quality Data Codes
– or QDC
• Usable to build a Registry
Submission
– Correct missing or mistaken data
– Pass/Fail is known at the time of
submission
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Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Quality Payment Program (QPP)
Merit-Based Incentive Payment Program (MIPS)
Reporting Dynamics unchanged from PQRS to QPP
QPP is entirely Pay-For-Performance
Measure Performance will need Continuous Attention
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View our series of Webinars reviewing the MIPS/MACRA Proposed Rule
http://mingleanalytics.com/webinars
The Final Rule will be released November 2016
Redesign / Remix / Rebranding
2016 (2018) is the Final Year
in their current form:
– Physician Quality Reporting
System (PQRS)
– Value Based Modifier (VBM)
– Quality Tiering
– Meaningful Use
Merit-Based Incentive Payment System (MIPS)
– [(Quality Tiering + PQRS + VBM + EHR) + a – b] x N
• Competition on a 100 point scale
– 30 Quality Points
– 30 Resource Use Points
– 25 Advancing Care Information Points
– 15 Practice Improvement Points
• Increasing Adjustments
– ±4% 2017 (2019)
– ±9% 2020 (2022)
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Quality Payment Program(QPP)
Merit-Based
Incentive Payment
System (MIPS)
Alternate Payment
Mechanisms (APM)
Eligible Clinicians
Qualified Providers (QP)
APM Type
APM Entity
Advanced APM
Partial QP
Split TIN
Virtual Groups
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Performance Matters
Strategies for Excellence in the Quality Tiering
Become
Strategies to Improve Quality Payment Program
(QPP) Performance
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Estimated Impact
Program Applies to Negative
Adjustments
Positive
Adjustments
MIPS Adjustments 687k to 747k providers $833m $833m
Exceptional Performance Payments $500m
Advanced APM Incentives 30,658 – 90k Providers $146m - $429m
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Quality Tiering
5% 90% 5%
Low
Qualit
y
Avg
Qualit
y
High
Qualit
y
0 +2x% +4x%
Low
Cost
5%
-2% 0 +2x%
Avg
Cost
90%
-4% -2% 0
High
Cost
5%
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The QPP Composite Performance Score
50 QualityPoints
10 CostPoints
15 CPIAPoints25 ACI
Points
PY 2019± 4%
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The QPP Composite Performance Score
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50 QualityPoints
10 CostPoints
15 CPIAPoints25 ACI
Points
45 QualityPoints
15 CostPoints
15 CPIAPoints
25 ACIPoints
PY 2019PY 2020± 4%± 5%
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The QPP Composite Performance Score
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50 QualityPoints
10 CostPoints
15 CPIAPoints25 ACI
Points
45 QualityPoints
15 CostPoints
15 CPIAPoints
25 ACIPoints
30
QualityPoints
15 CPIAPoints
25 ACIPoints
PY 2019PY 2020PY 2021
30 CostPoints
± 4%± 5%± 7%
The QPP Composite Performance Score
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50 QualityPoints
10 CostPoints
15 CPIAPoints25 ACI
Points
45 QualityPoints
15 CostPoints
15 CPIAPoints
25 ACIPoints
30
QualityPoints
15 CPIAPoints
25 ACIPoints
PY 2019PY 2020PY 2021
30 CostPoints
± 4%± 5%± 7%± 9%
PY 2022
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Quality Payment Program(QPP)
Merit-Based
Incentive Payment
System (MIPS)
Alternate Payment
Mechanisms (APM)
Eligible Clinicians
Qualified Providers (QP)
APM Type
APM Entity
Advanced APM
Partial QP
Split TIN
Virtual Groups
50 QualityPoints
10 CostPoints
15 CPIAPoints25 ACI
Points
PY 2019± 4%
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Final Questions & How to Obtain More Information
Dr. Dan Mingle, MD
(866) 359-4458
www.mingleanalytics.com
Mingle Analytics: Proudly Partnering with HBMA
• HBMA members receive 25% discount on
PQRS/MIPS Solutions™ Products and Services
• Visit HBMA.org/member_value_program to learn more
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