Understanding MACRA & MIPS Trudi MatthewsUK’s Kentucky Regional Extension Center

The information contained in this presentation is for general information purposes only. The information is provided by UK HealthCare’s Kentucky Regional Extension Center and while we endeavor to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to content.

CMS’ Network of Support for MACRA & MIPS

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UK’s Kentucky REC & the Great Lakes Practice Transformation Network (GLPTN)

• Great Lakes PTN is one of 29 Practice Transformation Networks (PTNs)

• GLPTN works with 10 Support and Alignment Networks (SANs)

GLPTN State Level Leadership: • Indiana University (primary grant recipient)• University of Kentucky (Kentucky)• Purdue Healthcare Advisors (Indiana)• Northwestern University (Illinois)• Altarum Institute (Michigan)

CMS established the Transforming Clinical Practices Initiative (TCPI) to help clinicians achieve large-scale health transformations through collaborative and peer-based learning networks

Recent legislative, regulatory and marketplace developments suggest that the transition from volume to value-based payment is accelerating from a “testing” phase to a “scaling” phase.

Volume to Value Based Shift

Affordable Care Act Enacted

March 2010

January 2012

October 2012

Hospital Value Based Purchasing

Program

April 2013

Bundled Payments for Care Improvement

(BPCI)

CMS Announces Value-Based Payment Goals;

Value Modifier Program Begins

January 2015

Medicare Access and CHIP Reauthorization Act (MACRA) Enacted

April 2015

April 2016

MACRA NPRM, Medicaid

Managed Care Final Rule Released

July 2016

Cardiac & CJR Episode Payment NPRM Released

MACRA Final Rule Released

October 2016

Pioneer ACO Program Launched

Testing Phase Scaling Phase

Payers, Providers Differ in Value Based Care, Health IT OpinionsPayers see value based care as a fixture in US healthcare

June 07, 2017 - Payers see the move towards value-based care as a permanent fixture in the nation’s healthcare delivery system, with 82 percent of organizations responding to a Quest Diagnostics and Inovalon survey expecting it to continue despite any national healthcare regulation changes.This move from a fee-for-service based system to an integrated value-based delivery system is far from complete, the survey exposed a gap between the outlooks of health payer executives and providers on how well those VBC goals are being achieved.

Commercial Insurers Moving Forward with Value-based Payment in Spite of Provider Reluctance

Source: https://healthpayerintelligence.com/news/payers-providers-differ-in-value-based-care-health-it-opinions

MACRA Has Bipartisan Support MACRA was passed on April 14, 2015 by both houses of a Republican-controlled Congress,

had substantial Democratic support and was signed by a Democratic president. It is highly unlikely it will be repealed under the new administration.

MACRA Vote in Congress

Senate Vote: 92-8 House Vote: 392-37

MACRA Creates New Medicare Payment Program

APMMIPSMerit-based Incentive

Payment System Alternative Payment

Models

Experts anticipate

> 80% of practices will

participate in MIPS initially.

October 14, 2016: Release of Final Rule

Jan – Dec 2017: 1st Performance Period for MACRA

March 31, 2018: Reporting Deadline for First Year

Jan – Dec 2019: 1st Payment Year = +/- up to 4%

MACRA Timeline

• Physicians, PAs, NPs, CNS, CRNA• After 2020, CMS may expand to other clinicians in Medicare FFS: PT, OT,

NMW, CSW, Clinical Psychologists, Dieticians and Nutrition professionals

5 Types of Eligible Clinicians (ECs):

• Hospitals/Medicare Part A payments • FQHCs/RHCs and Medicaid Providers (that do not bill Medicare Phys. Fee

Schedule)

Not covered by MACRA:

• 1st year ECs• Low Volume: Less than $30K and/or 100 Medicare patients• Advanced APM Qualifying Provider

Exclusions:

• “Non-patient facing” clinicians• MIPS APMs

Different Scoring & Reporting Requirements:

MACRA Eligible Clinicians (ECs)

Who is eligible? See the QPP NPI Lookup Tool

Want to know who is eligible for MACRA/QPP? Go to http://qpp.cms.govand click on the “Check NPI ” button

But what if I am excluded from MACRA/QPP?

Why Should I Pay Attention to all of this?

Option 1: Test Submission

Option 2: Partial Submission

Option 3: Full Submission

Option 4: Advanced APM Participation

QPP

New 2017 Reporting Options

CMS intention states more and more of its $ will be spent in APMs over time

5% Annual Participation Bonus for Advanced APM participants from 2019-2025

Favorable scoring under MIPS for all APM participants

Annual update after 2025 is 0.75% for APM entities versus 0.25% for MIPS entities

What’s the big deal about Advanced APMs?

Advanced Alternative Payment Models

Next Generation ACO Model

Medicare Shared Savings Program – Tracks 2 & 3

Comprehensive Primary Care Plus (CPC+)

Comprehensive ESRD Care Model

Oncology Care Model Two-Sided Risk Arrangement (in 2018)

CJR Episode Model (in 2018)

In new MACRA

Final Rule, Advanced

APMsinclude:

Advanced APM participants are eligible for 5% bonus payment.But, only some APMs are risk-bearing Medicare payment models that qualify for this bonus payment.

MACRA does not change how any particular APM rewards value.APM participants who are not “Qualifying Providers” (QPs) will receive favorable scoring under MIPS.

All APMParticipantsClinicians in Advanced APMs will be deemed

Qualifying APM Participants (“QPs”) if they: 1. Report APM quality measures comparable to MIPS 2. Use of Certified EHR 3. Meet Advanced APM criteria (risk-bearing or medical

home model) 4. Must meet APM thresholds for payment and patient

volumes

Most physicians and practitioners who participate inAPMs will be subject to MIPS and will receive favorable scoring under MIPS.

Only QPs receive the 5% bonus from Medicare

Catch: Not every APM Participant will qualify for the 5% APM bonus

All APM Participants

Advanced APM

Participants

QPs

Merit-Based Incentive Payment Systems (MIPS)

Value-Based

Modifier

EHR Incentive Program

Physician Quality

Reporting System

MIPS: A Consolidation of 3 Programs

Maximum MIPS Payment Adjustments

Source: Leavitt Partners - MACRA: Quality Incentives, Provider Considerations, and the Path Forward

Notes: Losers fund winners

Top performers: - Up to 3X more with scaling factor

- Additional bonus up to 10% from $500 M funded separately Non-participation

Only

MIPS Performance Measurement

Providers will receive a MIPS final score based on 4 weightedperformance categories:

Quality Cost

CY19 60% 0% 15% 25%

CY20 50% 10% 15% 25%

CY21 30% 30% 15% 25%

ImprovementActivities

Advancing CareInformation

Year 1 Thresholds Already Set

0 Points =Full 4% Penalty

3 Points Minimum Threshold =No Penalty, No Reward

Between 4-69 Points = Some Bonus Possible

70+ = Exceptional Performance

Split $500M Pool

Individual vs. Group Reporting

Individual

Under a NPI number and TIN where they

reassign benefits

Group

2 or more clinicians (NPIs)

who have reassigned their billing rights to a

single TIN*

As an APM Entity

Options

Improvement Activities:• Annual Registration in the Prescription Drug Monitoring Program• Completion of training and receipt of approved waiver for provision opioid medication-assisted

treatments (buprenorphine) Medium)• Consultation of the prescription drug monitoring program (high)• Implementation of medication management practice improvements (medium)• Practice improvement for bilateral exchange of patient information (medium)

Quality Measures:• Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use• Documentation of Signed Opioid Treatment Agreement• Opioid Therapy Follow-up Evaluation• Pain Assessment and Follow-Up• Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

MACRA Intersection with Opioid Treatment

Highlights of the 2018 Year 2 MACRA/QPP Proposed Rule

Review 2017 QPP NPRM for Year 2 • Performance Threshold • Performance Category Weights• Key Performance Category changes• Low Volume Thresholds• Bonus opportunities:

• Small Practice • Complex Patient

• Non-patient facing & Facility Based • Virtual Groups

QPP NPRM Y2: Objectives

NOTE: Most of the changes proposed for PY18 are oriented toward clinicians in small practices and in rural and underserved areas.

QPP NPRM Y2: Threshold

0 Points =Full 5% Penalty

15 Points Minimum Threshold =No Penalty, No Reward

Between 16-69 Points =

Some Bonus Possible

70+ = Exceptional Performance

Split $500M Pool

QPP NPRM Y2: MIPS Performance Measurement

Providers will receive a MIPS final score based on 4 weightedperformance categories:

Quality Cost

CY19 60% 0% 15% 25%CY20 60% 0% 15% 25%CY21 30% 30% 15% 25%

ImprovementActivities

Advancing CareInformation

For Year 2:

QPP NPRM Y2: MIPS Reporting Timeframe

Quality

Full Year

Cost

No reporting required

Advancing Care Information

90 days

Improvement activities

90 days

Reporting Deadline:

March 31st

Expanded measures to quality for ACI bonus

Additional measures available

% Final Score: Measures: Requirements: Method:

Makes up 15% of your final score

PCMH/PCSP requires 50% NPI’s in TIN

Reweight for Non patient facing

40 pts needed, 2-4 Activities:

Re-weighting for: Non-patient

facingSmall practicesHRSA

locations

Multiple submissions methods allowed

QPP NPRM Y2: Proposed Changes to IA

Increased from:

30,000 in Medicare Part B or

100 Medicare Patients

To:

90,000 in Medicare Part Bor

200 Medicare Patients

QPP NPRM Y2: Low Volume Threshold

2017 PY Eligibility: 2018 PY Eligibility:

Preparing for MACRA & QPP

1. Team

2. Assessment

3. Action Plan

To Start With

Get to Know your Quality & Resource Use Report (QRUR)

Playbook for the Value Journey

Culture of Continuous Quality Improvement & Team Based Care

Patient Attribution & Population Health

Performance Measurement, Data Analysis and Identification of Gaps in Care

Identification of Higher Risk, High Cost Patients & Targeted Care Management

Care Coordination across the Medical Neighborhood

Patient Engagement & Experience of Care

Determine Eligibility & Track

Determine if Group or Individual Reporting

Pick your Pace

Determine Submission Method(s)

Choose Measures to

Monitor/ReportReport before

March 31st 2018

Next Steps for MACRA/QPP Participation

CMS MIPS Benchmark Results 2017

Measure_NameCMS Quality Measure ID

CMS eMeasure ID

NQF Measure

IDSubmission

MethodMeasure

TypeDecile

3Decile

4Decile

5Decile

6Decile

7Decile

8Decile

9Decile

10

Controlling High Blood Pressure 236 CMS165v5 0018 EHR Process

50.00 -55.39

55.40 -59.72

59.73 -63.59

63.60 -67.38

67.39 -71.00

71.01 -75.33

75.34 -80.89

>= 80.90

Controlling High Blood Pressure 236 CMS165v5 0018

Registry/ QCDR Process

51.00 -58.20

58.21 -63.56

63.57 -68.27

68.28 -72.40

72.41 -76.69

76.70 -82.75

82.76 -91.06

>= 91.07

Example of QPP Quality Measure Scoring

To be eligible for bonuses under MACRA, entities must score in the highest deciles for every measure.

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