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MACRADR. JOSE DELGADO
Points to Consider
CMS Program
sMACRA
Bipartisan Approval
Retroactive Financial Adjustments
Budget Neutral
Provides Options
PQRS
Value Modifier
Meaningful Use
Qualified Providers
• MD/DO • Physician Assistants• Nurse Practitioners• CRNAs• Clinical Nurse specialists• Groups of previous blocks
Qualified (Year 1 & 2)
• Physical Therapists• Speech Pathologists• Audiologists• Nurse midwives• Clinical psychologists• Dietitians / Nutritionist• Speech Pathologists• Audiologists• Nurse Midwives• Clinical Psychologists• Dietitians / Nutritionists
Future Consideration (Year 3+)
Basic Options
APM
MIPS
MACRA
MACRA Models
Advanced Alternative
Payment Models (APMs)
Higher risk model
Risk is shared throughout APM
Limited number of acceptable models
Rules to being considered a qualified provider (QP)
Merit Based Incentive Program
(MIPS)Designed for individuals and
small group practices
Not all or nothing. Can receive partial credit. Incentive based on
sliding scale.
Replaces all current incentive programs
Fee for service with adjustments based on performance
Note: APM = Risk
Most Providers are expected to choose MIPS
MACRA – MIPS Components
Quality Reporting /PQRS
Resource Use or Cost (Value-based
Modifier)
Advancing Care Information (MU)
Clinical practice improvement
activities
MIPS
45%
15%
15%
25%
2020 MIPS Payment year
30%
30%15%
25%
2021+ MIPS Payment year
*The weight for advancing care information could decrease (not below 15 percent) if the Secretary estimates that the proportion of physicians who are meaningful EHR users is 75 percent or greater. The remaining weight would then be reallocated to one or more of the other performance categories.
How is Performance Categorized in MIPS?
60%15%
25%
2019 MIPS Payment year
Quality Resource UseAdvancing Care Information*
CPIA
Weighting
How is Performance Determined in MIPS?
Quality performance
category score x
Quality performance
category weight
Resource Use performance
category score x
Resource Use performance
category weight
CPIA performance
category score
x CPIA
performance category weight
Advancing Care Information
performance category score
x Advancing Care
Information performance category
weight
100
Composite Performance Score (CPS)
0-100 point scale
2019
2020
2021
2022 +
4%5%
7%9%
4%5%
7%
9%
Financial Incentives and Adjustments Through MIPS
Lowest 25% = maximum reduction Exceptional performance bonuses can be up to another 10% up to
$500M available each year from 2019 to 2024 MIPS will be a budget-neutral program. Total upward and
downward adjustments will be balanced so that the average change is 0%.
Performance Threshold
Mean/Median CPS
Penalties Comparison
< 2017 2019 Adjustments
PQRS - 2 %MU - 5 %
Value Based Modifier
- 4 % or more
Total Penalty Risk
- 11 % or more
Bonus PotentialValue Based Modifier
Unknown
MIPS Factors
2019 Scoring
Quality (PQRS) 60 %Advancing Care Information (MU) 25 %
Clinical Improvement
Activities15 %
Total Penalty Risk - 4 %
Bonus Potential 4 % MaxBonus Potential for High Performers 10 %
Prior to MACRA MACRA
Quality Reporting Basics - PQRS
• 60% in 2019• 45% in 2020• 30% in 2022
MIPS weight
• 6 measures instead of 9 (200 measures available), reported by physicians
• One cross-cutting measure, one outcome measure• 2 population health measures calculated by CMS administratively via
claims (Groups of 2 or more)
Measures
• Each measure worth up to 10 points• 80 total points for small groups 90 total points for groups
>10• Distribution of points for each measure based on performance
benchmarks (80% for claims reporting, 90% for registry reporting)
Scoring
• Up to 4 bonus points may be added for reporting on outcome and high priority measures
• 1 bonus point possible for each measure captured and reported through CEHRT
• Total bonus points capped at 5% of those used to calculate the quality score
Bonus points
Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
Controlling High Blood Pressure: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
MIPS Proposed Cross-Cutting Measures
Closing the Referral Loop: Receipt of Specialist Report: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.
MIPS Proposed Cross-Cutting Measures
Advancing Care Information - MU
• 25% in 2019• 25% in 2020• 25% in 2022 May be reduced if >75% of clinicians are successful
MIPS weight
• Protect Patient Information (Security Risk Analysis) – Yes/No• e-Prescribing - Numerator/Denominator • Provide Patient Access - Numerator/Denominator • Send Summary of Care - Numerator/Denominator • Request/Accept Summary of Care - Numerator/Denominator • Public Health and clinical data registry reporting – Yes/No
Measures
• 50 points for achieving 6 objectives (pass/fail)• Immunization registry reporting required; • Provide numerator/denominator or yes/no attestation for each
Scoring
• Reporting to more than one public health registry earns bonus pointBonus points
Advancing Care Information
▪ To receive the base score, physicians must simply provide the numerator/denominator or yes/no for each objective and measure▪ The overall Advancing Care Information score would be
made up of a base score and a performance score for a maximum score of 100 points▪ Protect Patient Information (Security Risk Analysis) yes
required or no points allotted
Advancing Care Information Performance Category
Score capped at 100 points with greater than 100 points available to allow more flexibility to achieve the maximum score. 100 points or more translates
into 25 points in final score
Base Score Performance Score Bonus Point Composite
Score
50 Points 80 Points 1 PointMaximum 100 points
Advancing Care Information – Base score
▪ Protect Patient Information (Security Risk Analysis) – Yes/No▪ e-Prescribing - Numerator/Denominator ▪ Provide Patient Access - Numerator/Denominator ▪ Send Summary of Care - Numerator/Denominator ▪ Request/Accept Summary of Care - Numerator/Denominator • Public Health and clinical data registry reporting – Yes/No
Advancing Care Information – Performance Score
Performance Score (80 Points)▪ Patient Electronic Access▪ Coordination of Care through patient engagement▪ Health Information ExchangeBonus Point (1 Point)▪ Immunization registry is required, but reporting to
another surveillance registry will award 1 bonus point to over all ACI score.
Clinical Practice Improvement Activities - New
• 15% in 2019• 15% in 2020• 15% in 2022
MIPS weight
• 9 activity categories• 90+ activities• Do not need activities in each category• Attest to four medium-weighted or two high-weighted activities
Measures
• 60 points = 100% CPIA score• 7 of 8 categories have both high (20 points) and medium (10 points)
weighted activitiesScoring
Subcategories
Expanded Practice Access
Beneficiary Engagement
Achieving Health Equity
Population Management
Patient Safety and
Practice Assessment
Emergency Preparedness
and Response
Care Coordination
Participations in APM
including Medical Home
Model
Integrated Behavioral and Mental
Health
CPIA categories and examplesExpanded Practice
Access
24/7 access to clinicians/care teams
Use of telehealth
Patient experience data used to improve
practice
Population Management
Participation in systematic
anticoagulation program
Participation in CMMI models such as Million
Hearts Campaign
QCDR participation that includes use of data for
QI
Care Coordination
Participate in Transforming Clinical
Practice Initiative
Closing the referral loop
Develop and update individual care plans
Beneficiary Engagement
Collect / follow up on patient experience &
satisfaction data
Use QCDR for shared clinical decision making
Provide access to enhanced patient portal
20 point activities
All others are 10 point activities
CPIA categories and examples--continuedPatient Safety &
Practice Assessment
Consult PDMP for Schedule-II opioid
prescriptions of >3 days
Participate in MOC part IV
Complete AMA STEPS Forward program
Achieving Health Equity
Timely care for Medicaid patients (including duals)
Participate in State Innovation Model
activities
Use QCDR to screen for social determinants of
health
Emergency Response & Preparedness
Participate in Disaster Medical Assistance
teams
Participate in domestic or international
humanitarian volunteer work
Integrated Behavioral & Mental Health
Colocation of mental health services in
clinical care settings
Depression screening and follow-up planning
Prevention & treatment for unhealthy alcohol or
tobacco use
20 point activities
All others are 10 point activities
Resource Use – Value Modifier
• 0% in 2019• 15% in 2020• 30% in 2022
MIPS weight
• CMS will calculate administratively via claims over full year• 40+ episode specific measures• No data submission requiredMeasures
• 10 points, calculated average of all attributable cost measures (worth 10 points each)
• 20 patient sample required for measure attribution• If patient volume insufficient for all measures, score is zero and other
MIPS categories will be reweighted
Scoring
Submission of Data – Individual
Quality (PQRS)
• CAHPS for MIPS
• Administrative Claims
• EHR Vendors• Qualified
Registry• Qualified
Clinical Data Registry
Advancing Care (MU)
• Attestation• EHR Vendors• Qualified
Registry• Qualified
Clinical Data Registry
Clinical Practice Improvement
Activities• Attestation• Administrative
Claims• EHR Vendors• Qualified
Registry• Qualified
Clinical Data Registry
CAHPS = Consumer Assessment of Healthcare Providers and Systems
Submission of Data – Groups
Quality (PQRS)
• CMS Web Interface (Groups of 25 or more)
• Administrative Claims
• EHR Vendors• Qualified
Registry• Qualified
Clinical Data Registry
Advancing Care (MU)
• Attestation• CMS Web
Interface (Groups of 25 or more)
• EHR Vendors• Qualified
Registry• Qualified
Clinical Data Registry
Clinical Practice Improvement
Activities• Attestation• CMS Web
Interface (Groups of 25 or more)
• EHR Vendors• Qualified
Registry• Qualified
Clinical Data Registry
Program Cycle
2017Performanc
e Year
Data Submission
Mar 31, 2018
Payment AdjustmentJan 1, 2019
Options
- %
+ %
+ %
0
Don’t Participate
• No data Submitted
• Receive a negative 4% payment adjustment
Submit Something• Submit
minimum amount of data
• Avoid downward adjustment
Partial Year• Submit 90 days• May earn a
neutral or small positive adjustment
Full Year• Submit a
full year• May earn a
moderate positive payment adjustment
Current Payment
Don’t Participat
e
Submit Somethin
g
Partial Year Full Year
Considerations and RecommendationsConsiderations
Bipartisan Support – not
going anywhere
Budget Neutral
Measurements started 1
Jan 2017
Payment adjustments begin 1 Jan
2019
Recommendations
Submit Meaningful
Use Attestation
Analyze current data
collection and select measures
Aim to submit data for full year
Review measures monthly
