MACRA and the New Quality Payment Program

MACRA and the New Quality Payment Program:Most Frequently Asked Questions

© 2016 Health Catalyst

Proprietary and Confidential

Responses from webinar in May 2016 after release of

proposed regulations

Are we ready?

2

12%

23%

56%

8%

1%

0%

10%

20%

30%

40%

50%

60%

Not at all Somewhat Unsure Ready Very Ready

How ready are you to participate in MACRA?



• New rule on how Medicare pays doctors

• Broader push to overhaul Federal health spending

• New bonus and penalties tied to performance

• Anne Phelps, U. S. healthcare regulatory director, Deloitte

“It’s a disruptive law.”

October 14- Wall Street Journal Article

3

Source: U.S. Officials Finalize Rule for Medicare Payment to Doctors

Melanie Evans, Oct 14, 2016



(1)Support care improvement by focusing on better

outcomes for patients, decreased provider burden,

and preservation of independent clinical practice;

(2) Promote adoption of alternative payment models that

align incentives across healthcare stakeholders;

(3) Advance existing efforts of Delivery System Reform,

including ensuring a smooth transition to a new

system that promotes high-quality, efficient care

through unification of CMS legacy programs.

Aims of Quality Payment Program

4



What is a good source? Qpp.cms.gov

5



Disruption signs

New future

New language

New economics

Source: Healthcare Disrupted, Jeff Elton and Anne

O’Riordan

Are we at a tipping point?

6



Two Tracks

7

2017 2019

2020

2018

.5% annual update

thru 2019

Combine

MU,

PQRS,

VBM

2018

MIPS

APM QP

2019

Performance year

+/- 5%

2021 2022

+/-4% +/- 7% +/- 9%

2017

Performance year

2023

20242020

2021 2022

2023

2024



Why is 2017 so important?

Transition Year

8



CMS Expenditures

9

30%

28%

19%

11%

4% 4%2%

2%

0%

5%

10%

15%

20%

25%

30%

35%

Inpatient OP PAC Physician E&M Hospice Part B DME Ambulance

2014 Breakout of CMS Expenditures

Source: Geographic variation file from CMS

89% of beneficiaries used

E&M code

13,058 encounters per

1,000 beneficiaries



Potential for Bonus Points

10



• Removed for first year, weighted at 10% for 2020

• Based on per capita and 10 episodes

Examples: Lens and cataract procedures

Hip repair or replacements

Knee arthroplasty

• CMS will calculate from claims

Cost Performance – Weighted 0%

11



Did you know this data is available?

State with high spending

12



Reporting period will be annual - only see your results

once a year

First report due March 2018

First feedback report – August 2017

When do I need to report for 2017?

13

MIPSMerit-based

Incentive Payment System



Status quo

15



Interesting Fact #1:

A survey conducted in March, 2016 by Weill

Cornell Medical College and the Medical Group

Management Association (MGMA) found that

physicians spend an average of ??? hours

every week processing quality metrics.



Interesting Fact #2:

The time physicians spend processing quality

metrics translates to an average cost of

$40,069 per physician, per year



MIPS combines 3 existing programs:

EHR (MU) Incentive Program

VBPM (Value Based Payment Modifier)

PQRS (Physician Quality Reporting Program)

And ADDS Clinical Practice Improvement Activities

Between approximately 592,000 and 642,000 eligible clinicians will be required to

participate in MIPS in its transition year.

Practices with fewer than 15 providers and in rural areas may be qualified for technical

assistance. Estimate of 14% providers will be low volume and excluded.

CMS expects MIPS to evolve and change

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Proprietary and Confidential19

The rule defines a group as a

single Taxpayer Identification

Number (TIN) with two or

more MIPS eligible clinicians,

as identified by their

individual National Provider

Identifier (NPI), who have

reassigned their Medicare

billing rights to the TIN.



Are you in the low volume threshold that

is excluded? This is $30,000 in Part B

charges OR less than or equal to 100

Medicare patients.

Newly Medicare-enrolled EP’s are also

excluded from reporting the first year.

Or you are a QP (Qualified Provider) as

part of an APM

For MIPS do I need to report individually or as a group?

20

Are you part of the Exclusion Criteria?



Additional considerations for reporting as an individual or a group:

21

1. Do you report to other external agencies today with your TIN or NPI

number? Do you participate in MU, PQRS or other reporting today? If

so, review the performance and how successful you are.

2. The submission requirements for Groups and Individuals are different.

You must participate in MIPS as a whole, either as a group or an

individual; not mixed. Group reporting performance will be assessed

and scored across the TIN and MIPS payment adjustments applied to

the group level of the eligible clinicians in the group.

3. You can join virtual groups in the future years once CMS has

determined that definition.



Composite Performance Score (CPS)

22

Area Weight in 2019

(Changes by year)

Quality 60%

Cost 0%

Improvement activities 15%

Advancing care information (Meaningful use of

certified EHR technology)

25%



• Stay in the pit and get penalty

• Try one lap

• Try one lap for 90 days

• Go for the entire race

Pick your pace in 2017

23



Full vs Minimal Participation

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Report on 6 quality measures OR 1 specialty-

specific or subspecialty specific measure set

one of those should be an outcome measure if

available, if no outcome measure available then

report on a high priority measure

Report on 4 medium weighted activities OR 2

high weighted activities in the Improvement

Activities performance category

Report on 5 Advancing Care measures;

additional measures for potential bonus3.

Report on 1 quality measures if not a group

submission; if a group submission via CMS

Web Interface, more measures are required

Report on 1 high weighted measure in the

Improvement Activities performance category

3.Report on the 5 required Advancing Care

measures

2.

1.

2.

1.

90 Days Minimal-Full Year

And/Or

And/Or



Neutral MIPS adjustment because the performance threshold is

set at 3 points

Scoring Minimal Participation for the first year

25

Individual A:

Submits 1 Quality Measure, No Improvement activity or ACI data

Quality

3 pts

out of

60

((5% * 60%) + (0%* 15%) + (0%* 25%) * 100)

Improvement

0 pts out of

40

ACI

0 pts

out of

100%

CPS

3 Points



Neutral MIPS adjustment because the performance threshold is

set at 3 points

Scoring Minimal Participation for the first year

26

Group A:

Submits 0 Quality Measure, 1 Improvement Activity and no ACI

Quality

0 pts

out of

60

((0% * 60%) + (.25%*15%) + (0%*25%) *100)

Improvement

10 pts out of

40

ACI

0 pts

out of

100%

CPS

3.75 Points



Clinicians who achieve a final score of 70 or higher will

be eligible for the exceptional performance adjustment,

funded from a pool of $500 million.

Scoring Full Participation for the first year

27

Individual or Group A:

Submits 6 Quality Measures, 4 Improvement activities and 5 required ACI measures

Quality

50 pts

out of

60

((83% * 60%) + (75%*15%) + (60%*25%) *100)

Improvement

30 pts out of

40

ACI

60 pts

out of

100%

CPS

76 Points



1. What is your organization currently doing?

2. Alignment efforts with Medicaid measure sets and

Core Quality Measure Collaborative is under way:

“Our strategic interest is a future state where measurement in multi-payer

systems, Medicaid, and Medicare can be seamlessly integrated into CMS

programs.” page 424 CMS-5517FC.pdf

3. This is 60% of your composite score the first year.

Existing measures finalized in CMS-1631-FC

What Quality Measures should you report?

28



1. There are 13 High Quality Measures and at least one must be selected from these 8

subcategories:

2. Are you participating in other activities such as a registry, Million Hearts, CMS

Transforming Clinical Practice Initiative, Health Information Exchange, Patient Experience and

Satisfaction Survey, Consumer Assessment of Healthcare Providers and Systems Survey,

Domestic or International volunteer work for 60 or more days as an example as these are

included in the Improvement activity measures.

3. Review what activities you are currently doing and align these Improvement Activities to

what is important to your practice.

4. This is 15% of your composite score the first year.

Improvement Activities

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Expanded Practice

Access

Population

Management

Care Coordination Beneficiary

Engagement

Patient Safety and

Practice Assessment

Achieving Health

Equity

Emergency Response

and Preparedness

Integrated Behavioral

and Mental Health



*Refer to Section II.E.5.g(7)(a) of final rule for final changes

30

Advancing Care Information

Objective

Advancing Care Information

Measure*

Required/ Not Required for Base

Score (50%)

Performance Score (up

to 90%) Reporting Requirement

Protect Patient Health Information Security Risk Analysis Required 0 Yes/No Statement

Electronic Prescribing e-Prescribing Required 0 Numerator/ Denominator

Patient Electronic Access Provide Patient Access Required Up to 10% Numerator/ Denominator

Patient-Specific Education Not Required Up to 10% Numerator/ Denominator

Health Information Exchange

Send a Summary of Care Required Up to 10% Numerator/ Denominator

Request/Accept Summary of Care Required Up to 10% Numerator/ Denominator

Clinical Information Reconciliation Not Required Up to 10% Numerator/ Denominator

Coordination of Care Through

Patient Engagement

View, Download, or Transmit (VDT) Not Required Up to 10% Numerator/ Denominator

Secure Messaging Not Required Up to 10% Numerator/ Denominator

Patient-Generated Health Data Not Required Up to 10% Numerator/ Denominator

Public Health and Clinical Data

Registry Reporting

Immunization Registry Reporting Not Required 0 or 10% Yes/No Statement

Syndromic Surveillance Reporting Not Required Bonus Yes/No Statement

Electronic Case Reporting Not Required Bonus Yes/No Statement

Public Health Registry Reporting Not Required Bonus Yes/No Statement

Clinical Data Registry Reporting Not Required Bonus Yes/No Statement

Bonus (up to 15%)

Report to one or more additional public health and clinical data

registries beyond the Immunization Registry Reporting measure 5% bonus Yes/No Statement

Report improvement activities using CEHRT 10% bonus Yes/No Statement

Advancing Care Information Performance Category


Proprietary and Confidential31

Webinar in February 2017

We are working to help organizations

and providers align their efforts,

measure their performance and help

gather the necessary data for reporting.



Work towards

32

Alignment

of Effort

Advanced APM

AdvancedAlternative Payment

Model



Goals of CMS

• Overall goal – 90% of

Medicare payments shifted to

quality or value by 2018

• Encourage participation in

APMs

• Expand to other payers

• Goals:

• Better care

• Smarter spending

• Healthier people

34



• Participants use CEHRT

• Payment received on quality measures comparable to

quality measures under MIPS

• Bear risk for monetary loss or be “MACRA” Medical

Home Model

Advanced APM requirements

35



• Comprehensive ESRD Care Model (Two sided risk)-12 participants

• Medicare Shared Savings Program—Track 2 and Track 3 – 24 participants

• Next Generation ACO Model -21 participants

• Comprehensive Primary Care Plus (CPC+)

• Oncology Care Model Two-Sided Risk Arrangement

FINAL LIST to be published by January 2017

Models that Qualify for Advanced APM

36



During a specific period comparing actual to expected

expenditures:

• Withhold payments to AMP entity

• Reduce payments to AMP entity

• Require APM entity to owe payment to CMS

Separate Medical Home Model Financial Risk Standard

Standard Provisions for Financial Risk

37



• New Medicare ACO Track 1+ Model for 2018

• New voluntary bundled payment model

• Comprehensive Care for Joint (CEHRT)

• Advancing Care Coordination thru Episode (CEHRT)

• Medical Home Model

List will grow, forecast 25% of clinicians by 2018

Pathways to performance-based risk

38



Alternative Payment

Model

Advanced APM

Advanced APM Entity

Qualifying Participant

Process

39



First qualify as advanced APM, then go to next step

QP Qualified Participants

Estimate 70,000 to 120,000 providers in

2017

Advanced APM Entity

40



Quality Participants (QP) Thresholds

Payment amount formula Patient Count formula-more flexible

** Partial QP could select MIPS

Professional services at CAH, FQHC ACO,

RHC ACO

41

2019 QP 25%

2019 Partial QP 20%

2019 QP 20%

2019 Partial QP 10%

OR

Snapshots- Three times in 2017

March, June, Aug



Now QP in advanced APM

• Do not participate in MIPS

• Get 5% increase in fee schedule

Met all criteria

42

Physicians



Physicians, Physician Assistants, Nurse Practitioners,

Clinical Nurse Specialists, Certified Registered Nurse

Anesthetists, groups that include clinicians who bill under

Part B.

However, any practitioner that does not exceed the low

volume threshold of $30,000 in Part B allowed charges;

that has 100 or fewer Medicare patients; is newly

enrolled in Medicare; or is a Qualified Participant in an

Advanced APM.

Who are eligible clinicians subject to MIPS?

44



Final Rule The Changes

Hospital-Based MIPS eligible clinician who furnishes 75 percent or

more of covered professional services in an inpatient

hospital, on-campus outpatient hospital or

emergency room setting in the year preceding the

performance period.

Change from Proposed Rule: The

threshold to determine hospital-based

MIPS eligible clinicians lowered from

90 percent to 75 percent. On-campus

outpatient hospital was added as a

site of service.

Non-Patient Facing • Individual MIPS eligible clinician who bills 100 or

fewer patient-facing encounters (including

Medicare telehealth services) during the non-

patient facing determination period.

• A group where more than 75% of the NPIs billing

under the group’s TIN meet the definition of a

non-patient facing individual MIPS eligible

clinician during the non-patient facing

determination period.

Change from Proposed Rule: The

threshold to determine non-patient

facing status increased from 25 to

100 encounters. Revision to the

methodology of identifying a non-

patient facing group finalized.

Defining Providers in Unique Situations

45



CMS estimates that between 592,000 and 642,000

Eligible clinicians will be required to participate in MIPS in

2017.

How many clinicians will be eligible for MIPS?

46



Physicians “who are practicing in big, well-organized organizations . . . we’re not worrying about MACRA”…if he were in a small practice, “there would be no way I could deal with this . . . . It requires scale and leadership and management to respond.”

Thomas H. Lee, M.D. CMO for the Press Ganey patient experience consulting firm

“MIPS and APM are very bad for the solo practitioner. They likely signify the destruction and death of the one- and two-doctor practices, particularly primary care physicians.”

A family practitioner in Georgia

“I’m frankly not going to report and take the penalty. It’s not worth it to report”.

Family physician in Southern California

What doctors are saying about MACRA

47



How did MACRA benefit practitioners?

48

Without the passage of MACRA, physicians could have been

subject to negative payment adjustments of 11% or more in 2019

as a result of the MU, PQRS and VBM programs, with even

greater penalties in future years. In contrast, under MACRA, the

largest penalty a physician can experience in 2019 is 4%. MACRA

also provides incentives for physicians to develop and

participate in different models of health care delivery and

payment known as alternative payment models (APMs).



Another reason to report: it’s all reported publicly!

Physician Compare



Doctors have urged CMS to "Make the transition to

MACRA as simple and as flexible as possible."Andy Slavitt, Acting CMS Director

Is CMS Listening?

50



“The AMA believes the actions that the administration

announced today will help give physicians a fair shot in

the first year of MACRA implementation. This is the

flexibility that physicians were seeking all along.”

Andrew Gurman, M.D., President, AMA

AMA commends CMS

51



• New opportunities to earn incentive payments for above average performance. MIPS presents the 1st real

opportunity for physicians to earn substantial bonuses for providing a higher quality of care. Additional funding is

provided for separate bonuses of up to 10% for exceptional performance, up to $500 million per year, from 2019

through 2024.

• A streamlined performance reporting system, which should be more easily managed than the multiple

existing reporting systems. The CMS currently allows group practices to report via QCDRs starting in 2017,

and MACRA encourages eligible professionals to use these registries for MIPS reporting.

• Improvements in performance scoring over current quality programs:

• Sliding scale assessment.

• Flexible selection of measures. Flexible weighting. The law has guidelines for the weighting of the 4 performance categories, yet

specifically allows administrative flexibility for those in practices or specialties that are at a disadvantage in meeting quality or Advancing

Care Information measure requirements.

• Credit for Improvement Activities.

• New measurement components. Small practices will receive $100 million in technical assistance.

• From fiscal years 2016 through 2020, $20 million per year will assist practices of up to 15 professionals to

participate in the MIPS program or transition to new payment models.

What are the Main Benefits Of Participation In MIPS?

52



Fifty percent say they have never heard of the law and 32 percent recognize it by name but are not

familiar with its requirements.

Twenty-one percent of self-employed or independent physicians say they are somewhat familiar with

the law, compared to nine percent of physicians employed by hospitals, health systems, or medical

groups owned by them.

Eight-in-ten say they prefer traditional fee-for-service (FFS) or salary-based compensation as

opposed to value-based payment models, some of which qualify under MACRA's alternative payment

model (APM) track.

Seventy-four percent of surveyed physicians believe that performance reporting is burdensome and

79 percent do not support tying compensation to quality, both requirements under MACRA.

Fifty-eight percent of physicians say they would opt to be part of a larger organization to reduce

individual increased financial risk and have access to supporting resources and capabilities.

How Ready are Physicians for MACRA?

53

The Deloitte Center for Health Solutions 2016 Survey of US Physicians



Beginning December of 2016 MACRA will provide $100 million to fund training and

education ($20 million each year for 5 years).

Medicare clinicians in individual or small group practices of 15 clinicians or fewer and those

working in underserved areas are eligible to receive this training.

The training will be conducted through local, experienced organizations using this funding

to help small practices select appropriate quality measures and health IT to support their

unique needs, train clinicians about the new improvement activities and assist practices in

evaluating their options for joining an Advanced APM.

Watch websites for additional details.

Assistance Needed!

54



1. Evaluate where you fall under MACRA (MIPS, APM or exempt?)

1. AMA payment model evaluator

2. Are you participating in a qualified clinical data registry, if

not, contact your specialty society about participating in

theirs (data registries can streamline reporting and assist with MIPS

performance scoring)

3. If you practice with >1 eligible clinician decide whether to

report individually or as a group.

4. Determine whether you meet the requirements for small,

rural or non-patient- facing physician accommodations.

What are steps can we take to prepare?

55



5. Access and review the 2014 annual PQRS feedback

reports to see where improvements can be made.

6. Review cost data from CMS in summer of 2017 for 2020

ramifications (attribution).

7. Consider how you plan to report through claims, electronic

health record (EHR), clinical registry, qualified clinical data

registry (QCDR) or group practice reporting option (GPRO)

Web-interface. The GPRO Web-interface is only available

for physicians in practices of 25 or more eligible clinicians.

Steps to take-continued

56



Connect locally with organizations and use their websites

AMA https://www.ama-assn.org/practice-management/medicare-payment-delivery-changes

AHA http://www.aha.org/advocacy-issues/physician/index.shtml

AAFP http://www.aafp.org/practicemanagement/payment/macraready.html

ONC https://chpl.healthit.gov/#/search list of certified vendors

CMS Quality Payment Program qpp.cms.gov

Resources

MACRA READY programs

http://www.aha.org/advocacy-issues/physician/index.shtml

http://www.aafp.org/practicemanagement/payment/macraready.html

https://chpl.healthit.gov/#/search



Questions

58

Bobbi Brown

[email protected]

Bryan T. Oshiro, M.D.

Chief Medical Officer

[email protected]

Dorian DiNardo

[email protected]

mailto:[email protected]





Appendix



• MACRA – Medicare Access and CHIP Reauthorization Act of 2015

• SGR – Sustainable Growth Rate (replaced by MACRA)

• MIPS – Merit-based Incentive Payment System

• APM – Alternative Payment Models (Advanced)

• EP – Eligible professional becomes EC Eligible clinician

• ACI- Advancing Care Information (replaces Meaningful Use)

• CPIA –Clinical Practice Improvement Activity

• CPS – Composite Performance Score

Acronyms

60



Proposed Rule Final Rule

Quality • 6 individual measures or 1

measure set with at least one

cross-cutting measure and

outcome measure (if no outcome

measure, one other high priority

measure)

• Required reporting on 80% of

patients(claims method ) or 90%

(other submission methods)

6 quality measures (including

outcome measure) or 1 measure set

(if no outcome measures are

available in the measure set, report

another high priority measure )

Requires reporting on 50% of patients

(all submission methods)

Advancing Care Information (ACI) 11 required measures 5 required measures

Clinical Practice Improvement

Activities (CPIA)

• 6 medium-weighted activities or

• 3 high- weighted activities

• 4 medium-weighted activities OR

• 2 high-weighted activities

Cost (previously called Resource

Use)

Continues measures from the Value

Modifier program and episode-based

measures, as applicable to MIPS

eligible clinicians

Not measured in 2017 performance

year

What do we have to report?

61



Maximum negative adjustment of 4% in MIPS

Reporting Option 1: No Reporting

62



Report some data in 2017 to the Quality Payments

Program (QPP).

Protected from negative payment adjustment in MIPS,

but no positive payment adjustment available either.

Not exactly defined as to what “some data” actually

means.

CMS considers this a test of how doctors will be ready for

more intense reporting requirements in the following

years.

Reporting Option 2: Minimal Reporting

63



Participate for part of 2017.

Eligible for positive payment adjustment

Protected from negative payment adjustment

Participants will be testing their systems for future

MACRA compliance and may end up with a small

Medicare pay increase.

Reporting Option 3: Partial reporting

64



Participate for all of 2017.

Doctors who begin reporting data on January 1st 2017

will be eligible for a “modest” pay increase in 2019

Data on quality measures, use of technology and practice

improvement must be reported

Reporting Option 4: full reporting

65



Participate in an Advanced Alternative Payment Model

Doctors who begin reporting data on January 1st 2017

will be eligible for a “modest” pay increase in 2019

Data on quality measures, use of technology and practice

improvement must be reported

Reporting Option 5: Advanced APM

66