MACRA Ready - Martin

MACRA: Medicare’s Shift to

Value-based Delivery &

Payment Models

Shawn Martin

AAFP Senior Vice President

Advocacy, Practice Advancement, & Policy

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What Does MACRA Do?

• Consolidates quality programs

Merit-Based Incentive Payment System (MIPS)

• Potential for bonus payment for participation

Advanced Alternative Payment Models (AAPM)

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2017/2018 QPP Participants

Physicians

(MD/DO)Physician

Assistant

Nurse

Practitioner

Clinical

Nurse

Specialist

Certified

Registered

Nurse

Anesthetist

MACRA defines eligible clinicians as:

MIPS Exemptions

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• Year 1 Medicare

• Eligible Advance Alternative Payment

Model with Bonus

• Below the Low Volume Threshold

• 2017: < $30,000 Medicare Part B

allowed charges; or cares for < 100

Medicare beneficiaries • 2018: < $90,000 Medicare Part B allowed

charges; or < 200 Medicare beneficiaries

Merit-Based Incentive Payment System

(MIPS)

MIPS Highlights

Consolidates existing quality and value programs

• Adds a category for Improvement Activities

Establishes a Final Score

• Weighted scoring by category

Provides opportunity for payment adjustments

• Both positive and negative

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MIPS Performance Categories

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Quality Cost Improvement

Activities

Advancing

Care

Information

(ACI)

Weighting by Category - 2017

Quality, 60%

Cost, 0%

Improvement Activities1, 15%

Advancing Care Information,

25%

1 - “Certified” PCMH receives

the full credit for IA; APM

Participants receive half credit

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Weighting Progression

**Proposed for 2018

Individual vs. Group

• If you choose to report as a group, all

performance categories must be reported as

a group

• Groups will be scored as a group and will

receive one MIPS score

• Groups must report the same measures for

all ECs

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Quality Measures

• Must report on measures

• May report more; only the highest scores will be used

to calculate the quality score

• Most measures need a 20 patient case minimum

• One must be an measure

– Controlling high blood pressure; A1C Poor Control

Cost Category Weight- 2017

Advancing Care Information

• ACI replaced Meaningful Use

• Must use certified EHR technology (CEHRT) to report for

the ACI performance category

• In 2017 and 2018, the CEHRT may be the 2014 edition,

2015 edition, or a combination of both (you might change)

• Physicians without an EHR are eligible to participate in

MIPS, but will not be able to receive any points in the ACI

category

Improvement Activities

There are 92 improvement activities available within the following overarching categories:

Expanded Practice Access

Population Management

Care Coordination

Beneficiary Engagement

Patient Safety and Practice Assessment

Achieving Health Equity

Emergency Response and Preparedness

Integrated Behavioral and Mental Health

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PCMH

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• Practices recognized or certified by:

NCQA, AAAHC, TJC, URAC; and

Accrediting bodies that have

certified 500 or more practices

– 2017: One member of the TIN

could have PCMH “recognition”

for 100% IA credit

– 2018: 50% of TIN members need

PCMH “recognition” for the TIN

to receive full IA credit**

Annual Performance Threshold

• Established by Secretary years 1 and 2

– For transition year 2017, threshold is 3

– Proposed for 2018, threshold increases to 15

• Below = negative payment adjustments

• Above = positive payment adjustments

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Adjust Payments

-4% -5% -7% -9%

4%

5%7%

9%

2019 2020 2021 2022 onward

*Adjustment to provider’s base rate of Medicare Part B payment

*Potential for

3Xadjustment

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Adjustment Summary

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Performance Score Payment Adjustment

Exceptional Performers

(Final Score over 70)=

Eligible for up to 10%

positive adjustment in

2019

25th Percentile or below =Maximum negative

adjustment

At threshold = Stable Payment

“Pick Your Pace” Reporting

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• Report one quality measure, one improvement activity, or all four of the required measures within the advancing care information (ACI) category

Test

• Report a minimum of 90 days for more than one quality measure, more than one improvement activity, or the measures within the ACI category.

Partial Participation

• Report to MIPS for a full 90-day period or full year

Full Participation

Advanced Alternative Payment Models

(AAPMs)

DefinitionsQualifying APM

• Based on existing payment models

Advanced APM

• Based on criteria of the payment model

Qualifying AAPM Participant

• Based on individual physician payment or patient volume

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Qualifying APMs

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• MSSP (Medicare Shares Savings

Program)

• Expanded under CMS Innovation

Center Model*

• Demonstration under Medicare

Healthcare Quality Demonstrations

(MHCQ) or Acute Care Episode

Demonstration

• “Demonstration required by Federal

Law”

Qualifying APMs

Advanced APM Eligibility

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• Quality measures comparable to MIPS

• Use of certified EHR technology

• More than nominal risk OR Medical Home model expanded under CMMI authority

Qualifying APMs

Advanced APMs

2017 Primary Care Advanced APMs

• Shared Savings Program (Tracks 2 & 3)

• Next Generation ACO Model

• Comprehensive Primary Care Plus (CPC+)

• Vermont Medicare ACO Initiative (as part of the

Vermont All-Payer ACO Model)

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Qualifying AAPM Participant

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• Percentage of patients or

payments thru eligible APM

• In 2019, the threshold is 25%

of Medicare payments or 20%

of beneficiaries

• QP status will be determined at

the group level

Qualifying APMs

Advanced APMs

Qualifying

AAPM

Participant

Additional Rewards for

Qualifying Participants

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• Not subject to MIPS

• 5% bonus 2019-2024

• Higher fee schedule update to 0.75% 2026

MACRA Timeline2017 2018 2019 2020 2021 2022-2024 2025 2026

Medicare Part B Baseline Payment Updates

+0.5% +0.5% +0.5% 0% 0% 0%+0.25%*

+0.75%**

*Non-qualifying APM Conversion Factor

**Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)

PQRS, Value-based

Modifier, & Meaningful UseQuality, Cost, Advancing Care Information, & Improvement Activities

-9% -9%? 0 or +/-4%*“Pick Your Pace”

+/-5% +/-7%

Qualifying AAPM Participant

5% Incentive payment

Excluded from MIPS

+0%

+/-9%

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What Can I Do Right Now?

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No Participation

TestPartial

ParticipationFull

Participation

‘Pick Your Pace’

Employed Physicians and Residents

• MIPS scores follow

you

• MIPS scores are

publicly available

• Consider a practices’

MIPS score as you

evaluate employment

contracts

*Check out the FPM Employed Physician Supplement

R. Shawn MartinSenior Vice President

Advocacy, Practice Advancement, & Policy

smartin@aafp.org

@rshawnm