2020 QUALITY PAYMENT PROGRAM FINAL RULE OVERVIEW … … · consequences of the use of this presentation. 2 . Quality Payment Program Topics • Merit-based Incentive Payment System

2020 QUALITY PAYMENT PROGRAM FINAL RULE OVERVIEW NOVEMBER 19, 2019

Disclaimers

This presentationwas prepared as a tool to assist providers and is not intendedto grant rights or impose obligations. Although every reasonableeffort has been made to assure the accuracy of the informationwithin these pages, the ultimate responsibility for the correctsubmissionof claims and response to any remittance advicelies with the provider of services.

This publicationis a general summary thatexplains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Programprovisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been providedwithin the document for your reference

The Centers for Medicare & Medicaid Services (CMS) employees,agents, and staff make no representation, warranty,or guaranteethat this compilation of Medicare informationis error-free and will bear no responsibility or liability for the results or consequences of the use of this presentation.

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Quality Payment Program Topics

• Merit-based Incentive Payment System (MIPS) Overview

• MIPS Value Pathways Overview

• Final Rule for the 2020 Performance Period – MIPS

• Final Rule: Public Reporting via Physician Compare Overview

• Alternative Payment Models (APMs) Overview

• Final Rule for the 2020 Performance Period – Advanced APMs

• Help & Support

• Appendix 3

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) Overview

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Merit-based Incentive Payment System (MIPS) Quick Overview

MIPS Performance Categories in 2020

*Revised weights according to the 2020 Proposed Rule

• Comprised of four performance categories.

• So what? The points from each performance category areadded togetherto give you a MIPS Final Score.

• The MIPS Final Score is compared to the MIPS performance threshold to determine if you receive a positive, negative, or neutral payment adjustment.

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Merit-based Incentive Payment System (MIPS) Terms and Timelines

As a refresher…

• TIN - Tax Identification Number

- Used by the Internal Revenue Service to identify an entity, such as a group medical practice, that is subject to federal taxes

• NPI – National Provider Identifier

- 10-digit numeric identifier for individual clinicians

• TIN/NPI

- Identifies the individual clinician and the entity/group practice through which the clinician bills services to CMS

Performance Period Also referred to as… Corresponding Payment Year

2017 2017 “Transition” Year 2019

2018 “Year 2” 2020

2019 “Year 3” 2021

2020 “Year 4” 2022

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Merit-based Incentive Payment System (MIPS) Timelines

Feedback available adjustment submit Performance period

2020 Performance Year

• Performance period opens January 1, 2020

• Ends December 31, 2020

• Clinicians care for patients and record data during the year

March 31, 2021 Data Submission

• Deadline for submitting data is March 31, 2021

• Clinicians are encouraged to submit data early

Feedback

• CMS provides performance feedback after the data is submitted

• Clinicians will receive feedback before the start of the payment year

January 1, 2022 Payment Adjustment

• MIPS payment adjustments are applied to each claim beginning January 1, 2022

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MIPS VALUE PATHWAYS (MVPS) Overview

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Current Participation in MIPS

What we’ve been hearing from clinicians:

• The current structure of MIPS and the reporting requirements are confusing

• There is too much choice and complexity when it comes to selecting and reporting measures and activities

• The measures and activities aren’t always relevant to a clinician’s specialty

• It’s hard for patients to compare performance across clinicians

While there have been incremental changes to the program each year, additional long-term improvements are needed to align with CMS’ goal to develop a meaningful program for every clinician, regardless of practice size or specialty.

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MIPS Value Pathways Overview

CMS is committed to the transformation of the Merit-based Incentive PaymentSystem (MIPS) through the MIPS Value Pathways (MVPs), a new participation framework beginning in the 2021 performance year. This new framework will:

- Remove barriers to Alternative PaymentModel (APM) participation

- Move away from siloed activities and towards an aligned set of measure options

more relevant to a clinician’s scope of practice that is meaningful to patient care

- Promote value by focusing on Quality and Cost measures and Improvement

Activities built on a foundation of population health measures calculatedfrom

administrative claims-based quality measures and Promoting Interoperability

concepts

- Further reduce reporting burden

- Keep the patient at the center of our work

After consideration of the comments submitted to the MVPs Request for Information,CMS is finalizing a modified proposal to define MVPs as a subset of measures and activities established through rulemaking. 10

MIPS Value Pathways Overview

Through this new framework, CMS intends to:

• Provide enhanced data and feedback to clinicians

• Analyze existing Medicare information to provide clinicians and patients with more information to improve health outcomes

• Reduce reporting burden by limiting the number of required specialty or condition-specific measures

- Note:All clinicians or groups reporting on a clinical area would be reporting the same measures sets

CMS recognizes concerns about the implementationtimeline of MVPs and will establish an incremental implementation that does not eliminate the current MIPS framework.

CMS is committed to working with stakeholders to develop this new framework, as well as develop additional ways to reduce burden in the MIPS program. We encourage the health care community to review the MIPS Value Pathways video and our illustrative diagram. You can find more information availableon the QPP website at: https://qpp.cms.gov/mips/mips-value-pathways.

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https://www.youtube.com/watch?v=ZhM3KiojPjY&feature=youtu.be

https://qpp.cms.gov/mips/mips-value-pathways

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MIPS Value Pathways

Future State ofMIPS (In Next 3 5Years)

Current Structure ofMIPS (In 2020)

New MIPS Value Pathways Framework (In Next 1 2Years)

• Simplified

• Increased Voice of thePatient

• Increased CMS Provided Data

• Facilitates Movement to Alternative Payment Models (APMs)

Fully ImplementedPathways Continue to increase CMS provided data and feedback to

reduce reporting burden on clinicians

Value

Cost

Quality and IA aligned

Foundation

Promoting Interoperability

Population Health Measures

Enhanced Performance Feedback

Patient Reported Outcomes

• Many Choices

• Not Meaningfully Aligned

• Higher Reporting Burden

Quality Promoting Interoperability

6+ 6+ MeasuresMeasures

Cost

1 or More Measures

Improvement Activities

2-4 Activities

• Cohesive

• Lower Reporting Burden

• Focused Participation around Pathways that are Meaningful to Clinician’s Practice/Specialty or Public Health Priority

Building Pathways Framework MIPS Value Pathways

Clinicians report on fewer measures and activities base on specialty and/or outcome within a MIPS ValuePathway

Moving toValue

Implementation to begin in 2021

Quality Improvement Activities

Cost

Foundation



Population Health Measures: a set of administrative claims-based quality measures that focus on public health priorities and/or cross-cutting population health issues;

CMS provides the data through administrative claims measures, for example, the All-Cause Hospital Readmissionmeasure.

Goal is for clinicians to report less burdensome data as MIPS evolves and for CMS to provide more datathrough Clinician/Group Reported Data CMS Provided Data

administrative claims and enhanced performance feedback that is meaningful to clinicians and patients.

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MIPS Value Pathways: Surgical Example

Current Structure of MIPS New MIPS Value PathwaysFramework Future State of MIPS (In 2020) (In Next 1 2 Years) (In Next 3 5 Years)

MIPS moving towards value; focusing participation on specific meaningful measures/activities or public health priorities; facilitating movement to Advanced APMtrack

Surgeon chooses from same set ofmeasures as all other Surgeon reports same “foundation”of PI andpopulationhealth Surgeon reports on same foundation of measures with clinicians, regardless of specialty or practicearea patient-reportedoutcomes also included

with surgical measures andactivities alignedwith specialty measures as all other cliniciansbut now has a MIPS Value Pathway

Four performance categories feel likefour different programs Surgeon reports on fewer measures overall in apathway that Performance category measures in Surgical Pathway are is meaningful to theirpractice more meaningful tothepractice

Reporting burden higher and population health not addressed CMS provides more data; reporting burden on surgeon CMS provides even more data (e.g. comparative analytics) reduced using claims data and surgeon’s reporting burden even

further reduced Clinician/Group CMS Clinician/Group CMS Clinician/Group CMS

Completion of an Accredited Safety or Quality Improvement Program (IA_PSPA_28)

Patient-Centered Surgical Risk Assessment and Communication (Quality ID:358) OR

Implementing the Use of Specialist Reports Back to Referring Clinicianor Group toClose Referral Loop (IA_CC_1)

Revascularizationfor Lower Extremity Chronic Critical Limb Ischemia (COST_CCLI_1)

Use of Patient SafetyTools (IA_PSPA_8)

Knee Arthroplasty (COST_KA_1)

Surgical Site Infection (SSI) (Quality ID:357)

Unplanned Reoperation within the 30-Day Postoperative Period (Quality ID: 355)

QUALITY MEASURES

MIPS Value Pathways for Surgeons

COST MEASURES

*Measures and activities selected for illustrative purposes and are subject to change.

IMPROVEMENT ACTIVITIES

Quality Improvement CostActivities

Cost

Qua ty and IA a gned

Medicare Spending Per Beneficiary (MSPB_1)


6+ 6+

MeasuresMeasures

Cost

1 or More Measures


2-4 Activities

Foundation



Foundation


Population Health Measures Enhanced Performance Feedback


Population HealthMeasures: a set of administrative claims-based quality measures that focus onpublichealth priorities and/or cross-cutting populationhealth issues; CMS provides the data through administrativeclaims measures, for example, the All-Cause Hospital Readmission measure. 13

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MIPS Value Pathways: Diabetes Example

Current Structure of MIPS New MIPS Value PathwaysFramework Future State of MIPS (In 2020) (In Next 1 2 Years) (In Next 3 5 Years)

MIPS moving towards value; focusing participation on specific meaningful measures/activities or public health priorities; facilitating movement to Advanced APMtrack

Endocrinologist chooses fromsame set of measuresas all Endocrinologist reports same “foundation”of PI and population Endocrinologist reports on same foundation of measures other clinicians, regardless of specialty or practice area health measures as all other clinicians but now has a MIPS Value with patient-reported outcomes also included

Pathway with measures and activities that focus on diabetes prevention and treatment

Four performance categories feel likefour different programs Endocrinologist reports on fewer measures overall in Performance category measures in endocrinologist’s a pathway that is meaningful to their practice Diabetes Pathway are more meaningful to their practice

Reporting burden higher and population health not addressed CMS provides more data; reporting burden on CMS provides even more data (e.g. comparative analytics) endocrinologist reduced using claims data and endocrinologist’s reportingburden

even further reduced Clinician/Group CMS Clinic ian/Group CMS Clinic ian/Group CMS

Electronic Submission of Patient Centered Medical Home Accreditation (IA_PCMH)

EvaluationControlling HighBlood Pressure (Quality ID: 236)

OR

Medicare Spending Per Beneficiary (MSPB_1)

Total Per Capita Cost (TPCC_1)

Diabetes: Medical Attentionfor Nephropathy (Quality ID: 119)

Glycemic Management Services (IA_PM_4) Hemoglobin A1c (HbA1c) Poor Care Control (>9%) (Quality ID: 001)

QUALITY MEASURES

MIPS Value Pathways for Diabetes

COST MEASURES

*Measures and activities selected for illustrative purposes and are subject to change.

IMPROVEMENT ACTIVITIES

Chronic Care and Preventative Care Management for Empaneled Patients (IA_PM_13)


CostQuality Cost

Qua ty and IA a gned


6+ 6+

MeasuresMeasures

Cost

1 or More Measures


2-4 Activities

Foundation



Foundation


Population Health Measures Enhanced Performance Feedback


Population HealthMeasures: a set of administrative claims-based quality measures that focus onpublichealth priorities and/or cross-cutting populationhealth issues; CMS provides the data through administrative claims measures, for example, the All-Cause Hospital Readmission measure. 14

Eligibility

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2020 FINAL RULE -MIPS

2020 Final Rule- MIPS MIPS Eligible Clinician Types

No changes to the MIPS eligible clinician types in the 2020 performance period; they are the same as in the 2019 performance period:

• Physicians

• Physician Assistants

• Nurse Practitioners

• Clinical Nurse Specialists

• Certified Register Nurse Anesthetists

• Clinical Psychologists

• Physical Therapists

• Occupational Therapists

• Audiologists

• Speech-language pathologists

• Registered Dietitians and other nutrition professionals

• Groups of such clinicians

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2020 Final Rule- MIPS Low-volume Threshold Determination

No changes to low-volume threshold criteria in the 2020 performance period.

The low-volume threshold includes MIPSeligible clinicians who:

• Bill more than $90,000a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS)

AND

• Furnish covered professional services to more than 200 Medicare beneficiaries

AND

• Provide more than 200 covered professional services under the PFS.

BILLING SERVICES AND AND

>$90,000 >200>200

To be included in MIPS, a clinician must exceed all three criteria.

• Note: For MIPS APMs participants, the low-volume threshold determination will continue to be calculated at the APM Entity level. 17

2020 Final Rule- MIPS Opt-in Policy

No changes in the 2020 performance period to the opt-in policy for MIPS eligible clinicians who are excluded from MIPS based on the low-volume threshold determination.

MIPS eligible clinicians who meet or exceed at least one of the low-volume threshold criteria may choose to participate in MIPS.

MIPS Opt-in Scenarios

Dollars Beneficiaries Professional Services (New-

proposed) Eligible for Opt-in?

≤ 90K ≤ 200 ≤ 200 No – excluded

≤ 90K ≤ 200 > 200 Yes (may also voluntarily report or not participate)

> 90K ≤ 200 ≤ 200 Yes (may also voluntarily report or not participate)

≤ 90K > 200 > 200 Yes (may also voluntarily report or not participate)

> 90K > 200 > 200 No – required to participate

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MIPS Eligibility Determinations

Merit-based Incentive Payment System (MIPS)

Is There Somewhere I can go to Check my MIPS Status?

• You can check your participation status using the National Provider Identifier (NPI) Look-up Tool on qpp.cms.gov: https://qpp.cms.gov/participation-lookup

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https://qpp.cms.gov/participation-lookup

https://qpp.cms.gov

Performance Categories Overview


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Performance Category High Level Changes

2020 Final Rule – MIPS

• Quality: Increase the data completeness threshold to 70%; continue to remove low-bar, standard of care process measures; address benchmarking for certain measures to avoid potentially incentivizing inappropriate treatment; focus on high-priority outcome measures; and add new specialty sets

• Cost: Add 10 new episode-based measures to continue expanding access to this performance category; revise the existing Medicare Spending Per Beneficiary Clinician (MSPB Clinician) and Total Per Capita Cost (TPCC) measures

• Improvement Activities: Increase the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice; update the Improvement Activity Inventory and establish criteria for removal in the future; and conclude the CMS Study on Factors Associated with Reporting Quality Measures

• Promoting Interoperability: Keep the Query of Prescription Drug Monitoring Program measure as an optional measure; remove the Verify Opioid Treatment Agreement measure; and reduce the threshold for a group to be considered hospital-based

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2020 Final Rule- MIPS Performance Category Weights

No changes to the MIPS performance category weights in 2020:

2019 Final 2020 Final

Performance Category

Performance Category Weight

Performance Category

Performance Category Weight

45% 45%

Quality Quality

15% 15%

Cost Cost

15% 15% Improvement Improvement

Activities Activities

25% 25% Promoting Promoting

Interoperability Interoperability 22

Quality Performance Category

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MIPS- 2020 Basics

Basics for 2020

• 45% of your MIPS Final Score

• Total of 218 quality measures

• You select 6 individual measures

- 1 must be an outcome measure OR a high-priority measure (if an outcome is not available)

• High-priority measures fall within these categories: Outcome, Patient Experience, Patient Safety, Efficiency, Appropriate Use, Care Coordination, and Opioid-Related

- If less than 6 measures apply, you should report on each applicable measure

- May also select a specialty-specific set of measures

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MIPS- 2020 Basics

Basics for 2020

• Bonus points are available

- 2 points for outcome or patient experience (after the first required outcome measure is submitted)

- 1 point for other high-priority measures (after the first required measure is submitted)

- 1 point for each measure submitted using electronic end-to-end reporting

- Small practice bonus of 6 points

• Data completeness

- What does this mean?

• We check to see if you or your group have submitted data on a minimum percentage of your patients that meet a quality measure’s denominator criteria

- In 2020, the thresholds are:

• 70% for data submitted on QCDR measures, CQMs, and eCQMS (all-payer data)

• 70% for data submitted on Medicare Part B claims measures (Part B data)

- Measures that do not meet the data completeness criteria earn 0 points

• Small practices receive 3 points for measures that do not meet data completeness 25

2020 Final Rule- MIPS Quality Performance Category Measure Changes

Quality Performance Category Measures – 2020 Final Rule

- Removed low-bar, standard of care, and process measures

- Focused on outcome and other high priority measures

- Added new specialty sets

• Speech Language Pathology

• Audiology

• Clinical Social Work

• Chiropractic Medicine

• Pulmonology

• Nutrition/Dietician

• Endocrinology 26

2020 Final Rule- MIPS Quality Performance Category Changes

Overview:

• Increased data completeness requirements

• Additional measure removal criteria

• Alternative benchmarks established

Data Completeness Requirements


• Medicare Part B Claims measures: 60% of Medicare Part B patients for the performance period.

• Qualified Clinical Data Registry (QCDR) measures, MIPS Clinical Quality Measures (CQMs), and electronic CQMs (eCQMs): 60% of clinician’s or group’s patients across all payers for the performance period.

• Medicare Part B Claims measures: 70% sample of Medicare Part B patients for the performance period.

• QCDR measures, MIPS CQMs, and eCQMs: 70% sample of clinician’s or group’s patients across all payers for the performance period.

• Note: Using data selection criteria

to misrepresent a clinician or group’s performance for a performance period, commonly referred to as “cherry-picking”, results in data that is not true, accurate, or complete.

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Measure Removal


• A quality measure may be considered for removal if the measure is no longer meaningful, such as measures that are topped out.

• A measure would be considered for removal if a measure steward is no longer able to maintain the quality measure.

In addition to current measure removal criteria: • MIPS quality measures that do

not meet case minimum and reporting volumes required for benchmarking for 2 consecutive years will be removed.

• We will consider a MIPS quality measure for removal if we determine it is not available for MIPS Quality reporting by or on behalf of all MIPS eligible clinicians (including via third party intermediaries).

Overview:




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Overview:




Modified Benchmarks to Avoid the Potential for Inappropriate Treatment


No special benchmarking policy. The general benchmarking policy for quality measures applies, where: • Performance on quality measures is

broken down into 10 “deciles.” • Each decile has a value of between

one and 10 points based on stratified levels of national performance (benchmarks) within that baseline period.

• A clinician’s performance on a quality measures will be compared to the performance levels in the national deciles. The points received are based on the decile range that matches their performance level.

• For inverse measures (like the diabetic HgA1c measure), the order is reversed – decile one starts with the highest value and decile 10 has the lowest value.

• Establish flat percentage benchmarks* in limited cases where CMS determines that the measure’s otherwise applicable benchmark could potentially incentivize treatment that could be inappropriate for particular patients.

• The modified benchmarks will be applied to all collection types where the top decile for a historical benchmark is higher than 90 % for

the following measures: • MIPS #1 (National Quality

Forum (NQF) 0059): Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

• MIPS #236 (NQF 0018): Controlling High Blood Pressure

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Cost Performance Category


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Cost Performance Category

MIPS- 2020 Basics

Basics for 2020


• No reporting requirement – data is pulled from administrative claims

• We will measure you on:

- Medicare Spending Per Beneficiary (MSPB) measure

- Total Per Capita Cost measure

- 18 episode-based measures

• In order to be scored on a cost measure, you or your group must have enough attributed cases to meet or exceed the case minimum for that cost measure

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2020 Final Rule- MIPS Cost Performance Category Measure Changes

Cost Performance Category Measures – 2020 Final Rule

- Added 10 new episode-based measures to continue expanding access to the Cost performance category

- Revised the existing Medicare Spending Per Beneficiary Clinician (MSPB Clinician) and Total Per Capita Cost (TPCC).

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2020 Final Rule- MIPS Cost Performance Category Changes

Measures


Measures: • Total Per Capita Cost (TPCC) • Medicare Spending Per

Beneficiary (MSPB) • 8 episode-based measures Case minimums: • 10 for procedural episodes • 20 for acute inpatient

medical condition episodes

Measures: • TPCC measure (Revised) • MSPB Clinician (MSPB-C)

measure (Name and specification Revised)

• 8 existing episode-based measures

• 10 new episode-based measures

No changes to case minimums

Overview:

• New episode-based measures and current global measures’ attribution methodologies revised

• Different measure attribution for individuals and groups

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2020 Final Rule- MIPS Cost Performance Category Changes

Overview:

• New episode-based measures and current global measures’ attribution methodologies revised

• Different measure attribution for individuals and groups

Measure Attribution 2019 Final 2020 Final

• All measures are attributed at the TIN/NPI level for both individuals and groups

• Plurality of primary care services rendered by the clinician to determine attribution for the total per capita cost measure

• Plurality of Part B services billed during the index admission to determine attribution for the MSPB measure

• TPCC attribution will require a combination of 1) E&M services and 2) primary care service or a second E&M service from the same clinician group

• TPCC attribution will exclude certain clinicians who primarily deliver certain non-primary care services or are in specialties that are unlikely to be responsible for primary care services.

• MSPB clinician (MSPB-C) attribution changes will have a different methodology for surgical and medical patients

• Measure attribution will be different for individuals and groups and will be defined in the applicable measure specifications.

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Improvement Activities Performance Category

2020 FINAL RULE CHANGES - MIPS

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Improvement Activities Performance Category

MIPS- 2020 Basics

Basics for 2020


• Total of 105 Improvement Activities for 2020

• Each activity contains a weight:

- Medium – worth 10 points

- High – worth 20 points

• Select an activity and attest“yes” to completing

• You must earn 40 points to receive the full ImprovementActivities category score

- Small practices,non-patient facing clinicians,and/or clinicians located in rural or health professional shortage areas (HPSAs) receive double-weightingand report on no more than 2 activities to receive the highest score

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2020 Final Rule- MIPS Improvement Activities Performance Category Measures Changes

Improvement Activities Performance Category Measures – 2020 Final Rule

- Added 2 new Improvement Activities

- Modified 7 existing Improvement Activities

- Removed 15 existing Improvement Activities

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2020 Final Rule- MIPS Improvement Activities Performance Category Changes

Definition of Rural Area 2019 Final 2020 Final

• Rural area means a ZIP code designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data set available.

Rural area means a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP Code file available.

Overview:

• Modification of definition of rural areas

• Increased participation threshold for groups

• Conclusion of CMS study

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Overview:




Patient-Centered Medical Home Criteria 2 0 19 Final 2 0 2 0 Final

The practice must meet one of the following criteria: • Has received accreditation from one of

four accreditation organizationsthat are nationally recognized:

• The Accreditation Association for Ambulatory Healthcare;

• The National Committee for Quality Assurance (NCQA);

• The Joint Commission; or • The Utilization Review

Accreditation Commission (URAC); OR

• Is participating in a Medicaid Medical Home Model or Medical Home Model; OR

• Is a comparable specialty practice that has received the NCQA Patient-Centered Specialty Recognition.

The practice must meet one of the following criteria: • Has received accreditation from an

accreditation organization that is nationally recognized (such as the four organizationsspecified for PY 2019);

• Is participating in a Medicaid Medical Home Model or Medical Home Model;

• Is a comparable specialty practice that has received recognition through a specialty recognition program offered through a nationally recognized accreditation organization; OR

• Has received accreditation from other certifying bodies that have certified a large number of medical organizations and meet national guidelines, as determined by the Secretary.

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Removal of Improvement Activities 2019 Final 2020 Final

Overview:




• No formal policy but invited public comments on what criteria should be used to identify improvement activities for removal from the Inventory.

An activity will be considered for removal if:

• It is duplicative of another activity

• An alternative activity exists with stronger relationship to quality care or improvements in clinical practice

• The activity does not align with current clinical guidelines or practice

• The activity does not align with at least one meaningful measures area

• The activity does not align with Quality, Cost, or Promoting Interoperability performance categories

• There have been no attestations of the activity for 3 consecutive years

• The activity is obsolete

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Requirement for Improvement Activity Credit for Groups

Overview:

• Removal of improvement activities

• Modification and addition of improvement activities



Group or virtual group can attest to an improvement activity if at least one clinician in the TIN participates.

Group or virtual group can attest to an improvement activity when at least 50% of the clinicians (in the group or virtual group) perform the same activity during any continuous 90-day period within the same performance year.

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Promoting Interoperability Performance Category

2020 FINAL RULE-MIPS

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Promoting Interoperability Performance Category

MIPS- 2020 Basics

Basics for 2020


• Must use 2015 Edition Certified EHR Technology (CEHRT)

• Performance-based scoring at the individual measure level

• Four Objectives:

- e-Prescribing

- Health Information Exchange

- Provider to Patient Exchange

- Public Health and Clinical Data Exchange

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2020 Final Rule- MIPS Promoting Interoperability Performance Category Measures Changes

Promoting Interoperability Performance Category Measures – 2020 Final Rule

- The Query of Prescription Drug Monitoring Program (PDMP) measure is an optional measure, available for bonus points

- Removed the Verify Opioid Treatment Agreement measure

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2020 Final Rule- MIPS Promoting Interoperability Performance Category Changes

Hospital-Based MIPS Eligible Clinicians in Groups

Overview:

• Reduction of the threshold for a group to be considered hospital-based

• Revised measures


A group is identified as hospital-based and eligible for reweighting when 100% of the MIPS eligible clinicians in the group meet the definition of a hospital-based MIPS eligible clinician.

A group is identified as hospital-based and eligible for reweighting when more than 75% of the NPIs in the group meet the definition of a hospital-based individual MIPS eligible clinician.

No change to definition of an individual hospital-based MIPS eligible clinician.

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2020 Final Rule- MIPS Promoting Interoperability Performance Category Changes

Objectives and Measures 2019 Final 2020 Final

• One set of objectives and measures based on the 2015 Edition CEHRT.

• Four objectives: e-Prescribing, Health Information Exchange,

Provider to Patient Exchange, and Public Health and Clinical Data Exchange.

• Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is claimed.

• Two new measures for the e-Prescribing objective: Query of Prescription Drug Monitoring

Program (PDMP) and verify Opioid Treatment Agreement as

optional with bonus points available.

Beginning with the 2019 performance period: • The optional Query of PDMP

measure will require a yes/no response instead of a

numerator/denominator. • CMS will redistribute the

points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Access to Their Health Information measure if an exclusion is claimed.

Beginning with the 2020 performance period:

• CMS will remove Verify Opioid Treatment Agreement Measure

• CMS will keep the Query of PDMP measure as optional

Overview:

• New reweighting standards for groups

• Revised measures

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Third Party Intermediaries


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2020 Final Rule- MIPS Third Party Intermediaries

• CMS is focusing on improved partnerships with third parties to help reduce the clinician reporting burden and improve the services clinicians receive.

Measure Requirements:

• Beginning with the 2020 performance period, requiringQCDRs to work together to harmonize their similar QCDR measures

• Beginning with the 2021 performance period,third party intermediaries, such as Qualified Clinical Data Registries (QCDRs) and Qualified Registries, are required to consolidate and enhance their services by:

- Supporting all MIPS performance categories that require data submission;

- Providing enhanced performance feedback and allowing clinicians to view their performance on a given measure in comparison to others; and

- Requiring that QCDR measures be fully developed and tested prior to self-nomination.

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Performance Categories Policy:

In the 2019 performance period, QCDRs/Qualified Registries are not required to support multiple performance categories.

Beginning in 2021 performance period: • QCDRs and Qualified Registries are required to provide services for the entire

performance year and applicablesubmission period. • In the event they must discontinue services, they must support the transition to an

alternate submission method or third party intermediary. • QCDRs and Qualified Registries will be required to support the reporting of

measures and activities in the: — Quality; — Improvement Activities; and — Promoting Interoperability performance categories.

• Health IT vendors will be required to submit data for at least one category.

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Performance Feedback Policy:

In the 2019 performance period, Qualified Registries and QCDRs must provide timely performance feedback at least 4 times a year on all of the MIPS performance categories that the Qualified Registry or QCDR reports to clinicians.

Beginning in 2021 performance period: • Feedback (still required 4x per year) must include information on how participants

compare to other clinicians within the Qualified Registry or QCDR cohort who have submitted data on a given measure (MIPS quality measure and/or QCDR measure).

• QCDRs and Qualified Registries will be required to attest during the self-nomination process that they can provide performancefeedback at least 4x a year. • If unable to submit feedback 4x a year, the vendor must notify CMS

immediately.

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QCDR Measure Requirements

• In the 2019 performance period, QCDR measures must be beyond the measure concept phase of development.

• Beginning in 2020 performance period: CMS created new guidelines to help QCDRs understand when a QCDR measure will likely be rejected during the annual self-nomination process, such as:

- In instances in which multiple, similar QCDR measures exist that warrant approval, we may provisionally approve the individual QCDR measures for 1 year with the condition that QCDRs address certain areas of duplication with other approved QCDR measures in order to be considered for the program in subsequent years. Duplicative QCDR measures will not be approved if QCDRs do not elect to harmonize identified measures as requested by CMS within the allotted timeframe.

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QCDR Measure Requirements

• Beginning in 2021 performance period:

- QCDRs must identify a linkage between their QCDR measures to, at the time of self-nomination, a cost measure, Improvement Activity, or CMS developed MVPs as feasible.

- QCDR Measures must be fully developed with completed testing results at the clinician level and must be ready for implementation at the time of self-nomination.

- QCDRs must collect data on a QCDR measure, appropriate to the measure type, prior to submission.

- If CMS determines that a QCDR measure is not available to MIPS eligible clinicians, groups, and virtual groups reporting through other QCDRs, CMS may not approve the measure.

- A QCDR measure that does not meet case minimum and reporting volumes required for benchmarking after being in the program for 2 consecutive CY performance may not continue to be approved in the future.

- At CMS discretion, QCDR measures may be approved for two years, contingent on additional factors.

• 52


2020 Final QCDR Measure Rejections

CMS finalized guidelines to help QCDRs understand when a QCDR measure will likely be rejected during the annual self-nomination process, such as:

• QCDR measures that are duplicative of an existing measure or one that has been removed from MIPS or legacy programs

• Existing QCDR measures that are “topped out” (though these may be resubmitted in future years*)

• QCDR measures that are process-basedor have no actionablequality action

• QCDR measures that have the potential for unintended consequences to patient care

• QCDR measures that split a single clinical practice/action into several measures or that focus on rare events

53

Performance Threshold and Payment Adjustment


54

2020 Final Rule- MIPS Performance Threshold and Payment Adjustments

2019 Final Performance Threshold

• 30 pointperformance threshold.

• Additional performance threshold for exceptional performance set at 75 points.

• Payment adjustment could be up to +7% or as low as -7%.

2020 Final Performance Threshold

• 45 pointperformancethreshold

• Additional performance threshold for exceptional performanceset at 85 points.

• Payment adjustment could be up to +9% or as low as -9%.

*To ensure budget neutrality, positive MIPS payment adjustment factors will be increased or decreased by an amount called a “scaling factor.” The amount of the scaling factor depends on the distribution of final scores across all MIPS eligible clinicians. 55

-

-

-

-

-

-

2020 Final Rule- MIPS Performance Threshold and Payment Adjustments

2019 Final 2020 Final Final

Score

2019 Payment Adjustment 2021

>75

points

• Positive adjustment greater than 0%

• Eligible for additional payment for

exceptional performance —minimum of additional 0.5%

30.01

74.99

points


• Not eligible for additional payment

for exceptional performance

30

points • Neutral payment adjustment

7.51

29.99

• Negative payment adjustment

greater than -7% and less than 0%

0 7.5

points • Negative payment adjustment of -7%

Final Score

2020 Payment Adjustment 2022

>85

points


• Eligible for additional payment for

exceptional performance —minimum of additional 0.5%

45.01

84.99

points


• Not eligible for additional payment

for exceptional performance

45

points • Neutral payment adjustment

11.26

44.99

• Negative payment adjustment

greater than -9% and less than 0%

0 11.25

points • Negative payment adjustment of -9%

2021 Final: PerformanceThreshold = 60 points; Additional Performance Threshold = 85 points

56

Reweighting and Targeted Reviews

57


2020 Final Rule- MIPS Reweighting Due to Data Integrity Issues

2019 Final Performance Category Reweighting

• No formal policy to account for data integrity concerns.

• Several scenarios for reweighting have previously been finalized, including extreme and uncontrollable events (all performance categories) and hardship exemptions specific to the Promoting Interoperability performance category.

2020 Final Performance Category Reweighting

Beginning with the 2018 performance period and 2020 payment year:

• We will reweight performance categories for a MIPS eligible clinician who we determine has data for a performance category that are inaccurate, unusable or otherwise compromised due to circumstances outside of the control of the clinician or its agents if we learn the relevant information prior to the beginning of the associated MIPS payment year. MIPS eligible clinicians or third party intermediaries should inform CMS of such circumstances. (CMS may also independently learn of qualifying circumstances).

• If we determine that reweighting is appropriate, we will follow our existing policies for reweighting.

58

2020 Final Rule- MIPS Targeted Reviews

2019 Final Targeted Review

MIPS eligible clinicians and groups may submit a targeted review request by September 30 following the release of the MIPS payment adjustment factor(s) with performance feedback.

2020 Final Targeted Review

Beginning with the 2019 performance period, all requests for targeted review must be submitted within 60 days of the release of the MIPS payment adjustment factor(s) with performance feedback.

59

FINAL RULE: PUBLIC REPORTING VIA PHYSICIAN COMPARE OVERVIEW

60

Public Reporting via Physician Compare: 2020 Final Rule

2019 Final Release of Aggregate Performance Data

No established schedule for release of aggregate MIPS data on Physician Compare.

2020 Final Release of Aggregate Performance Data

Aggregate MIPS data, including the minimum and maximum MIPS performance category and final scores, will be available on Physician Compare beginning with the 2018 performance period data (available in late 2019) as technically feasible.

61

https://www.medicare.gov/physiciancompare/

Public Reporting via Physician Compare: 2020 Final Rule

No policy in the 2019 performance period.

2020 Final Facility-based Clinician Indicator

Publicly report an indicator if a MIPS eligible clinician is scored using facility-based measurement as technically feasible and appropriate.

Link from Physician Compare to Hospital Compare where facility-based measure information that applies would be available, beginning with 2019 performance information (available in late 2020).

62

ALTERNATIVE PAYMENT MODELS (APMS) Overview

63

Alternative Payment Models (APMs) Overview

• A payment approach that provides Advanced APMs are added incentives to clinicians to a Subset of APMs provide high-quality and cost-efficient care

• Can apply to a specific condition, care episode or population

• May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs

APMs

MIPS APMs

Advanced APMs

64

Advanced APMs Benefits

Clinicians and practices can:

• Receive greater rewards for taking on some risk related to patient outcomes.

Advanced APMs +

Advanced APM-specific rewards

“So what?” It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

65

Advanced APMs Advanced APM Criteria

To be an Advanced APM, the following three requirements must be met:

The APM:

Requires participants to use certified EHR technology;

Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and

Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk.

66

Advanced APMs Terms at a Glance

• APM Entity - An entity that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation.

• Advanced APM – A payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition,a care episode, or a population.

• Affiliated Practitioner - An eligible clinician identified by a unique APM participant identifier on a CMS-maintained list who has a contractual relationship with the Advanced APM Entity for the purposes of supporting the Advanced APM Entity's quality or cost goals under the Advanced APM.

• Affiliated Practitioner List - The list of Affiliated Practitioners of an APM Entity that is compiled from a CMS-maintained list.

67

Advanced APMs Terms at a Glance

• MIPS APM – MostAdvanced APMs are also MIPS APMs so that if an eligible clinician participating in the Advanced APM does not meet the threshold for sufficient paymentsor patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard. The APM scoring standardis designed to account for activities already required by the APM.

• Participation List - The list of participants in an APM Entity that is compiled from a CMS-maintained list.

• Qualifying APM Participant (QP) - An eligible clinician determined by CMS to have met or exceeded the relevant QP payment amount or QP patient count threshold for a year based on participation in an Advanced APM Entity.

68

Overview

2020 FINAL RULE-APMS

69

2020 Final Rule- APMs Overview of Changes

• For the APM Scoring Standard, CMS is allowing APM Entities participating in APMS the option to report for the MIPS Quality performance category through MIPS on behalf of their MIPS eligible clinicians to offer flexibility and improve meaningful measurement.

• CMS created a MIPS APM Quality Reporting Credit for MIPS APMs where APM quality data are not used for MIPS purposes.

- The credit will be equal to 50% percent of the MIPS Quality performance category weight

70

2020 Final Rule- APMs Medical Home Models

2019 Final Medical Home Models

Medical Home Models and Medicaid Medical Home Models have a primary care focus with participants that provide primary care, empanelment of each patient to a primary clinician and at least four of the following:

• Planned coordination of chronic and preventive care;

• Patient access and continuity of care;

• Risk-stratified care management;

• Coordination of care across the medical neighborhood;

• Patient and caregiver engagement;

• Shared decision-making; and/or

• Payment arrangements in addition to, or substituting for, fee-for-service payments.

71

2020 Final Rule- APMs Medical Home Models

2020 Final Medical Home Models

CMS finalized a new Aligned Other Payer Multi-Payer Medical Home Model definition as an aligned other payer arrangement (not including Medicaid arrangements) operated by another payer formally partnering in a CMS Multi-Payer Model that is a Medical Home Model through a written expression of alignment and cooperation with CMS, and is determined by CMS to have the following characteristics:

• A primary care focus with participants that primarily include primary care practices or multispecialty practices that include primary care physicians and practitioners and offer primary care services.

• Empanelment of each patient to a primary clinician; and

• At least four of the following: - Planned coordination of chronic and preventive care; - Patient access and continuity of care; - Risk-stratified care management; - Coordination of care across the medical neighborhood; - Patient and caregiver engagement; - Shared decision-making; and/or - Payment arrangements in addition to, or substituting for, fee-for-service payments.

72

2020 Final Rule- APMs Other Payer Advanced APM

2019 Final Marginal Risk Currently, when a payment arrangement’s marginal risk rate varies depending on the amount by which actual expenditures exceed expected expenditures,we use the lowest marginal risk rate across all possible levels of actual expenditures that would be used for comparison to the marginal risk rate to determine whether the payment arrangementhas a marginal risk rate of at least 30%, with exceptions for large losses and small losses as provided in CMS regulations.

2020 Final Marginal Risk When a payment arrangement’s marginal risk rate varies depending on the amount by which actual expenditures exceed expected expenditures, we will use the average marginal risk rate across all possible levels of actual expenditures that would be used for comparison to the marginal risk rate to determine whether the payment arrangement has a marginal risk rate of at least 30%, with exceptions for large losses and small losses as provided in CMS regulations.

73

2020 Final Rule- APMs Scoring Standard: Quality Performance Category

2019 Final Quality Scoring MIPS APMs receive quality scores based on their participation in the model. If no data is available for scoring, the category is reweighted to:

• 75% Promoting Interoperability and 25% Improvement Activities

Exception: We will use data submitted by the Participant TIN in a Shared Saving Program ACO in the rare event that no data is submitted by the Entity.

2020 Final Quality Scoring • Allow MIPS eligible clinicians participating in

MIPS APMs to report on MIPS quality measures in a manner similar to the Promoting Interoperability under the APM Scoring Standard for purposes of the MIPS Quality performance category.

• Allow MIPS eligible clinicians in MIPS APMs to receive a score for the Quality performance category either through individual or TIN-level reporting based on the generally applicable MIPS reporting and scoring rules for the Quality performance category.

• Apply a minimum score of 50 percent, or an ‘‘APM Quality Reporting Credit’’ under the MIPS Quality performance category for certain APM entities participating in MIPS, where APM quality data are not used for MIPS purposes.

74

HELP & SUPPORT

75

Technical Assistance Available Resources

Learn more about technical assistance for SURS: https://qpp.cms.gov/about/small-underserved-rural-practices

Get help and support: https://qpp.cms.gov/about/help-and-support#technical-assistance 76

https://qpp.cms.gov/about/small-underserved-rural-practices

https://qpp.cms.gov/about/help-and-support#technical-assistance

Q&A Session

To ask a question, please dial:

1-866-452-7887

If prompted, use passcode: 244 2508

Press *1 to be added to the question queue.

You may also submit questions via the chat box.

Speakers will answer as many questions as time allows.

77

APPENDIX

78

Appendix Previously Finalized MIPS Policies Unchanged in PY 2020 Final Rule

MIPS Eligibility • Low-Volume Threshold (LVT)

• Eligible Clinician Types

• Opt-in Policy

• MIPS Determination Period

No change

Data Collection and • MIPS Performance Period No change Submission • Collection Types

• Submitter Types

• Submission Types

• CEHRT Requirements

Quality Measures • Topped-Out Measures

• Measures Impacted by Clinical Guideline Changes

No change

MIPS Scoring • Measure, Activity and Performance Category Scoring Methodologies

• 3 Point Floor for Scored Measures

• Improvement Scoring

• Bonus Points:

• Complex Patient Bonus

• Small Practice Bonus

• High-Priority Measures

• End-to-End Electronic Reporting

No change

Facility-Based Clinicians • Definition and Determination

• Scoring Methodology and Policies

No change

Note: There are several 2020 policies that were finalized in the CY 2019 PFS Final Rule. 79

https://qpp.cms.gov/mips/how-eligibility-is-determined#lowVolumeThreshold-2019

https://qpp-cm-prod-content.s3.amazonaws.com/uploads/394/2018%20Data%20Submission%20FAQs.pdf

https://qpp-cm-prod-content.s3.amazonaws.com/uploads/350/2019%20MIPS%20Quality%20Performance%20Category%20Factsheet.pdf

https://qpp-cm-prod-content.s3.amazonaws.com/uploads/0/2019%20MIPS%20Scoring%20Guide.pdf

https://qpp-cm-prod-content.s3.amazonaws.com/uploads/454/2019%20Facility-Based%20Measurement%20Fact%20Sheet_Final.pdf

Questions

80

Documents

2020 QUALITY PAYMENT PROGRAM FINAL RULE OVERVIEW … … · consequences of the use of this presentation. 2 . Quality Payment Program Topics • Merit-based Incentive Payment System