2018 Quality Payment Program (QPP) Overview -MACRA ... · MACRA: Medicare Access and CHIP Reauthorization Act of 2015 Source: 1. Avalere Health. Avalere Policy 360 Summary of H.R

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2018 Quality Payment Program (QPP) Overview - MACRANovember 2017

SC PCMH AlliancePresenter Name: Ryan UrgoDate: 11/17/17

MANAGEDHEALTHCARESERVICES


MACRA Further Encourages Quality and the Shift to Value-Based Payments

• The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – enacted on April 16, 2015 – establishes a comprehensive framework for providers to move to a value-based payment system

• Specifically, MACRA:

Source: MACRA 2015. Quality Payment Program. Slide 7. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Performance-Category-training-slide-deck.pdf

Permanently repeals the Sustainable Growth Rate (SGR) formula

Stabilizes Medicare payments to physicians with a 0.5% payment update in each of the four years before the start of

the MIPSEstablishes a Medicare physician payment system with

consolidated quality and value programs

Encourages providers to participate in alternative payment models (APMs)

Path to Value

*Appendix B offers additional details on Path to Value


Flexibility and Relief for Small and Rural Providers in 2018

Virtual groups: groups of 10 or fewer

clinicians can come together “virtually” to

meet reporting requirements,

increasing chances for higher score

Increase to Low-Volume Threshold:

providers with 200 or fewer patients or

$90,000 or lower in Part B payments

exempt from MIPS reporting; 134,000

fewer MIPS-eligible clinicians in 2018

Bonus Point eligibility: extra credit

(up to 5 pts) if providers see complex patients, are in practice

with 15 or fewer physicians, or are

using a 2015 certified electronic health

record technology (CEHRT)

1/4/18 3Source: Center for Medicare & Medicaid Services, 2018 QPP Final Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf



MACRA Reforms Physician Payment Schedule; Major Driver Behind Future Growth of APMs and Provider Integration

ACO: Accountable Care OrganizationMACRA: Medicare Access and CHIP Reauthorization Act of 2015Source: 1. Avalere Health. Avalere Policy 360 Summary of H.R. 2 - Medicare Access and CHIP Reauthorization Act of 2015

• Beginning in 2019, MACRA will encourage all providers to participate in one of two value-based payment tracks:

• Merit-Based Incentive Payment System (MIPS): preserves traditional Medicare fee-for-service (FFS) reimbursement, but creates incentives for providers to publicly report their performance on a set of measures related to quality, use of electronic health records (EHR), cost, and practice-improvement activities

• Alternative Payment Models (APMs): offers incentives for providers to participate in alternative reimbursement programs such as Accountable Care Organizations, bundled payment arrangements, and patient-centered medical home models where they also assume partial risk for outcomes and costs

• Failure to participate in either track will result in significant cuts to physician reimbursement under Medicare

Path to Value

• Eligible Clinicians include Physicians, PAs, NPs, Clinical Nurse Specialists, Certified Registered Nurse, Anesthetists


2018 Will Continue To Be A Transition Year

• 2018 will offer some flexibility from full reporting requirements• Payment adjustment range from - 5% to + 5% based on 2018

performance; $118M in total payment adjustments • CMS allows several options to submit reporting (e.g., claims,

QCDRs, qualified registries, EHR, CMS web interface, or CAHPS for MIPS survey)

• Budget neutrality constrains high performers• While reporting flexibility and opportunities for higher scoring are positive,

fewer negative payment adjustments means less money to distribute to higher performers

• +5% bonus for 2018 performance represents a maximum, not a guarantee, for high performers

5Source: Center for Medicare and Medicaid Services, 2018 QPP Final Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf


• Eligible Clinicians (ECs)§ Physicians§ Physician Assistants§ Nurse Practitioners§ Clinical Nurse Specialists§ Certified Registered Nurse

Anesthetists

• Excluded§ Clinicians billing Medicare for

the first time§ Clinicians who fall below the

low volume threshold§ <$90,000 in Medicare

billing; or§ <200 Medicare patients

Fewer Clinicians Expected To Participate in MIPS in 2018 Due to Increase in Low-Volume Threshold

6

• CMS estimates that LVT will exempt additional 134,000 providers from MIPS program in 2018 vs 2017 (622,000 total clinicians expected to participate in 2018)

• Only 40% of all clinicians who bill Medicare will be subject to MIPS participation in 2018• Exempt solo/small group clinicians cannot opt-in, but CMS seeking comment on how to allow• Exempt clinicians that join virtual groups can be included in MIPS scoring

Source: Centers for Medicare & Medicaid Services, 2018 QPP Final Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf

622,000 Participating EC’s in 2018



MIPS Pathway Streamlines Existing Quality Reporting Programs and Adjusts Payments Based on a Composite Score

MIPS

PQRS

CEHRT/MU

Value-based

Modifier

• High performers may receive additional positive adjustments under the exceptional performance bonus payment (up to additional 10%)

• 2017 performance will dictate 2019 payment adjustments• MIPS payment adjustments will be revenue neutral• New quality/performance measures will be developed for the composite score• EC composite scores and performance by category will be published on Physician Compare

Maximum Positive / Negative Adjustment under MIPS – Payment Year

Calendar Year Maximum Adjustment Percentage

2019 4%

2020 5%

2021 7%

2022 and beyond 9%

Source: CMS, “The Medicare Access and Chip Re-Authorization Act of 2015 Path to Value”, available at www.cms.gov; H.R. 2: Medicare Access and CHIP Reauthorization Act of 2015 Source: Adapted from Slides 18, 41, 42, 43.

**Resource Use % increases to 30% and Quality % decreases to 30% by 2021

Path to Value

15%

50%

25%

10%

Components of Composite Score (Performance Year 2)

Clinical Practice Improvement Activities

Quality

Advancing Care Information (CEHRT)

Cost



• Medicare providers receiving an established percentage of their revenues from APM arrangements receive a 5% annual bonus from 2019 to 2024 and an increase in the base rate from 0.25% to 0.75% in 2026 and beyond

• MACRA will allow APM revenue from other payers to count toward the threshold if Medicare APM options in a given region are limited

MACRA APM Pathway Will Expand Incentives for Clinicians to Enter Into Such Arrangements

*Minimum of 25% must be Medicare payments. Note: EPs receiving 20% of revenue from Medicare APMs in 2019-20, 40% from All Payers in 2021-2022, and 50% from All Payers in 2023 and beyond will also be exempt from MIPS reporting but ineligible for APM bonuses. ACO, accountable care organization; APM, alternative payment model; CMS, Centers for Medicare & Medicaid Services; EP, eligible professional; MACRA, Medicare Access and Children’s Health Insurance Program Reauthorization Act; MIPS, Merit-Based Incentive Payment System; MSSP, Medicare Shared Savings ProgramSource(s): Adapted from Slides 60, 70. MACRA 2015. Quality Payment Program. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Performance-Category-training-slide-deck.pdf; CMS. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models Proposed Rule (Truncated). Available at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-10032.pdf.

Percentage of Revenue or Lives From APMs Required to Qualify for Bonuses

PATH TO VALUE



CMS Proposes to Expand Models Meeting Advanced APM Criteria in 2018

Medicare Shared Savings Program (MSSP) Tracks 2

and 3

Next Generation ACO

Comprehensive Primary Care Plus

(CPC+)

Oncology Care Model (Two-sided

Risk)

Comprehensive ESRD Care (Large

Dialysis Organization)

MSSP Track 1+ CEHRT Track of CJR

Vermont All-Payer ACO Model

• CMS estimates that between 185,000 and 250,000 clinicians will participate in an AAPM in 2018 and can qualify for 5% lump sum bonus

• Total of $675 to $900 million estimated to be distributed in AAPM bonus dollars for the 2020 payment year

• Bonuses assessed at the individual QP level, but paid out at the TIN level• QP determinations will be made at three points in 2018 (March 31, June 30, August 31)

Path to Value

Source: Center for Medicare and Medicaid Services, 2018 QPP Final Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf



What is an Advanced APM? Must Meet Three Criteria

Require participants to use Certified Health IT

Pay providers based on quality measures

Have APM entities bear financial risk (includes financial mechanisms and thresholds)

APM: Alternative Payment ModelCF: Conversion Factor*In addition to the 0.25% update to the fee-for-service CF update for all providers.Source: MACRA 2015. Quality Payment Program. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Performance-Category-training-slide-deck.pdf

5%Part B bonus payment

(2019—2024)

0.50%Extra CF update*

(2026+)

Clinicians in Advanced APMs can earn payment incentives

Path to Value



What is a MIPS APM? An APM with an Adjusted MIPS Composite Scorecard

ACO: Accountable Care Organization; APM: Alternative Payment Model; MIPS: Merit-Based Incentive Payment System*Medicare Shared Savings Program and Next Generation ACOs.Source: Quality Payment Program Proposed Rule for 2018: https://www.gpo.gov/fdsys/pkg/FR-2017-06-30/pdf/2017-13010.pdf.

50%

0%

20%

30%

50%

0%

20%

30%

0%

10%

20%

30%

40%

50%

60%

QUALITY RESOURCE USE CLINICAL PRACTICE IMPROVEMENT

ACTIVITIES

ADVANCING CARE INFORMATION

Medicare ACO - MIPS APMs* All Other MIPS APMs

MIPS APMS MEET THREE CRITERIA AND HAVE REPORTING FLEXIBILITY IN 2018

Path to Value



Looking Ahead at Advanced APMs

• For the 2019 performance year, CMS will allow “All Payer” APM volume to contribute towards the threshold for AAPM bonuses

• To determine which APMs qualify, CMS proposes two determination processes: a payer-initiated process and an eligible clinician initiated process. • For 2019, CMS has defined “All Payer” APMs as only those occurring

within Medicare Advantage, State Medicaid, and payers in CMS Multi-Payer Models

• For 2020, CMS will permit Commercial APMs to seek All-Payer APM status

• CMS also creating new opportunities for physicians to submit new APM proposals that may also qualify as AAPMs

• Broader criteria will grow the ranks of those eligible for the AAPM Track

Source: Center for Medicare and Medicaid Services, 2018 QPP Proposed Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-13010.pdf



MACRA Implications forProviders and Manufacturers

APM: alternative payment modelEP: eligible professionalMACRA: Medicare Access and Children’s Health Insurance Program Reauthorization ActMIPS: Merit-Based Incentive Payment SystemSource: 1. Estimated Financial Effects of the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2). April 9 2015. Available at: https://www.cms.gov/research-statistics-data-and-systems/research/actuarialstudies/downloads/2015hr2a.pdf.

Providers

• Many ECs will benefit from a continued ramp-up of full MIPS implementation

• Exceptional performing ECs may not see as large of bonuses under relaxed scoring standard, making MIPS less attractive

• Advanced APM arrangements will accelerate under MACRA

o Office of the Chief Actuary estimates that payments to physicians in APMs could represent 60 percent of all Medicare payments by 2019 and continue to increase1

Pharmaceutical and Device Manufacturers

• MACRA’s incentives will accelerate the pace of change and foster greater demand for value and outcomes

• Alignment between a treatment’s clinical profile and evolving quality measures will be critical

• Cost must account for 30% of a provider’s Composite Performance Score beginning 2019 (Parts A and B spending)

Path to Value



Path To Value Continues with the Implementation of the MIPS and APMs

• The Quality Payment Program changes the way Medicare pays clinicians and offers financial incentives for providing high value care.• Qualified Clinical Data Registries will be a pivotal vehicle to help

providers meet reporting requirements

• Ongoing flexibility may slow pace towards value and limit financial incentives for high-performers under MIPS.• Providers must continually evaluate which track is best for them.

• Practice Transformation activities must continue despite new flexibility• To be successful, continued investments in staffing,

quality/performance measure reporting, and IT capability will be needed.

Source: 1. MACRA 2015. Quality Payment Program. Slide 79. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Performance-Category-training-slide-deck.pdf

Path to Value



Back-up



MACRA Changes How Medicare Pays Physicians

DOES THE PROVIDER DECIDE TO JOIN AN APM?

DOES IT MEET ADVANCED APM CRITERIA?

DOES THE APM SATISFY THE MIPS APM CRITERIA?

Y

1. ADVANCED APM

Y

N 2. MIPS APM

3. MIPS N

Y

N

APM: Alternative Payment Model; MIPS: Merit-Based Incentive Payment System; MACRA: Medicare Access and Chip Reauthorization Act; SGR:Sustainable Growth Rate*Providers participating in commercial, Medicaid, or Medicare Advantage APMs can receive credit for participating in an “Other Payer Advanced APM” on a case-by-case basis starting in 2019Source: Adapted from Slide 92. MACRA 2015. Quality Payment Program. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Performance-Category-training-slide-deck.pdf

MACRA REPEALS SGR AND CREATES THREE PATHWAYS

Y

N

IS THE PROVIDER IN AN APM?*

Path to Value

Documents

2018 Quality Payment Program (QPP) Overview -MACRA ... · MACRA: Medicare Access and CHIP Reauthorization Act of 2015 Source: 1. Avalere Health. Avalere Policy 360 Summary of H.R