MACRA and the Merit-Based Incentive Payment System (MIPS)

Presented by Aaron Elias

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MACRA and the Merit-Based Incentive Payment System (MIPS)

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Fact of the Day

50% Of polled non-pediatric physicians have never heard of MACRA.

Source: 2016 MACRA survey by Deloitte


Topics

1

2

3

4

Introduction to MACRA

Provider Considerations Under MACRA

MIPS Components and Scoring

Additional Considerations

Introduction to MACRA


CMS Payment Goals

30% of traditional Medicare payments through APMs

50% of traditional Medicarepayments through APMs

85% of Medicare fee-for-service payments tied to scoreson quality and efficiency measures.

90% of Medicare fee-for-service payments tied to scoreson quality and efficiency measures.

03/03/2016 - Mission Accomplished

By December 31, 2016: By December 31, 2018:


VBR Framework

FEE-FOR-SERVICE(FFS) PAYMENTS

POPULATION-BASEDAPMs

ADJUSTED FFSPAYMENTS

APMs INCORPORATINGFFS PAYMENTS

$ $ $

Bank

A Pay For Reporting

B Pay For Performance

C Pay/PenaltyForPerformance

A Total Cost of Care Shared Savings

B Total Cost of Care SharedRisk

C Retrospective BundledPayment

D Prospective BundledPayment

A Condition-Specific Population-Based Payments

B Primary Care Population-Based Payments

C Comprehensive Population-Based Payments

A Traditional FFS

B Infrastructure Incentives

C Care Management Payments


Medicare Access and CHIP Reauthorization Act of 2015(MACRA)

$ FFS payment adjustments based on individual composite performance scoreQualityEfficiency and Resource UseAdvancing Care Information (Meaningful Use)Clinical Practice Improvement Activities

Exception for qualifying APM participants!

MACRA


Transition to MIPS

Through December 31, 2018

• 0.5% annual MPFS update (2016-2019)

• Payment adjustments• 2% PQRS reporting penalty• 3% EHR meaningful use penalty• +/- 4% Value-Based Modifier

bonus/penalty

Starting January 1, 2019

• Annual MPFS update• 0% in 2020 - 2025 • 0.25% thereafter (0.75% for

participants in qualifying APMs)• Single payment adjustment based on

composite performance score (CPS) • Incentives for participation in APMs


MIPS Regulation – As It Stands

Provider Considerations Under MACRA

MIPS and Advanced APM Eligibility


*Clinicians ineligible the first two years may voluntarily report to gain experience in the MIPS program, though these clinicians will not receive a MIPS adjustment during the period.

Years 1 and 2 Years 3+*

Physicians (MD/DO & DMD/DDS), PAs, NPs, CNSs, CRNA

Physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical

psychologists, dieticians/nutritional professionals

MIPS Eligible Clinicians (MECs)


Non-MECs

1. First year of Medicare Part B participation2. Below low volume threshold

Medicare billed charges of $10,000 or less; and Provide care for 100 or fewer Medicare beneficiaries

3. Qualifying Participants (QPs) in Advanced APMs

Note: MIPS does not apply to Part A providers (including hospitals, rural health clinics, federally qualified health centers)


Advanced APMs

Qualifying Advanced APMs

Medicare Shared Savings Program (Tracks 2 & 3 Only)

Next Generation ACO Model

Comprehensive ESRD Care

Comprehensive Primary Care Plus (CPC+)

Oncology Care Model (OCM) – two-sided risk track only, available in 2018


Be excluded from MIPS

Minimum % of patients/ payments through Advanced APM

Receive 5% lump sum bonus

Bonus applies in 2019-2024; QPs receive higher MPFS updates

starting in 2026

QPs will:

QPAdvanced APMLower thresholdfor Partial QPs

Partial QPs not eligible for bonus, but can opt out of MIPS payment

adjustments

QPs and Partial QPs


MIPS Decision Tree

Are you a physician or eligible non-physician practitioner?Q:

NO

YESWill you be newly enrolled in

Medicare in 2017?

Will you have less than $10,000 in charges or see less than 100 Medicare

patients in 2017?

Are you a participant in an Alternative Payment Model?

MIPS Participation Choice

Is your APM on the list of Advanced APMs for 2017?

GROUP MIPS Reporting

INDIVIDUAL MIPS Reporting

Determined to be a Qualified Participant (QP)*?

APM ENTITYMIPS Reporting

EXEMPT from MIPS

* Or partial qualifying APM Participant (Partial QP) and elects not to be subject to MIPS

NO

YES NO

YES

YES

YES

NO

NO

NO

YES

• Quality• Resource Use• Clinical Practice Improvement Activities• Advancing Care Information

MIPS Components


Composite Score Components

2019 2020 2021(and beyond)

50% 45%30%

10% 15%30%

15% 15% 15%

25% 25% 25%

Quality

Resource Use($)

Clinical Practice Improvement Activities

(CPIA)

Advancing Care Information (ACI)


Quality Measure Component

Closely related to historic PQRS Reporting requirements less strict; various reporting mechanisms

available Specialty-specific measures groups or individual measures Plus 3 population-based measures (no reporting necessary)Measure Type Reporting Mechanism Criteria Data Completeness

Individual MIPS Eligible Clinicians (ECs) Part B Claims

6+ measuresIncluding: one cross-cutting and one outcome**

80% of MIPS eligible clinicians’ patients

Individuals MIPS Eligible Clinicians (ECs) or Groups

QCDRQualified RegistryEHR

6+ measuresIncluding: one cross-cutting and one outcome**

90% of MIPS eligible clinicians’ or groups’ patients*

Groups CMS Web Interface Report on all measures included

Sampling requirements for Medicare Part B patients

Groups CAHPS for MIPS SurveyCMS-approved survey vendor paired with other mechanism, counts as one measure

Sampling requirements for Medicare Part B patients

* This includes all patients, not just Medicare patients, which is a major change for some groups who have historically participated in PQRS.** If less than 6 measures apply, then report on each measure that is applicable. Choice between individual measures or specialty-specific measures.


Quality Measure Component

Quality measure benchmarks established prior to performance period (benchmarks for 2017 based on 2015)

Points given for actual performance, split into deciles Decile 1 = 1 point (lowest possible) Decile 10 = 10 points (highest possible)

Bonus points for: Reporting high-priority measures (1-2 bonus points per measure) Using QCDR or CEHRT for reporting (1 bonus point)

If you report more than the minimum, CMS will select your best measures

Scoring Methodology


Resource Use Component Incorporate current VBM total cost of care measures No reporting requirements – CMS automatically calculates

based on administrative claims Still using a beneficiary attribution process Change from VBM: over 40 episode-specific measures to

account for differences among specialties Greater than 20-patient sample Score based on total score divided by highest possible score


Resource Use Component

Resource use benchmarks set during the actual performance year (benchmarks for 2017 based on 2017 actual)

Points given for actual performance, split into deciles: Decile 1 (highest cost) = 1 point Decile 10 (lowest cost) = 10 points

Average of points for all applicable resource measures

Scoring Methodology


Resource Use Component Measures development (for future years)

CMS to develop new classification codes in 2016-17 Care episode groups Patient condition groups Patient relationship categories

Beginning January 1, 2018, claims must include new codes as appropriate


CPIA Component Clinical Practice Improvement Activities Activities weighted as either “high” or “medium” Eight different subcategories of activities, plus participation in an APM

• Same day appointments• After-hours access to clinician advice• Use of tele-health services• Collect patient experience and satisfaction

data

Expanded Practice Access

• Monitoring health conditions• Participation in qualified data registries• Participate in Million Hearts• Participate in research for targeted patient

populations

Population Management

• Timely communication of test results• Implement regular care coordination

training• Develop care plans for at-risk patients

Care Coordination

• Establishment of care plans• Use of shared decision-making

mechanisms• Use group visits for common chronic

conditions

Beneficiary Engagement

• Use of clinical and surgical checklists• Practice assessments• Use decision support and protocols

Patient SafetyPractice Assessment

• See new and follow-up Medicaid patients in a timely manner

• Use QCDR to screen for social determinants of health

Achieving Health Equity

• Participate in humanitarian volunteer work• Participate in Disaster Medical Assistance

Teams

Emergency Response and Preparedness

• Engage patients with behavioral health conditions

• Offer behavioral health services

Integrated Behavioral and Mental Health


CPIA Component

Maximum score = 60 points Medium weight = 10 points High weight = 20 points

Exceptions: Small groups (<=15 professionals), HPSA, etc., must only report on two

activities (30 points given for any activity) APM participants start with 30 points Patient-Centered Medical Homes automatically receive 60 point max

Scoring Methodology


Advancing Care Information (ACI) Formerly known as Meaningful Use (MU) Component is split into two parts: base score and performance score Performance measures correlate to MU Stage 3 or modified Stage 2

**must attest to a “yes” response to protection of patient health information to receive a non-zero base score

Points for submitting numerators and denominators:

Protection of patient health information** Electronic prescribing Patient electronic access Coordination of care through patient

engagement Health information exchange Public health and clinical data registry

reporting

Based on reported results for base score measures

Patient electronic access Coordination of care Health information exchange

Bonus percentage point for public health registry

Performance ScoreBase Score


ACI ComponentScoring Methodology

Base Score

50 Points

Performance Score

80 Points

Composite ACI Score

100 Points (Maximum)

**Opportunity for 1 bonus point for public health registry participation

Note: Potential to score more than 100 points based on performance score; however, score will be capped at 100.


Differences for APM Entities

Shared Savings Program Participants

Next-Gen ACO Participants

Other APM Entity Participants

Quality Group reporting via Web Interface on MSSP standard measures (50%)

Group reporting via Web Interface on Next-Gen ACO standard measures (50%)

No quality consideration in Year 1 (0%)

Resource Use Not Applicable (0%) Not Applicable (0%) No resource use consideration in Year 1 (0%)

Clinical Practice Improvement Activities

Receive a minimum of half of the total points; participant TIN scores will be aggregated (20%)

Receive a minimum of half of the total points; participant TIN scores will be aggregated (20%)

Receive a minimum of half of the total points; other APM Entity group eligible clinician scores aggregated (25%)

Advancing Care Information

Participant TIN scores aggregated (30%)

Participant TIN scores aggregated (30%)

APM Entity group eligible clinician scores aggregated and averaged (75%)

Goal: Allow APM entities to focus on the goals and objectives of their respective APMs while lowering costs and improving quality. CMS also desires to avoid duplicative reporting requirements for these entities.

MIPS Composite Performance Score

Calculation of CPS and Other Factors


Composite Performance Score

Composite Performance Score = CPS Assigned lowest potential score for a category if failure to

report required information Multiple reporting methods; option to be assessed as a group,

as an individual, or with your APM entity Score will ultimately be tied to a TIN/NPI combination number CPS will follow the individual, regardless of reporting mechanism

Starting in 2020, formula to reward year-to-year score improvement



CMS to provide Eligible Clinicians (ECs) with regular performance feedback reports Beginning 07/01/17, ECs to receive confidential feedback on quality

and resource use measures Beginning 07/01/18, ECs to receive patient claims data

CMS to establish informal review process; limits on administrative and judicial review

CMS to calculate CPS of 1 to 100 for each EP at conclusion of performance period



QualityScore

Resource UseScore

CPIAScore

Advancing Care Information

Score

Component Weight

Component Weight

Component Weight

Component Weight

ACI Points

CPIA Points

Resource Use Points

Quality Points

COMPOSITE PERFORMANCE SCORE

(CPS), 1 – 100


Performance Threshold

Threshold Value

•Must be the mean or median of composite performance score for all EPs•2019 threshold will be modeled based on 2014 and 2015•CMS will aim to set the threshold such that 50% of ECs will fall above/below•By Year 3, CPS must be at or above prior year values

Impact on Eligible Clinicians

•Score below threshold = penalty•Score above threshold = bonus•Must remain a budget- neutral program•Scaling factor, like VM, for additional upward potential


MIPS Payment Adjustments

2019 2022(and beyond)

2020 2021

+4%

-4%

+5%

-5%

+7%

-7%

+9%

-9%

Plus: Scaling FactorPlus: Scaling Factor

Plus: Scaling Factor

Plus: Scaling Factor

Composite Performance ScoreImpact on Medicare Part B Payments:

Performance Threshold

Additional Considerations

Moving Forward Under MACRA


Physician Compare

For each eligible clinician, MIPS composite score and performance category scores

For each EC in a qualifying APM, name and performance of APM (when feasible)

Periodically, aggregate information on the MIPS (range of scores for all eligible clinicians)


Timing2018 2019

No change in payments; eligible clinicians report on 2017 performance

MECs receive payments based on 2019 adjustment factor (+ exceptional performance incentives); MECs report on 2018 performance

CMS calculates MIPS composite performance score for each MEC based on 2017 performance

CMS calculates MIPS composite performance score for each MEC based on 2018 performance

CMS calculates and announces mean/median composite performance score

CMS calculates and announces mean/median composite performance score

CMS calculates and announces each MEC’s 2019 adjustment factor (based on 2017 performance compared to mean/median composite performance score)

CMS calculates and announces each MECs 2020 adjustment factor (based on 2018 performance compared to mean/median composite performance score)

CMS calculates and announces 2019 exceptional performance incentive payments

CMS calculates and announces 2020 exceptional performance incentive payments


Possible Delay Significant concerns from legislators and physician advocacy

groups about implementation of MACRA

Recent indications from CMS that MACRA could be delayed

July 1, 2017?

Bottom Line: Must prepare for MACRA implementation by

January 1, 2017… until told otherwise.

Information in this presentation was from the Notice for Proposed Rulemaking (NPRM) on MIPS and APMs published on April 26, 2016. The final rule is expected to be released Fall 2016.

Thank You

Note:

PERSHING YOAKLEY & ASSOCIATES, P.C.800.270.9629 | www.pyapc.com

AARON ELIAS, MSHAConsulting [email protected](404) 266-9876

‐ “Simple is better”‐ Advisory practice focused on value transformation and strategy‐ Analytic focus

Healthcare

MACRA and the Merit-Based Incentive Payment System (MIPS)