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Understanding MACRA & The Quality Payment Program (QPP)Wyatt Packer, VP Regional Operations, HealthInsightQPP Webinar SeriesMay 9, 2017
HealthInsight
Our business is redesigning health care systems for the better
HealthInsight is a private, non-profit, community based organization dedicated to improving health
and health care in the western United States.
www.healthinsight.org | Twitter: @HealthInsight_
Mountain-Pacific Quality Health
We are the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for• Montana• Wyoming• Hawaii• Alaska
• Guam• American Samoa• The Commonwealth of the
Northern Mariana Islands
What You Will Learn Today
• Why MACRA (or any health payment reform)• Where MACRA fits in the big picture• What MACRA is (also see QPP.CMS.gov)• Which arm of the program to start in• When MACRA will start• How to succeed at MACRA including available
support and resources
Why Payment Reform?
• Why create any health payment reform program?
• How we got to where we are today– Linkage of health insurance to employment
• Customers of product insulated from cost• Great clinicians stuck in administrative
quagmire of producing and documenting visits• Health care cost increases are unsustainable
U.S. Spends Too Much on Health Care
0
2
4
6
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10
12
14
16
18
1980 1985 1990 1995 2000 2005 2010 2015
Health Care Spending as a Percentage of GDP, 1980-2015Percent
United States
All Other OECD Countries
Source: OECD Health Data 2015. Note: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only and exclude spending on capital formation of health care providers.
Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation
and Workers’ Earnings, 1999-2016
98%
160%
213%
92%
167%
242%
24%
45%
60%
21%
35% 44%
0%
50%
100%
150%
200%
250%
300%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Health Insurance PremiumsWorkers' Contribution to PremiumsWorkers' EarningsOverall Inflation
Source:: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2016. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2016; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2016 (April to April).
High Quality, Necessary Services
High Quality, Necessary Services
Preventable Complications
Unnecessary Treatments
InefficienciesErrors
We buy: We should buy:
100% Quality
for Less Cost
$0.60 Quality
$0.40 Waste
For every $1:
Cost Savings
Payment Reform: The Vision
What Is Being Done?
Public and Private Payment Reforms• Federal Programs
– MACRA & the Quality Payment Program (QPP)– Bundled payments– Payment models (Medicare Shared Savings Program
ACOs, Shared-risk programs)• State Initiatives
– Medicaid Managed Care– Other Patient-Centered, Primary Care models
• Private Models– Accountable Care Organizations (ACOs)– Patient Centered or Primary Care Medical Homes
Framework For Payment Models
Where does MACRA fit in the big picture?
• Where CMS goes, others will follow• Track/report quality of care and understand
and act on information about the cost of care• Use technology to support internal
improvement efforts as well as coordinate across the continuum of care
• (Very likely) leading to changes in patient engagement and experience
Medicare Access and CHIP Reauthorization Act of 2015
The intent of MACRA is four-fold:1. Sustainable Growth Rate (SGR) repeal
2. Improve care for Medicare beneficiaries
3. Reauthorizes the Children’s Insurance Program (CHIP)
4. Change our physician payment system from focus on quantity of services to quality of care
What is MACRA?MACRA = Quality Payment Program
• MACRA is being implemented as the Quality Payment Program (QPP)
• The QPP encompasses two pathways:
The Merit-based Incentive
Payment System (MIPS)
orAdvanced
Alternative Payment Models
(APMs)
Quality Payment Program Strategic Goals
Improve beneficiary outcomes
Increase adoption of Advanced APMs
Improve data and information
sharing
Enhance clinician experience
Maximize participation
Ensure operational excellence in
program implementation
MIPS Eligible Clinicians
Medicare Part B clinicians billing more than $30,000 a year AND providing care for
more than 100 Medicare patients a
year.
Physicians Physician Assistants
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered
Nurse Anesthetists
Quick Tip:Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function.
These clinicians include:
Who is Excluded from MIPS?
Below the low-volume threshold• Medicare Part B
allowed charges less than or equal to $30,000 a year
OR• See 100 or fewer
Medicare Part B patients a year
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 your Medicare payments
OR• See 20% of your
Medicare patients through an Advanced APM
MIPS Eligibility Letters
• Letters mailed from CMS late April – May 2017
• Assist in determining eligibility/requirement for MIPS reporting
• Groups by TIN and Individuals by NPI
• Letter plus Attachments A & B
Merit-Based Incentive Payment System (MIPS)
MIPS streamlines the existing programs into one program:
Physician Quality Reporting System (PQRS) -> Quality
Value-Based Modifier -> CostMeaningful Use of EHRs -> Advancing Care
Information
MIPS also adds a new category:
Improvement Activities (IA)
MIPS Category: Quality
• 60 percent of Final Score in 2017• 270+ measures available
– Most participants: Report up to six quality measures, including an outcome measure, for a minimum of 90 days.
– Groups using the web interface: Report 15 quality measures for a full year. To submit data as a group through the CMS Web Interface, you must register your group between April 1 and June 30, 2017.
• Replaces PQRS programFor a full list of measures, please visit QPP.CMS.gov
MIPS Category: Cost
• No reporting requirement; 0 percent of Final Score in 2017
• Clinicians assessed on Medicare adjudicated claims data
• CMS will still provide feedback on how you performed in this category in 2017, but it will not affect your 2019 payments.
• Uses measures previously reported in the Quality and Resource Use Report (QRUR)
MIPS Category: Improvement Activities
• 15 percent of Final Score in 2017• Attest to participation in activities that improve
clinical practice– Examples: Shared decision making, patient safety, coordinating care,
increasing access
• Choose 1-4 activities from 90+ in nine subcategories:
For a full list of activities, please visit QPP.CMS.gov
Expanded Practice Access Population Management Care Coordination
Beneficiary Engagement Patient Safety and Practice Assessment
Participation in an APM
Achieving Health Equity Integrating Behavioraland Mental Health
Emergency Preparedness and Response
MIPS Category: Improvement Activities
Special consideration for:Participants in certified patient-
centered medical homes, comparable specialty practices, or an APM designated as a Medical
Home Model: Automatically earn full credit
Current participants in APMs, such as MSSP Track 1: Automatically receive
points based on the model -full or half credit
Groups with 15 or fewer participants, non-patient facing clinicians, or if you are in a rural or health professional shortage
area: Lesser requirements - attest that you completed twoactivities for a minimum of 90 days.
MIPS Category: Advancing Care Information (ACI)
• 25 percent of Final Score in 2017• Promotes patient engagement and the electronic
exchange of information using certified EHR technology
• Replaces the Medicare EHR Incentive Program (a.k.a. Meaningful Use)
• Greater flexibility in choosing measures• In 2017, there are two measure sets for reporting:
– ACI for those using 2015 edition CEHRT – 2017 Transition for 2014 edition CEHRT
MIPS Category: Advancing Care Information (ACI)
• Fulfill the required measures for a minimum 90 days:– Security Risk Analysis– e-Prescribing– Provide Patient Access– Send Summary of Care– Request/Accept Summary of CareChoose to submit up to nine measures for a minimum of 90 days for additional credit.
• Bonus Credit for Public Health and Clinical Data Registry Reporting Measures
Meaningful Use in Medicaid
• MIPS applies to services under Medicare Part B. MIPS does not replace the Medicaid EHR Incentive Program, which continues through program year 2021.
• Clinicians eligible for Medicaid EHR Incentive Program will continue to attest to their State Medicaid Agencies to receive their incentive payments.
• If those clinicians serve patients in Medicare Part B, they may also participate in MIPS.
Submission Methods for MIPS
Category Individual Group
Quality
• Qualified Clinical Data Registry (QCDR)
• Qualified Registry• EHR• Claims
• QCDR• Qualified Registry• EHR• Administrative Claims• CMS Web Interface• CAHPS for MIPS Survey
Improvement Activities
• QCDR• Qualified Registry• EHR• Attestation
• QCDR• Qualified Registry• EHR• CMS Web Interface• Attestation
Advancing Care Information
• QCDR• Qualified Registry• EHR• Attestation
• QCDR• Qualified Registry• EHR• CMS Web Interface• Attestation
Cost • No submission required• CMS will use claims data
• No submission required• CMS will use claims data
2017 2018 2019
Quality decreases 60% 50% 30%
Cost increases 0% 10% 30%
Advancing Care Information 25% 25% 25%
Improvement Activities 15% 15% 15%
Merit-based Incentive Payments
MIPS BreakdownA physician’s MIPS composite score, which determines future payment adjustments, is calculated through a changing ratio of four key categories of information each year.
MIPS adjustments for Practices in an ACO (MSSP Track 1)
Category Advantages for Practices
Quality• No reporting required from the practice – ACO
submits on behalf of practice• ACO’s quality measures replace MIPS measures
Improvement Activities
• Same overall requirements (60 points = full credit)
• Practice gets 30 points automatically for being in MSSP
Advancing Care Information
• None (same requirements and submission methods)
Cost• Shared savings from MSSP replaces this category• Practices will not be assessed on cost
performance for MIPS
Clinicians who score at the threshold final score will receive no payment adjustment.
Clinicians with final scores below threshold* will receive a negative adjustment of up to - 4% on each claim in 2019, increasing to - 9 % in 2022.
Clinicians whose score is above the threshold will receive a positive payment adjustment of up to + 4% on each claim in 2019, increasing to + 9 % in 2022 (Another bonus pool for top performance, >=70 pts in 2017).
Eligible clinician final score of 0-100 from four weighted components:• Clinical Quality (PQRS): 60% (30% later)• Cost – total and episodes: 0% (30% later)• Advancing Care Information = use of
certified EHR; HIE; etc.: 25%• Improvement Activities: 15%
Source (adapted): Dr. Steven Phillips
Winners and Losers: How MIPS Works
MIPS information publicly reported on Physician Compare website*transition year, 2017, only doing nothing gets negative adjustment
Individual Final Score Compared to Performance Threshold
Test Pace
• Submit somedata after January 1, 2017
• Neutral or small payment adjustment
Partial Year
• Report for 90-day period after January 1, 2017
• Small positive payment adjustment
Pick Your Pace in 2017 (Transition Year)
Full Year
• Fully participate starting January 1, 2017
• Modest positive payment adjustment
MIPS
Not participating in the Quality Payment Program for the transition year will result in a negative 4 percent payment adjustment.
Participate in an Advanced Alternative
Payment Model
• Some practices may choose to participate in an Advanced Alternative Payment Model in 2017
Checklist for Clinicians in MIPS
Determine your eligibility and understand the QPP & MIPS requirements
Access your latest QRUR to gain understanding of your quality and cost score
Choose whether you want to submit data as an individual or as a part of a group
Choose submission method and verify its capabilitiesDetermine your measures for 2017 reporting periodPrepare to participate by reviewing practice readiness,
ability to report, and the Pick your Pace options
Checklist for Clinicians in MIPS
Verify the information you need to report successfully. Pull applicable reports to ensure data matches expected performance o Quality: Past or current PQRS/Quality Measures and QRURo ACI: Current Meaningful Use Reports or Dashboardo Improvement Activities: Pick from list at QPP.CMS.govo Cost: Quality Resource Use Report (QRUR)
Consider measure adjustments or quality improvement efforts to improve measure scores
Care for your patients and record the dataSubmit your data by March 31, 2018
When Does QPP Officially Begin?
Performance: The first performance period opens January 1, 2017 and closes December 31, 2017. During 2017, you will record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can provide care during the year through that model.
Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, 2018. In order to earn the 5% incentive payment for participating in an Advanced APM, just send quality data through your Advanced APM.
Feedback: Medicare gives you feedback about your performance after you send your data.
Payment: You may earn a positive MIPS payment adjustment beginning January 1, 2019 if you submit 2017 data by March 31, 2018. If you participate in an Advanced APM in 2017, then you could earn 5% incentive payment in 2019.
2017Performance Year
March 31, 2018Data Submission
Feedback January 1, 2019Payment
Adjustment
Feedback available adjustmentsubmitPerformance year
Alternative Payment Models (APM)
• APMs provide 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.
• APMs may offer opportunities to eligible clinicians to prepare to take on the additional risk and requirements of Advanced APMs.
APMs
AdvancedAPMs
Advanced APMs are a subset of APMs
Advanced APM Criteria
• Advanced APM requires participants to use certified EHR technology
• Advanced APM bases payment on quality measures comparable to those in the MIPS quality performance category
• Advanced APM either: 1. Requires advanced APM entities to bear more
than nominal financial risk for monetary losses, OR
2. Is an enhanced medical home model expanded under CMMI authority
Advanced APMs in 2017
• Shared Savings Program: Tracks 2 and 3• Next Generation ACO Model• Comprehensive End Stage Renal Disease Care:
two-sided risk arrangements• Comprehensive Primary Care Plus (CPC+)• Comprehensive Care for Joint Replacement:
Track 1• Oncology Care Model (OCM): Two-sided risk track
Anticipated Advanced APMs in 2018
• CMS said that it anticipates the following models will qualify in 2018:– ACO Track 1+– New voluntary bundled payment model– Comprehensive Care for Joint Replacement Payment
Model (Certified Electronic Health Record Technology (CEHRT) track)
– Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT track)
• The list of Advanced APMs is posted at QPP.CMS.gov and will be updated with new announcements on an ad hoc basis.
Additional Rewards for Participating in APMs
Not in APM In APM In Advanced APM
=+
If you are a Qualifying APM Participant (QP)
Potential financial rewards
+APM-specific
rewardsAPM-specific
rewards
5% lump sumbonus
MIPS adjustments MIPS adjustments
Putting it all together
%
Roadmap to Success: An Integrated Approach to QPP Competency
• Practices should build on what they are already doing, including participating in Quality Improvement Organization (QIO) initiatives
• Consider projects that address multiple categories of MIPS
• Be forward thinking – design your teams and work in a way that gets you ready for Advanced APMs
• Build resiliency in staff (and patients)
Earn Revenue Now to Pay for Change
• QPP itself rewards (or penalizes) two years out• Practices need new types of staff, such as care managers
or IT support, to impact cost and quality• Use every opportunity to bring in new revenue now to
cover the cost of the new staff and process changes– Well-planned execution of Annual Wellness Visits, Chronic Care
Management, Transitional Care Management, PCMH– Revenue to support the changes practice needs to invest in– Use those visits to update coding for most accurate patient
attribution and risk adjustment, which is critical to have right at the start of APM
– Specialists: reach out to referring practices and associations
CMS QPP Resources
The CMS Quality Payment Program website offers information on MIPS, including a fact sheet,
multiple slide decks, in-depth information on the four MIPs components and scoring, etc.
Website: QPP.CMS.gov
A Small Analogy – Assistance Needed
HealthInsight & Mountain-Pacific Are Ready To Help
• MACRA/QPP training and support – including a portfolio of improvement activities – Quality Improvement Organization (QIO) – practices with
more than 15 eligible clinicians– Small, Underserved and Rural Support (SURS) – practices
with 1-15 eligible clinicians, especially those serving rural and underserved communities
• Resources on Annual Wellness Visits, Chronic Care Management and Transitions of Care Management– codes for increased revenue and improved patient care
• HIPAA Privacy and Security Solutions– webinars, boot camps, and compliance training and tools
QIN-QIO Improvement Activities
• Diabetes Self Management and Chronic Disease Self Management – emphasis on Rural Patients
• Million Hearts Coalition – website, resources, best practices for hypertension and blood pressure
• Appropriate use of antibiotics with links to the Choosing Wisely initiative
• Immunizations – flu and pneumonia
• Depression and alcohol misuse screenings, measurement and billing (NM, NV, OR, UT)
Key Takeaways
• CMS Quality Payment Program is here and you will be required to report for 2017 to avoid penalties
• Check eligibility and determine your pathway• Understand the four areas that will impact your
MIPS score and your Medicare FFS (Part B) payments beginning in 2019
• Use an integrated approach and align with support and resources that can help
Upcoming Webinar Series
•MIPS Deep Dive – Quality and Improvement Activities
May 16
•MIPS Deep Dive – Advancing Care Information and Costs
May 23
All sessions will be held at 1-2 p.m. MTRegister at www.healthinsight.org/qpp
Questions
This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, 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. 11SOW-D1-17-23
How to Ask a Question
For More Information Contact a QPP Expert in Your State
Mountain-Pacific Quality Health
Please contact us for assistance!
MontanaAmber [email protected](406) 544-0817
WyomingBrandi [email protected](307) 472-0507
Hawaii and TerritoriesCathy [email protected](808) 545-2550
AlaskaPreston [email protected](907) 561-3202
Region/Senior Account ManagerSharon [email protected](307) 271-1913
Visit us online at www.mpqhf.org.
For More Information Contact a QPP Expert in Your State
HealthInsight QPP SupportCall: 801-892-6623
Email: [email protected]: www.healthinsight.org/qpp
NevadaAaron HubbardCall: 702-948-0306Email: [email protected]
OregonDavid Smith Call: 503-382-2962Email: [email protected]
Utah Brock StonerCall: 801-892-6602Email: [email protected]
New Mexico Ryan Harmon or Danielle PickettCall: 505-998-9752 or 505-998-9768Email: [email protected] [email protected]
