MACRA Roadmap: An Overview of the Quality Payment Program in 2019
Suzanne Falk, MPPSenior Associate, Regulatory [email protected]
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Today’s Game Plan:
At a Glance: Major Proposed QPP Changes
QPP Deep Dive: What you need to know in 2019
* Not-yet finalized proposals noted throughout
ACP Advocacy in Action: 2019 QPP Proposals
Live Q&A
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But first, a few housekeeping items...
Please save Questions for the end, or...
• Chat with me after the presentation or over lunch
• Email me at [email protected]
Yes... slides will be made available!
2019 changes are proposed and subject to change.
Remember: this presentation is a summary!
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Major 2019 MIPS Proposals at a Glance
Increase both MIPS performance thresholds
Expand low-volume threshold and add “opt-in” option
Overhaul Promoting Interoperability scoring
Require 2015 CEHRT
Retire quality measures deemed to be low-value
Add new facility-based scoring option
Increase weight of Cost Category
Introduce 8 new episode-based cost measures
Make changes to reporting terminology
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Just as important… what didn’t change?
Minimum reporting periods (quality still a full-year)
Quality measure data completeness requirements for most reporting mechanisms remains at 60%
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Maintain 8% revenue-based risk threshold through 2024
Allow QP determinations at TIN-level
Increase APM CEHRT threshold to 75%
New All-Payer Combination Option in 2019
Medicaid, MA & CMMI multi-payer models would count in 2019
Strictly private payer APMs would not count until 2020
Allow Other Payer APM determinations to remain in effect for multiple years provided there are no changes
Must provide evidence that CEHRT threshold is being met
Major 2019 APM Proposals at a Glance
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Important Dates/Deadlines
July 12017 MIPS Performance Available in QPP portalusing EIDM credentials
Oct. 12017 MIPS Targeted ReviewRequests Due
Aug. 132018 MIPS Participation & APM QP Status Info Available Through QPP Look-Up Tool
Dec. 31Deadline for 2018 MIPS Hardship Exception Applications
March 31Reporting Deadline for 2018 MIPS Data
Want more? Check out ACP’s Physician Practice Timeline >>
Jan. 12019 MIPS Payment Adjustments & APM QP Bonuses Applied Based on 2017 Data
Oct. 2Last day to start 90-day reporting for PI & IA Categories
Feb. 28Deadline for 2018 CAHPS Data
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QPP Deep Dive: What you Need to Know in 2019
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MIPS
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Who Participates in MIPS?
Physicians, PAs, NPs, CNSs, CRNAs
Proposed Additions for 2019:
Physical Therapists
Occupational Therapists
• Clinical Social Workers
• Clinical Psychologists
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Who does NOT participate in MIPS?
Automatic Exclusions:
1st year enrolled in Part B
QP or Partial QP in AAPM
Proposed: neutral adjustment for ECs who join a TIN in Oct-Dec if the practice is not reporting as a group or TIN is newly formed
Application-Based Exceptions:
Extreme & uncontrollable circumstances hardship exceptions
Due Dec. 31st of performance year
Proposed: Can apply at TIN-level!
MAQI Demonstration for those with “significant participation” in MA alternative payment arrangements
• Below low-volume threshold
• Excluded practitioner types
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Low-volume Threshold
Excluded individuals or groups must meet one
of the following criterion:
≤ $90,000 Part B allowed charges OR
≤ 200 Part B patients OR
≤ 200 covered professional services under the PFS
^ Proposed for 2019!
Proposed: Clinicians, groups or APM Entities could “opt-in” to
MIPS if they meet 1-2 criteria (but not all 3)
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Proposed Streamlined MIPS Determination Period
Aligns with fiscal year & features two segments:
1st: Oct. 2017 - Sept. 2018 (30-day claims run-out) 2nd: Oct. 2018 - Sept. 2019 (no claims run-out)
*Clinicians/groups would only have to qualify during one
Would apply to the following determinations:
Low-volume threshold Non-patient facing Small practice Hospital-based
ASC-based Virtual groups* Facility-based*
*Use only 1st segment
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MIPS Payment Adjustments
Standard MIPS adjustments are budget neutral
Based on allowed charges for Part B covered prof. services
BBA excluded Part B drugs from MIPS $ adjustments & extended MIPS performance threshold flexibility through 2021
5%
9%
-9%2017 2018 2019 2020+
-7%-5%-4%
7%4%
2018
3 pts
15 pts
100 pts
70 pts
max penalty
performance
threshold
Exceptional
performance
threshold
max bonus
2019
7.5 pts
30 pts
100 pts
80 pts
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MIPS Bonuses and Special Scoring Scenarios
MIPS Bonus for Complex Patients
• 1-5 points depending on severity based on HCC score
Small Practices (≤15 eligible clinicians)
• Increased low-volume threshold
• 5-point bonus *CMS proposes to move to Quality
• 3 pts for quality measures that fail data completeness
• 3 pt bonus for reporting at least 1 quality measure
MIPS APM Scoring Standard (more on that later)
Facility-Based Scoring Option…
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New Facility-Based Scoring Option
Clinicians Groups
Eligibility Bill at least 1 service with POS codes 21,23 & furnish 75%+ of covered professional services in POS codes 21,22,23 during a prior determination period
75%+ of cliniciansqualify as individuals
Attribution hospital where they provide services to most patients
hospital where most clinicians are attributed
• Uses data from Hospital VBP Program for performance period• Automatically applied when it benefits a clinician’s/group’s score• CMS would assign corresponding percentile score in MIPS• Groups would need to report data for 1 other category as a group
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Minimum Reporting Period
Performance Category 2018 2019
Quality Full calendar year No change
Cost No reporting
required
No change
Improvement Activities 90 consecutive
days
No change
Promoting Interoperability 90 consecutive
days
No change
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Reporting Options
Individual Clinician under an NPI number and TIN where they reassign benefits
Group 2+ clinicians who have reassigned their billing rights to a single TIN
Virtual Group 10 or fewer ECs who come together “virtually” (regardless of specialty or location) to participate in MIPS for a performance period
Proposed for 2019: can inquire about eligibility prior to making an election through QPP Portal
APM Entity
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Proposed Terminology Changes
MIPS CQMs: formally registry measures (since other vendors can report them)
Collection type: set of quality measures with specs & completeness criteria (e.g. eCQMs, MIPS CQMs, QCDR measures, claims measures, Web Interface measures, CAHPS measures & admin claims measures)
Submitter type: MIPS eligible clinician, group, or 3rd party intermediary
Submission type: mechanisms that submit data to CMS (e.g. direct log in, upload, attestation, Part B claims & Web Interface)
3rd party intermediaries: Entities that have been approved to submit data on behalf of a MIPS EC, group, or virtual group (e.g. QCDRs, qualified registries, health IT vendors & CMS-approved survey vendors)
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Proposed Changes to Data Submission
Oversight: CMS proposes to strengthen oversight of & penalties for vendors who submit inaccurate, unusable, or compromised data.
Part B claims: would ONLY be available to small groups (regardless whether they reported at NPI or TIN level)
Web Interface: would no longer report IA or PI data; no more high priority bonus pts; soliciting input on expanding to groups of 16+ clinicians & incorporating specialty-specific measures
QCDRs and Qualified Registries: new vendor criteria proposed
CAHPS: measures that don’t meet sampling req’s would = 0 pts but Quality would be scored out of 50 pts (valid for 1 year only)
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Data Submission Types: Individual Reporters
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Data Submission Types: Group Reporters
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• Reports data for PI, Quality & Cost Categories
• Performance results & measure feedback
• National benchmark& peer specialty comparisons
Genesis Registry
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Performance Category Weighting
Performance Category 2018 2019
Quality 50% 45%
Cost 10% 15%
Improvement Activities 15% 15%
Promoting Interoperability 25% 25%
* BBA extended flexibility for setting weight of Cost Category
through 2021 (though it cannot be <10%)
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Quality: What hasn’t changed?
* All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases.
Must report 6 measures OR specialty set (or all applicable)
Points scored /10 pts based on performance against benchmarks*
At least 1 outcome or high-priority measure
Potential bonus points worth up to 10% of Quality score
Can earn points for quality improvement if fully participate
60% data completeness for most submission mechanisms
* Measures that fail = 1 point for most; 3 points for small practices
Topped out measures: 4-year process to remove; max 7 pts*
45%
????
60-70 pts
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Quality: What has changed?
34 “low-value” measures removed (updated inventory)
“Extremely” topped out measure may be removed sooner
QCDR measures wouldn’t qualify as topped-out
Measures significantly impacted by clinical guideline changes/ patient safety concerns would not be scored.
• To compensate, Quality would be scored out of 50 points.
Benchmarks would be based on collection type.
Measure validation would only be applied to MIPS CQMs & claims collection types (not eCQMs).
Opioid-related measures would be considered high-priority.
45%
????
60 pts
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Cost
No reporting required (pulled from admin claims)
BBA: No credit for cost improvement until 2022
MSPB and TPCC measures
Risk adjustment based on HCC scores
8 brand-new episode-based measures proposed... Risk-adjusted and payment-standardized
Based on allowed amount from Parts A & B claims
Case min. = 10 for procedural; 20 for acute inpatient condition episodes
Procedural episodes attributed based on “trigger” HCPCS/CPT codes
Acute inpatient medical condition episodes attributed based on clinician who bills E&M claim lines during “trigger” inpatient hospitalization under TIN that renders 30%+ of inpatient E&M claim lines in that hospitalization
15% ????
20-100 pts
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Proposed 2019 Episode-Based Cost Measures
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Improvement Activities
Yes/no attestation; scored on all-or-nothing basis
Flexible documentation requirements
Only 1 clinician in group has to perform activity
“High-weighted” = 20 pts; “medium-weighted” = 10 pts
Small practices, non-patient facing clinicians & clinicians located in rural/HPSAs get double credit
MIPS APMs, PCMHs & PCSPs get full credit (must attest)
6 new activities added; 1 removed; 5 modified
See Tables A and B in Exhibit 2
15% ????
40 pts
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Promoting Interoperability
2015 CEHRT required
No more separate performance, base & bonus scores
Each measure scored independently; on performance
Must meet all 6 required measures or claim an exclusion
Would remove bonus points for end-to-end reporting, but add new bonus points for opioid-related measures
25%
????
100 pts
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2019 Proposed PI Objectives & Measures
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PI Category Level Exceptions
Automatic Exceptions :
• Non-patient facing (<100 patient-facing encounters or groups where this applies to 75%+ of clinicians)
• Hospital- or ASC-based clinicians (75%+ of services performed in POS 21, 22, 23; or ASC)
• Non-physicians
• Certain extreme circumstances determined by CMS
* Note: PI Category will be scored if you submit data
Application-Based Exceptions:
• Small practices
25% would be redistributed to
Quality Category
• Lack of control over availability of CEHRT
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PI Measure-Specific Exclusions
E-Prescribing
Support Electronic Referral Loops by Sending Health Information
Support Electronic Referral Loops by Receiving & Incorporating Health Information
Provide Patients Electronic Access to Their Health Information
Two Public Health and Clinical Data Exchange measures
If exclusions are claimed, points will be reallocated amongst remaining measures
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Advanced Alternative Payment Models(APMs)
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Step 1: What Makes an Advanced APM?
1. Use CEHRT
Proposed: 75%+ of clinicians must use CEHRT (up from 50%)Proposed: Must provide evidence that threshold is being met
2. Base payment on quality measures comparable to MIPS
3. Either:
• Are a Medical Home Model under CMMI; OR• Bear more than “nominal” financial risk…
• 8% of average estimated Parts A & B revenue; OR• 3% of estimated expenditures (e.g. benchmark)Proposed: maintain 8% revenue-based standard through 2024
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Proposed 2019 Medicare Advanced APMs
Medicare Shared Savings Program Tracks 1+, 2, 3*
Next Generation ACOs
Comprehensive Primary Care Plus (CPC+)
Comprehensive ESRD Care (2-sided risk)
Oncology Care (2-sided risk)
Comp Care for Joint Replacement (CEHRT track)
BPCI Advanced
* A separate proposed rule would drastically restructure MSSP &
solicit applications for a July 1, 2019 start date.
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Step 2: Do I qualify as a Qualified Participant?
Can qualify through…
Medicare Option OR
All-Payer Combination Option *new in 2019!
• Medicaid, MA & CMMI multi-payer models count in 2019
• Private payer APMs would not count until 2020
• Payers and clinicians/practices will be able to begin submitting APMs for approval next year
• Other Payer APM determinations could remain in effect for up to 5 years provided there are no changes to design
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Step 2: Do I qualify as a Qualified Participant?
Payments Patients
QP 50% 35%
Partial QP 40% 25%
Payments Patients
QP 50% (25%)* 35% (20%)*
Partial QP 40% (20%)* 25% (10%)*
2019-2020 Medicare Threshold Option
2019-2020 All-Payer Combination Threshold Option
()* = Medicare Minimum
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QP Status “Snapshot” Dates
3 “snapshots” all start Jan 1 & end Mar 31, June 30, or Aug 31
Must surpass threshold during at least 1 snapshot
4th snapshot added on Dec. 31st for MIPS APMs only
Proposed for 2019: QP determinations at TIN level
Check your QP status: https://data.cms.gov/qplookup
#1
#2
B#3
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
#4 MIPS APMs only!
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Step 3: What’s the incentive?
1. NOT subject to MIPS
2. Receive 0.5% higher PFS update for 2026 onward
3. Share in rewards of APM
4. Receive 5% lump sum bonus in 2019-2024
1. Have the option to participate in MIPS
2. Receive favorable scoring if they do
3. Share in rewards of APM
Qualified Participants (“QPs”): Partial QPs:
2017 2018 2019
QP StatusBonus Calculated Bonus
Paid
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APMs: A Visual Breakdown
APMs
QPs
Advanced APMs
MIPS APMs
Partial QPs
Not a QP
MIPS APM scoring
standard
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More About the MIPS APM Scoring Standard
Streamlines certain MIPS reporting & scoring…
• Ex: ACO reports quality data (*but not PI data!!)
MIPS scores aggregated at the APM entity level
Performance Categories are weighted differently
Quality: 50% Cost: 0% IA: 20% PI: 30%
Generally full credit toward IA
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ACP Advocacy in Action
Stay tuned for 2019 PFS/QPP comments
APM stakeholder coalition
Patients Before Paperwork Initiative
Feedback; Statement to Ways and Means Subcommittee on Health for Medicare Red Tape Relief Initiative
Meetings with senior CMS staff including CMS Administrator Seema Verma & CMMI Director Adam Boehler
Group of 6 coalition released principles; held fly-in on reducing admin. burdens
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ACP Top QPP Advocacy Asks:
Reduce admin. burden in MIPS; implement consistent 90-day min. reporting period across categories & provide more opportunities for cross-category credit.
Reduce MIPS complexity; streamline scoring across categories.
Maximize MIPS participation, including finalizing the proposed “opt-in” option for those currently excluded under the low-volume threshold.
Increase MIPS flexibility, including a set of optional measures for the PI Category and expanded opportunities for Advanced APM participation.
Allow for a more gradual implementation of 2015 CEHRT.
Avoid low-reliability measures, including proposed new cost measures.
Implement MIPS gradually; don’t rush to increase Cost weight while adding new measures or double MIPS performance threshold based on non-MIPS data.
Provide more opportunities for small and rural practices to succeed.
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Resources
CMS fact sheet (with comparison chart)
CMS press release
FR version of proposed rule
ACP press release
CMS QPP Resource Center
CMS QPP Participation Lookup Tool
ACP Physician Practice Timeline
ACP QPP Resource Page
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Questions?
1. Got a good question for the group? Ask me now!
2. Chat with me later today. (I’ll be hanging out immediately following the presentation and will be at lunch.)
3. E-mail me at [email protected].