MACRA and QPP · 2018-05-05 · MACRA = Medicare Access and Children’s Health Insurance Program [CHIP] Reauthorization Act of 2015 CMS = Centers for Medicare & Medicaid Services

MACRA and the CMS Quality Payment Program

Maximizing Your Payments

Howard Pitluk, MD, MPH, FACSVice President, Medical Affairs & Chief Medical Officer

Health Services Advisory Group (HSAG)AOMA 96th Annual Convention

April 13, 2018

MACRA = Medicare Access and Children’s Health Insurance Program [CHIP] Reauthorization Act of 2015CMS = Centers for Medicare & Medicaid Services

Disclosure

I have nothing to report nor are there any real or perceived conflicts of interest, implied or expressed, in the following presentation.

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HSAG’s QIN‐QIO Territory

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HSAG is the Medicare QIN‐QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.

Nearly 25 percent of the nation’s Medicare beneficiaries

Origins of the Quality Payment Program: MACRA

• Bipartisan Legislation: the “Medicare Access and CHIP Reauthorization Act,” 2015

• Increases focus on quality of care delivered– Clear intent that outcomes needed to be rewarded, not number of

services– Shifts payments away from number of services to overall work of

clinicians– Moving toward patient‐centric health care system

• Replaces Sustainable Growth Rate (SGR)

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Overall physician costs

Target Medicare

expenditures

Physician payments cut across the board

SGR eliminated by MACRA

New Model ‐ Quality Payment Program (QPP)

AccountableCareInstitute.com 9

Federal Policy Goals For Value Based Alternative Payment

1. Financial viability of Federal and State Healthcare Coverage Programs

2. Payment Incentives are based on value based care

3. Joint Accountability for clinical and healthcare cost outcomes

4. Effectiveness of the care provided reduces unnecessary or avoidable

healthcare cost

5. Ensuring Access to affordable high quality care

6. Safety and Transparency in the provision of quality care

7. Care Transitions are well-coordinated across different systems of care

8. Electronic Health Records are used effectively to delivery high quality,

efficient, and coordinated care

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Quality Payment Program:MIPS and Advanced APMs

The Medicare Access and CHIP* Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program (QPP), that provides for two participation tracks:

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OR

Advanced Alternative Payment ModelsIf you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for

sufficiently participating in an innovative payment model.

Merit Based Incentive Payment Program

If you decide to participate in MIPS, youwill earn a performance-based payment

adjustment through MIPS.

* Children’s Health Insurance Program

Source: The Centers for Medicare & Medicaid Services

MIPS Advanced APMs

MIPS

MIPS Quick Overview

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Combined legacy programs into a single, improvedprogram

Physician Quality Reporting System (PQRS)

Value-Based Payment Modifier (VM)

Medicare EHR Incentive Program (EHR)

MIPS


EHR = Electronic health record

MIPS: Quick Overview

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100 Possible Final Score

Points

=

• Comprised of four performance categories in 2018.

• The points from each performance category are added together to 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.

MIPS Performance Categories for Year 2 (2018)

Quality

50

+ + +

Cost

10

Improvement Activities

15

AdvancingCare

Information

25


MIPS Year 2 (2018): Who Is Included?

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Physicians PhysicianAssistants

NursePractitioners

Clinical

Nurse Specialists

CRNAs

No change in the types of clinicians eligible to participate in 2018

MIPS eligible clinicians include:


Incentive Payments

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MIPS Year 2 (2018): Who Is Exempt?

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Below the low‐volume threshold

• Medicare Part B allowed charges less than or equal to $90,000 a year

OR• See 200 or fewer Medicare Part B patients a year

No Change in Basic Exemption Criteria*

*Only Change to Low‐volumeThreshold

Newly‐enrolled in Medicare

• Enrolled in Medicare for the first time during the performance period (exempt until following performance year)


Significantly participating in Advanced APMs

• Receive 25% of Medicare payments

OR• See 20% of their

Medicare patients through an Advanced APM

AdvancedAPM

Accommodations for Small Practices

In Effect for 2017

• Pick your pace transition

• Low‐volume threshold $30K/100 patients

• Reduced Improvement Activity (IA) reporting

• $100 million in grants for technical assistance via QIOs and regional health improvement collaboratives

Proposed for 2018

• Low‐volume threshold raised to $90K/200 patients

• Reduced IA reporting continued

• Technical assistance grants continued

• Virtual groups created

• Advancing Care Information (ACI) hardship exemption for small practices

• Bonus points added to final score for small practices

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CMS estimates 81.2% of Eligible physicians (EPs) in practices of 1–15will experience positive or neutral adjustments in 2020.

Source: Medicare Quality Payment Program Overview. American Medical Association. January 2017. Available at https://webcache.googleusercontent.com/search?q=cache:qslkN9HDxRAJ:https://www.ama‐assn.org/sites/default/files/media‐browser/specialty%2520group/washington/macra‐january‐2017‐slides.pptx+&cd=1&hl=en&ct=clnk&gl=us

MIPS Year 2 (2018): Non‐Patient Facing

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No Change in Non‐Patient Facing Criteria

Transition Year 1 (2017) Final

• Individual—If you have <100 patient‐facing encounters.

• Groups—If your group has >75% of NPIs billing under your group’s TIN during a performance period are labeled as non‐patientfacing.

Year 2 (2018) Final

• No Change to Individual and Group definitions.

• NEW—Virtual Groups areincluded in the definition.

• Virtual Groups that have>75% of NPIs within a virtual group during a performance period are labeled as non‐patient facing


MIPS Year 2 (2018): Reporting Options

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* If clinicians participate as a group, they are assessed as a group across all 4 MIPS performance categories. The same is true for clinicians participating as a VirtualGroup.

2. As aGroup of 2 or more clinicians (NPIs) who have reassigned their billingrights to a single TIN* or

a)As an APMEntity

1. Individual—under an National Provider Identifier (NPI) number and Taxpayer Identification Number (TIN) where they reassignbenefits

3. As a Virtual Group—solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter what specialty or location) to participate in MIPS for a year performance period

Options

Individual Group Virtual Group


Potential Advantages of Virtual Groups

• Share burden of MIPS reporting– Combine credit for MIPS categories like Improvement Activities

• Combine patient counts in quality reporting for more reliable sample sizes

• Maintaining independence• Take advantage of group reporting options

– But non‐patient facing MIPS clinician and small practice, rural area, and HPSA designation would not apply

• CMS will provide technical assistance• Challenges:

– IT infrastructure lacking– Different EHR systems– Workflow and staff training changes

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MIPS Year 2 (2018): Virtual GroupsWhat Else Do I Need to Know?

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What else do I need to know?

• Solo practitioners and groups who want to form a virtual group must go through the election process.

• Virtual groups election must occur prior to the beginning of the performance period and cannot be changed once the performance period starts.

• Election period was October 11 to December 31, 2017, for the 2018 MIPS performance period.

New: Virtual Groups


MIPS Year 2 (2018): Quality Basics

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Basics:

• 50 percent of Final Score in 2018

• 270+ measuresavailable

• You select 6 individualmeasures

• 1 must be anOutcomemeasure

OR

• High‐prioritymeasure

• You may also select a specialty‐specific set of measures

Component Transition Year1(2017) Final

Year 2 (2018) Final

Weight to Final Score

• 60% in 2019 payment year

• 50% in 2020

payment year

DataCompleteness

• 50% for submission mechanisms except for Web Interface and CAHPS.

• Measures thatdo not meet datacompleteness criteria earn 3 points.

• 60% for submission mechanisms except for Web Interface and CAHPS®.

• Measures that donot meet datacompleteness criteria earn 1point.

• Burden Reduction Aim: Small practices will continue to receive 3 points.

CAHPS® = Consumer Assessment of Healthcare Providers and Systems® Source: The Centers for Medicare & Medicaid Services

MIPS Year 2 (2018): Cost Basics—Reporting and Scoring

$

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Reporting/Scoring:

• Each individual MIPS eligible clinician’s and group’s cost performance will be calculated using administrative claims data if they meet the case minimum of attributedpatients.

• Individual MIPS eligible clinicians and groups are not required to submit any additional information for the cost performance category.

• Performance is compared against performance of other MIPS eligible clinicians and groups during the performance period so benchmark is not based on a previousyear.

• Performance category score is the average of the two measures: Medicare Spending per Beneficiary (MSPB) andtotal per capita costmeasures.

• If only one measure can be scored, it will serve asthe performance category score.

Basics:

• Change: 10 percentCounted toward FinalScore in 2018

• MSBP* and total per capita cost measures are included in calculating Cost performance category score for the 2018 MIPS performanceperiod.

• These measures wereused in the Value Modifier and in the MIPS transition year.


*Medicare Spending per Beneficiary

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MIPS Year 2 ( 2018)Improvement Activities

• Attest to participation in activities that improve clinical practice

• Clinicians choose from 112 activities under 9 subcategories:

20 Source: The Centers for Medicare & Medicaid Services

1. Expanded Practice Access 2. Population Management 3. Care Coordination

4. Beneficiary Engagement5. Patient Safety and Practice

Assessment6. Participation in an APM

7. Achieving Health Equity8. Integrating Behavioral and

Mental Health9. Emergency Preparedness and

Response

MIPS Year 2 (2018): Improvement Activities

Basics:


• 112 activities available in the inventory• Medium and HighWeights

remain the same from Year1

• Medium = 10points

• High = 20points

• A simple “yes” is all that is required to attest to completing anImprovement Activity.

Patient‐centered Medical Home:• We finalized the term “recognized” is equivalent to the

term “certified” as a patient‐centered medical home orcomparable specialty practice.

• 50% of practice sites* within a TIN or TINs that are part of a virtual group need to be recognized as patient‐centeredmedical homes for the TIN to receive the full credit for Improvement Activities in 2018.

Number of Activities:

• No change in the number of activities that MIPS‐eligible clinicians must report to achieve a total of 40points.

• Burden Reduction Aim: MIPS‐eligible clinicians in smallpractices and practices in a rural areas will continue to report on no more than 2 activities to achieve the highest score.

*We have defined practice sites as the practice address that is available within the Provider Enrollment, Chain, and Ownership System (PECOS).

Source: The Centers for Medicare & Medicaid Services 21

MIPS Year 2 (2018): Improvement Activities (cont.)

AdditionalActivities:

• CMS is finalizing additional activities, and changes to existing activities for the Improvement Activities Inventory includingcredit for using Appropriate Use Criteria (AUC) through a qualified clinical support mechanism for all advanced diagnostic imaging services ordered.

Scoring:

• Continue to designate activities within the performancecategory that also qualify for an Advancing Care Informationperformance category bonus.

• For group reporting, only one MIPS‐eligible clinician in a TINmust perform the Improvement Activity for the TIN to receivecredit.

• For virtual group reporting: only one MIPS‐eligible clinician in a virtual group must perform the Improvement Activity for the TINto receive credit.

• Continue to allow simple attestation of ImprovementActivities.

Basics:


• 112 activities available in the inventory• Medium and HighWeights

remain the same from Year1

• Medium = 10points

• High = 20points

• A simple “yes” is all that is required to attest to completing anImprovement Activity


MIPS Year 2 (2018): Advancing Care Information

Basics:


• Comprised of Base, Performance, and Bonus score

• Promotes patient engagement and the electronic exchange of information using certified EHR technology(CEHRT)

• Two measure sets available to choose from based on EHR edition.

Scoring:

• No change to the base score requirements for the 2018 performance period/2020 payment year.

• For the performance score, MIPS eligible clinicians and groups will earn 10% for reporting to any one of the Public Health and Clinical Data Registry Reporting measures as part of the performance score.

• For the bonus score a 5% bonus score is available for reporting to an additional registry not reported under the performance score.

• Additional Improvement Activities are eligible for a 10% Advancing Care Information bonus for completion of at least 1 of the specified Improvement Activities using CEHRT.

• Total bonus score available is 25%

CEHRT Requirements

• Burden Reduction Aim: MIPS‐eligible clinicians may use either the 2014 or 2015 CEHRT or a combination in 2018.

• A 10% bonus is available for using only 2015 Edition CEHRT.

Measures and Objectives:• CMS finalizes exclusions for the E‐Prescribing and Health Information

ExchangeMeasures.


MIPS Year 2 (2018): Advancing Care Information Exceptions

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Basics:


• Comprised of Base, Performance, and Bonus scores

• Promotes patient engagement and the electronic exchange of information using CEHRT

• Two measure sets available to choose from based on EHR edition.

Exceptions:

• Based on authority granted by the 21st Century Cures Act and MACRA , CMS will reweight the Advancing Care Information performance category to 0 and reallocate the performance category weight of 25% to the Quality performance category for the following :

Automatic reweighting:

o Hospital‐based MIPS eligible clinicians;

o Non‐Patient Facing clinicians;o Ambulatory Surgical Center (ASC)—based MIPS‐eligible clinicians, finalized

retroactive to the transition year;

o Nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists

Reweighting through an approved application:

o New hardship exception for clinicians in small practices (15 or fewerclinicians);

o New decertification exception for eligible clinicians whose EHR was decertified, retroactively effective to performance periods in 2017.

o Significant hardship exceptions—CMS will not apply a 5‐year limit to theseexceptions;

• New deadline of December 31 of the performance year for the submission of hardship exception applications for 2017 and futureyears.

• Revised definition of hospital‐based MIPS‐eligible clinician to include covered professional services furnished by MIPS‐eligible clinicians in an off‐campus‐outpatient hospital (POS 19).


MIPS Year 2 (2018): Submission Mechanisms

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No change: All of the submission mechanisms remain the same from Year 1 to Year 2

Please note:

• Continue with the use of 1 submission mechanismper performance category in Year 2 (2018). Same policy as Year 1.

• The use of multiple submission mechanisms per performance category is deferred to Year 3 (2019).

Performance Category

SubmissionMechanisms forIndividuals

Submission Mechanisms for Groups (Including Virtual Groups)

Quality

Qualified Clinical Data Registry (QCDR)QualifiedRegistry EHRClaims

QCDRQualifiedRegistry EHRCMS Web Interface (groups of 25 ormore)

Cost

Administrative claims (no submissionrequired)

Administrative claims (no submission required)

ImprovementActivities

AttestationQCDRQualifiedRegistryEHR

AttestationQCDRQualifiedRegistryEHRCMS Web Interface (groups of 25 ormore)

AdvancingCare Information

AttestationQCDRQualifiedRegistryEHR

AttestationQCDRQualifiedRegistryEHRCMS Web Interface (groups of 25 ormore)


MIPS Year 2 (2018) Scoring

MIPS Year 2 (2018): Calculating the Final Score

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Quality

50%

+ + +

Cost

10%


15%

Advancing CareInformation

25%

100Possible Final Points

=

Remember: All of the performance category points are added together to 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.


MIPS Year 2 (2018): Complex Patient Bonus

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• Up to 5 bonus points available for treating patients based on medical complexity.

o As measured by Hierarchical Condition Category (HCC) risk score anda score based on the percentage of dual eligible beneficiaries.

• MIPS‐eligible clinicians or groups must submit data on at least 1 performance category in an applicable performance period to earn the bonus.

New: Complex Patient Bonus


MIPS Year 2 (2018): Small Practice Bonus

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• 5 bonus points added to final score of any MIPS‐eligible clinician or group who is in a small practice (15 or fewer clinicians), so long as the MIPS‐eligible clinician or group submits data on at least 1 performance category in an applicable performance period.

• Burden ReductionAim:o CMS recognizes the challenges of small practices and will provide a 5

point bonus to help them successfully meet MIPS requirements.

New: Small Practice Bonus


MIPS Year 2 (2018): Facility‐based Measurement

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New: Facility‐based Measurement

Please note:

• Facility‐based measurement policies are finalized, but with a 1‐year delay to Year 3 (2019).

• Facility‐based measurement assesses clinicians in the context of the facilities at which they work to better measure their quality.

• Voluntary facility‐based scoring mechanism will be aligned with the Hospital Value‐Based Purchasing Program (Hospital VBP) to help reduce burden forclinicians.

• Eligible as individual: You must have 75% of services in the inpatient hospital or emergency room.

• Eligible as group: 75% of eligible clinicians must meet eligibility criteria as individuals.

• Measures will be based on Hospital VBP for quality and cost measures.

• Scores will be derived using the data at the facility where the clinician treats the highestnumber of Medicare beneficiaries.

• The facility‐based measurement option converts a hospital Total Performance Score into a MIPS quality performance category and cost performance category score.


MIPS Year 2 (2018) Performance Threshold and

Payment Adjustment

Performance Category

Minimum PerformancePeriod

Quality

12‐months

Cost

12‐months


90‐days

AdvancingCare Information

90‐days

MIPS Year 2 (2018): Performance Period

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Year 2 (2018) Final

Change: Increase to Performance Period

Transition Year 1 (2017) FinalPerformance Category

Minimum PerformancePeriod

Quality

90‐days minimum; full year(12 months) was anoption

Cost

Not included.12‐months for feedback only.


90‐days

AdvancingCareInformation

90‐days


MIPS Year 2 (2018): MIPS Performance Threshold & Payment Adjustment

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Change: Increase in Performance Threshold and Payment Adjustment

Transition Year 1 (2017) Final Year 2 (2018) Final

How can I achieve 15 points?• Report all required ImprovementActivities.• Meet the Advancing Care Information base score and submit 1 Quality measure thatmeets data completeness.

• Meet the Advancing Care Information base score, by reporting the 5 base measures, andsubmit one medium‐weighted ImprovementActivity.

• Submit 6 Quality measures that meet data completenesscriteria.

• 3 point threshold

• Exceptional performerset at 70 points

• Payment adjustment set at +/- 4%

• 15 point threshold

• Exceptional performer set at 70 points

• Payment adjustment set at +/- 5%


MIPS Year 2 (2018): MIPS Performance Threshold & Payment Adjustment (cont.)

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FinalScore

2017

Payment Adjustment 2019

>70

points

Positive adjustment Eligible for exceptional

performance bonus—

minimum of additional

0.5%

4‐69

points

Positive adjustment Not eligible for

exceptional

performance bonus

3

points Neutral payment

adjustment

0

points

Negative payment

adjustment of ‐4%

0 points = does not

participate

FinalScore

2018

Change

Y/N

Payment Adjustment 2020

>70

pointsN

Positive adjustment greater than0%

Eligible for exceptional

performance bonus—

minimum of additional 0.5%

15.01‐

69.99

points

Y

Positive adjustment

greater than 0%

Not eligible for exceptionalperformancebonus

15

pointsY

Neutral payment

adjustment

3.76‐

14.99points

Y Negative payment

adjustment greater than

‐5% and less than 0%

0‐3.75

points Y Negative payment

adjustment of ‐5%

Year 1 (2017) Year 2 (2018)


Changes in MIPS from 2017 to 2018 (Summary)

•MIPS performance threshold raised from 3 points to 15 points out of 100•MIPS cost category weight increased from 0% to 10%, and quality down from 60% to 50%•Introduction of virtual groups as a new way to group clinicians for reporting •Raising the low‐volume MIPS exclusion threshold, which causes an estimated 80% of MIPS eligible clinicians to be in organizations of greater than 25 clinicians each for 2018•Minimum quality reporting period expanded from 90‐days to the full year•Data completeness threshold for most quality reporting methods increased from 50% to 60%•New 10% ACI category bonus for exclusively using 2015 Edition CEHRT•New deadline of December 31st of the performance year to apply for an ACI hardship exemption•Exclusions for the ACI e‐Prescribing and Health Information Exchange base measures, effective for both 2017 (retro‐active) and 2018•MIPS bonus points for complex patients and small practices•Category Improvement Scores for Quality Category

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Alternative Payment Models (APMs)

APMs

• APM = payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high‐quality and cost‐efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.

• Advanced APM = term established by CMS; these APMs have greatest risks and offer potential for greatest rewards.

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APMs participation options as outlined by CMS

• “Advanced” APMs have greatest risks and offer potential for greatest rewards

• Qualified Medical Homeshave different risk structure but otherwise will be treated as Advanced APMs

• MIPS APMs receive favorable MIPS scoring

• Physician‐focused APMs areunder development

Advanced APMs

and Qualified Medical Homes

MIPS APMs

Physician‐focused

APMs TBD

In order to qualify for the 5‐percent APM incentive payment for a year, eligible clinicians mustreceive a certain percentage of payments for covered professional services or see a certain percentage of patients through an Advanced APM during the associated performance year.

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) requiresparticipants to bear a more than nominal amount of financial risk.

Advanced APMs: Advanced APM Criteria

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Advanced APMs are a subset of APMs. To be an Advanced APM, a model must

meet the following three statutory requirements:


Requirements for APM Incentive Payments for Qualified Participants (QP) in Advanced APMs

(Clinicians must meet payment OR patient requirements)

Performance Year 2017 2018 2019 2020 20212022 and later

Percentage of

Payments through an Advanced APM

Percentage of

Patients through an Advanced APM

CMS Requirements for Advanced APMs

25% 25%

20% 20% 35% 35% 50% 50%

50% 50% 75% 75%


Transition Year 1 (2017) FinalYear 2 (2018) Final

Advanced APMs: Generally Applicable Nominal Amount Standard

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Total potential risk under the APM must be equal to at leasteither:

o 8% of the average estimated Parts A and B revenue of providers and suppliers in participating APM Entities for the QP performance period in 2017 and 2018, OR

o 3% of the expected expenditures an APM Entity is responsible for under theAPM for all performanceyears.

The 8% revenue‐based standard is extended for two additional years, through performance year 2020.

Total potential risk under the APM mustbeequal to at least either:

• 8% of the averageestimatedParts A and B revenue of providers and suppliers in participating APM Entities for QP Performance Periods 2017, 2018, 2019, and 2020, OR

• 3% of the expected expenditures an APM Entity is responsible for under the APM for all performance years.

Change: Extend the 8 percent revenue‐based nominal amount standard for an additional two years, through performance period 2020.


Advanced APMs: Medical Home Model

At least four of the followingadditional elements:

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.

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

Empanelment of each patient to a primary clinician;and…

Participantsinclude primary care practices or multispecialty practices that include primary care physicians and practitioners and offer primary care services.

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A Medical Home Model is an APM that has the following features:


Advanced APMs: Medical Home Model Nominal Amount Standard

Transition Year 1 (2017) Final

• Total potential risk that an APM Entity potentially owes CMS or foregoes must be equal to at least:o 2.5% of the average estimated total Part A and B revenues of all providers and suppliers participating APM Entities for performance year 2017.

Year 2 (2018) Final

• Total potential risk that an APM Entity potentially owes CMS or foregoes must be equal to at least:o 2.5% of the average estimated total Part A and B revenues of all providers and suppliers in participating APM Entities for performance year 2018.

o 3% … for performance year 2019.

o 4% … for performance year 2020.o 5% … for performance year 2021 and after.

Change: Increasing the minimum required amount of total risk increases more gradually, maintaining the standard at 2.5 percent in 2018 and ramping up to 5 percent in 2021 and thereafter.


Medical Home Models are subject to different (more flexible) standards in order to meet

the financial risk criterion to become an AdvancedAPM.

Timeline for Determining Eligibility and Bonuses• Qualified Medicare APM participants identified by CMS

via 3 “snapshots”: March 31, June 30, August 31– Physicians listed as participants on one of those dates will

be considered participants for that performance year– Performance of all participants in an APM entity to be

judged as a whole– New flexibility proposed to allow start‐up APMs

to participate

• Performance year ends August 31– Provides time for MIPS reporting for those not

meeting thresholds

• 5 percent bonus will be calculated on Medicare revenues for second calendar year– Lump sum payment provided in third calendar year

• CMS estimates that 100 percent of APM participants in 2017 will be eligible for bonus payments in 2019

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Example of bonus calculation timeline: • 2017 performance year

determines eligibility (as of August 31)

• 2018 year‐end revenues provide base for calculating bonus

• Lump sum bonus payment mid‐2019 after all 2018 claims are submitted


2017 Advanced APMs

Comprehensive ESRD Care Model

(A portion of 37 ESCOs* will qualify)

*ESRD Seamless Care Organizations

Comprehensive Primary Care Plus

(2,893 practices)

Medicare Shared Savings Track 2

(6 ACOs, 1% of total)

Medicare Shared Savings Track 3

(36 ACOs, 8% of total)

Next Generation ACO Model

(currently 45)

Oncology Care Model Track 2

(A portion of 190 practices qualify)

45


ESCOs = End‐Stage Renal Disease [ESRD] Seamless Care Organizations

New Advanced APMs for 2018 or 2019

ACO Track 1+

New participants in 2017 APMs

(i.e., CPC+ Round 2)

Comprehensive Care for Joint Replacement Payment Model

Advancing care coordination through episode payment models Track 1 (CEHRT)

Vermont Medicare ACO Initiative (all payer ACO

model)New APMs TBD

46 46


Proposed All‐Payer APM Combination Option

• Available beginning 2019 performance year

• Option only for clinicians who fail to become qualified APM participants under the Medicare‐only APM pathway

• Payers must submit applications to CMS, beginning for performance year 2019

– Medicaid, Medicare Advantage, and Center for Medicare & Medicaid innovation (CMMI) multi‐payer models may submit arrangements; will be expanded to commercial payers and other non‐Medicare/Medicaid plans in future years

• Model requirements similar to Medicare advanced APMs

– 50 percent of clinicians must use certified EHR technology (CEHRT) and clinician payments based on quality measures similar to MIPS.

– Must be a Medicaid Medical Home model similar to a Medicare expanded PCMH model or require participants to bear more than nominal financial risk.

• Qualifying All‐Payer participant determination period will differ, January 1 through June 30 (vs. August 31 for Medicare APM determinations)

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APM Scoring Standard for MIPS APMs

The APM scoring standard offers a special, minimally‐burdensome way of participating in MIPS for eligible clinicians in APMs who do not meet the requirements to become QPs and are therefore subject to MIPS, or eligible clinicians who meet the requirements to become a Partial QP and aretherefore able to choose whether to participate in MIPS. The APM scoring standard applies to APMs that meet the following criteria:

49

APM Entities participate in the APM under an agreement with CMS;

APM Entities include one or more MIPS‐eligible clinicians on a Participation List; and

APM bases payment incentives on performance (either at the APM Entity or eligible clinician level) on cost/utilization and quality.

APM Scoring Standard


APM Scoring Standard: Category Weighting for MIPS APMsIn the 2017 Final Rule, CMS finalized different scoring weights for Medicare Shared Savings Program and the Next Generation ACO model, which were assessed on quality, and other MIPS APMs, which had quality weighted to zero. For 2018 CMS is proposing to align weighting across all MIPS APMs, and assess all MIPS APMs on quality.

Transition Year (2017) Year 2 (2018) Final

All MIPSAPMs

50%

0%

20%

30%

DomainSSP & Next Generation

ACOs

OtherMIPS APMs

50% 0%

0% 0%

20% 25%

30% 75%


APM Scoring Standard: Additional Changes for Year 2

51

CMS finalized additional details on how the quality performance category will be scored under the APM scoring standard for non‐ACO models, who had quality weighted to zero in 2017.• In 2018, participants in MIPS APMs will be scored under MIPS

using the quality measures that they are already required to report on as a condition of their participation in their APM.

• Additional “Snapshot" date of December 31st for full TIN APMs (Medicare Shared Savings Program) for determining which eligible clinicians are participating in a MIPS APM for purposes of the APM scoring standard will be added to the existing March 31, June 30, and August 31 snapshot dates.

• This allows participants who joined full TIN APMs between September 1st and December 31st of the performance year to benefit from the APM scoring standard.


The QPP Website: www.QPP.CMS.gov

52Source: Quality Payment Program. CMS. Available at www.qpp.cms.gov.

CMS has free resources and organizations on the ground to provide help to clinicians who are eligible for the QPP:

Technical Assistance for Clinicians


To learn more, view the Technical Assistance Resource Guide: https://www.cms.gov/Medicare/Quality‐Payment‐Program/Resource‐Library/Technical‐Assistance‐Resource‐Guide.pdf

HSAG

HSAG

Call to Action – Request No‐Cost Assistance

54

www.hsag.com/QPP

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare &

Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Publication No. CA‐11SOW‐D.1‐01052018‐01

55

HSAG is an open, objective, and collaborative partner working across organizational, cultural, and geographic boundaries to share

knowledge and resources with all stakeholders.

Documents

MACRA and QPP · 2018-05-05 · MACRA = Medicare Access and Children’s Health Insurance Program [CHIP] Reauthorization Act of 2015 CMS = Centers for Medicare & Medicaid Services