MACRA, MIPS, and APMs

Transcription

1 MACRA, MIPS, and APMs 1 Copyright 2017 State Volunteer Mutual Insurance Company The Sea of MACRA Requirements 2 1

2 Is Fee-for-Service Sailing into the Sunset? 3 4 2

3 Triple Aim Value Lower Healthcare Costs 5 Triple Aim Incentive or Penalty? Lower Healthcare Costs 6 3

4 Commercial Payer Trends Premium Designation Network Tier ing Narrow Networks 7 Quality Payment Program Replaces Legacy Quality Reporting Programs. PQRS Physician Quality Reporting System VBPM Value Based Payment Modifier MU Meaningful Use 8 4

5 CMS Payment Adjustments 2018 Based on % PQRS 3% Meaningful Use 2-4% Value Based Payment Modifier Total = 9% 9 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Medicare Physician Fee Schedule (MPFS) 0.5% Increase July 1, % Annual Increase 2016 thru % Change 2020 thru 2025 Merit-based Incentive Payment System (MIPS) Alternative Payment Models (APM) 10 5

6 APMs 11 Advanced APMs MSSP Tracks 2 & 3 and the new Track 1 + ^ Next Generation ACOs Comprehensive Primary Care Plus Comprehensive ESRD Care (2-sided risk) * Oncology Care Model (2-sided risk) * Comp Care for Joint Replacement (CEHRT track) ^ Bundled Payments for Care Improvement (BPCI) Advanced < starting in 2019 * Not accepting new applicants ^ New opportunity in

7 Advanced APM Minimum through APM Benefits 25% of Medicare reimbursement, OR 20% of Medicare beneficiaries 5% payment incentive MIPS exemption 13 MIPS APMs Oncology Care Model (one-sided risk) Comprehensive ESRD Care MSSP Track 1 ACOs Must participate in MIPS Receives favorable scoring and weighting

8 MIPS 15 MIPS Categories for Payment Performance Year % 50% Quality 15% 15% Improvement Activities 25% 25% Advancing Care Information 0% 10% Cost 16 8

9 Reporting Period Quality 90 Days 12 Months Improvement Activities 90 Days 90 Days Advancing Care Information 90 Days 90 Days Cost (CMS Calculated) N/A 12 Months 17 MIPS Scoring for Track 1 MSSP ACOs Quality 50% Reported through ACO Advancing Care Information 30% Reported through practice TIN Improvement Activities 20% Automatically earn full credit Score will be assessed at the ACO level 18 9

10 Step 1: Determine Eligibility 19 Step 1 - Determine Eligibility Eligible Clinicians Physician Physician Assistant* Nurse Practitioner* Clinical Nurse Specialist* Certified Registered Nurse Anesthetist* Exemptions First year of Part B participation Advanced APM participants Low Volume Threshold *Not required to report Advancing Care Information (ACI), but will be score if reported 20 10

11 Low volume threshold exemption Eligibility for low volume exclusion Medicare allowed charges <30K <90K OR Medicare patient encounters (Does not include Medicare Advantage or Part C) <100 < Check Your Status

12 Step 2: Determine 2018 Strategy 23 Strategy Bonus Penalty 24 12

13 MIPS Composite Score Exceptional 80 Performance 70 Points Small Bonus Points Exceptional Performance 70 Points Small Bonus 15 Points Step 3: Group or Individual Reporting? 26 13

14 Determine Group / Individual Reporting Group Performance aggregated at TIN level One Score Less burdensome Will include all practice data Must report same Quality measures May not use claims based reporting for Quality Individual NPI level May be beneficial if majority of providers not reporting or using EHR Each provider scored based on his/her performance May use claims based reporting for Quality 27 Step 4: Select Quality Measures 28 14

15 Reporting Threshold 2018 EHR, QCDR or Qualified Registry 60% All Patients Claims 60% Medicare Patients 29 Quality Quality = 50% Replaces PQRS Must report 6 measures (may/should report more) Measures 60 points groups <15 70 points for larger groups Cost = 10% Improvement Activity = 15% Advancing Care Information = 25%

16 Interactive Tool 31 Example Quality Measures Documentation of current medications in medical record Preventative care and screening: Influenza immunization Adult sinusitis: Antibiotic prescribed for acute sinusitis (overuse) Controlling high blood pressure Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Preventative care and screening: BMI screening and follow-up 32 16

17 2018 Quality Reporting Requirements 1-15 Clinicians 16+ Clinicians 1 Quality Measure 1 Patient 3 Points 1 Point 1 Quality Measure Data completeness = 20 patients & 60% pts 3-10 Points 3-10 Points 33 Step 5: Understand Cost Category 34 17

18 Cost Category Quality = 50% Cost = 10% Replaces VBPM Medicare spending per beneficiary (MSPB) Total cost for attributed beneficiaries Total cost for attributed beneficiaries No submission requirement Download Quality and Resource Use Report (QRUR) Risk adjusted Improvement Activity = 15% Advancing Care Information = 25% 35 Definitions Medicare Spending Per Beneficiary Hospital Cost Per Patient per Episode of Care Medicare Part A and Part B claims (not Part D) 3 days prior to a hospital admission through 30 days after discharge Medicare Advantage excluded Cost attributed by TIN (or TIN/NPI) Total Per Capita Cost Per Attributed Beneficiary Medicare Part A and Part B costs for each beneficiary Risk adjusted and specialty adjusted 36 18

19 Access PQRS and QRUR Report Enterprise Identity Management System (EIDM) account is required to access the report CMS Enterprise Portal (

20 Step 6: Select Improvement Activities 39 Improvement Activities Category focuses on Care Coordination, Beneficiary Engagement and Patient Safety 112 activities Weighted as Medium or High Highest potential score is 40 points 40 20

21 Improvement Activities Quality = 50% Cost = 10% Improvement Activity = 15% Submit 4 measures > 15 providers Submit 2 measures 15 providers Small practices get double credit If Group reporting, only 1 MIPS eligible clinician (EC) in a Tax Identification Number (TIN) needs to attest Advancing Care Information = 25% 41 Improvement Activities Categories Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Participation in an APM Achieving Health Equity Integrating Behavioral and Mental Health Emergency Preparedness and Response 42 21

22 CMS Improvement Activity Examples Categories Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Achieving Health Equity Examples Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record Chronic care and preventative care management for empaneled patients Implementation of use of specialist reports back to referring clinician or group to close referral loop Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms Consultation of prescription drug monitoring program Seeing new and follow-up Medicaid patients in a timely manner Emergency Preparedness and Response Behavior and Mental Health Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams Depression screening and follow-up plan for patients with cooccurring conditions of behavioral or mental health conditions 43 Sample IA Patient Safety 44 22

23 JB1 JB2JB3 Step 7: Advancing Care Information 45 Advancing Care Information (ACI) ACI category replaces the Medicare EHR Incentive Program (Meaningful Use) Greater flexibility in choosing measures Eligible Clinicians (EC) report on a set of four or five required measures (Base Measures) EC s can increase their score by reporting on additional measures (Performance and Bonus Measures) 46 23

24 Slide 45 JB1 Jackie Boswell, 2/5/2018 JB2 Jackie Boswell, 2/5/2018 JB3 Jackie Boswell, 2/5/2018

25 Advancing Care Information *Clinicians must use certified EHR technology to report In 2017 and 2018 there are 2 measure sets for reporting based on EHR edition: For those using EHR technology Certified in 2014 Edition For those using EHR technology Certified in 2015 Edition Option 1: 2017 Advancing Care Information Transition Objectives and Measures Option 2: Combination of the two measure sets Option 1: Advancing Care Information Objectives and Measures Option 2: Combination of the two measure set 47 Advancing Care Information Advancing Care Information Objectives and Measures: Base Score Required Measures 2014 CEHRT Objective Measure 2017 Transition Measure Protect Patient Health Security Risk Analysis Information Security Risk Analysis Electronic Prescribing e-prescribing e-prescribing Patient Electronic Access Provide Patient Access Provide Patient Access Health Information Exchange Send Summary of Care Health Information Exchange 48 24

26 Advancing Care Information Advancing Care Information Objectives and Measures: Base Score Required Measures 2015 CEHRT Objective Measure 2017 Transition Measure Protect Patient Health Security Risk Analysis Information Security Risk Analysis Electronic Prescribing e-prescribing e-prescribing Patient Electronic Access Provide Patient Access Provide Patient Access Health Information Exchange Send Summary of Care Health Information Exchange Health Information Exchange Request/Accept a Summary of Care 49 Advancing Care Information Scoring (25% of Final Score) Advancing Care Information Performance Category Score Base Score Performance Score Bonus Score 50 25

27 2017 Advancing Care Information Transition Objectives and Measures Performance Score* Measures 2014 CEHRT Objective Measure Patient Electronic Access Patient Electronic Access Patient-Specific Education Secure Messaging Health Information Exchange Medical Reconciliation Public Health Reporting Provide Patient Access* View, Download and Transmit (VDT) Patient-Specific Education Secure Messaging Health Information Exchange* Medication Reconciliation Immunization Registry Reporting *Performance Score: Additional achievement on measure above the base score requirements 51 Advancing Care Information Objectives and Measures Performance Score* Measures 2015 CEHRT Objective Measure Patient Electronic Access Patient Electronic Access Coordination of Care through Patient Engagement Coordination of Care through Patient Engagement Coordination of Care through Patient Engagement Health Information Exchange Health Information Exchange Health Information Exchange Public Health and Clinical Data Registry Reporting Provide Patient Access* Patient-Specific Education View, Download and Transmit (DVT) Secure Messaging Patient-Generated Health Data Send a Summary of Care* Request/Accept a Summary of Care* Clinical Information Reconciliation Immunization Registry Reporting *Performance Score: Additional achievement on measure above the base score requirements 52 26

28 Advancing Care Information For reporting on one or more of the following Public Health and Clinical Data Registry Reporting measures For using CEHRT to report certain Improvement Activities Syndromic Surveillance Specialized Registry Reporting (14) Electronic Case Reporting (15) Public Health Registry Reporting (15) Clinical Data Registry Reporting (15) 53 Advancing Care Information Improvement Activities Bonus Score (examples) Improvement Activity Performance Category Subcategory Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Achieving Health Equity Activity Name Provide 24/7 access to eligible clinicians or groups who have real-time access to patients medical record Chronic care and preventative care management for empaneled patients Implementation of use of specialist reports back to referring clinician or group close referral loop Engagement of patients through implementation of improvements in patient portal Use of decision support and standardized treatment protocols Leveraging of QCDR to standardize processes for screening Improvement Activity Performance Category Weight High Medium Medium Medium Medium Medium 54 27

29 Advancing Care Information Performance Category Base Score Performance Score Bonus Score Final Score Account for of the total Advancing Care Information Performance Category Score Account for up to of the total Advancing Care Information Performance Category Score Account for up to of the total Advancing Care Information Performance Category Score Earn 100% and receive FULL 25 POINTS of the total Advancing Care Information Performance Category Final Score The overall Advancing Care Information score would be made up of a base score, a performance score, and a bonus score for a maximum score of 100 percentage points 55 Hardships Exceptions Eligible clinicians who faced have significant hardship Insufficient internet connectivity Based on the Federal Communication s National Broadband Map Extreme or uncontrollable circumstances (natural disaster or significant issues related to CEHRT) Lack of control over the availability over CEHRT Lack of face-to-face interaction (EC s who are non-patient facing) 56 28

30 Additional Information 57 Attestation and Reporting Go to CMS Enterprise Portal Create an EIDM account Use those credentials to sign in to

31 Bonus Pool for Exceptional Performers 500 Million available in 2018 Exceptional Performance MIPS Score >70 Points in New Bonus Opportunities 5 bonus points to the final scores of small practices Bonus for using only 2015 CEHRT 5 bonus points on your final score for treatment of complex patients 60 30

32 New in 2018 Virtual Groups < 10 Clinicians Leverage infrastructure No location or specialty restriction Increase sample size Sign agreement by 12/31/ Resources SVMIC MGMA CMS EIDM CMS QPP Resource Library Payment-Program/Resource-Library/Resourcelibrary.html YOUR EHR Vendor State and specialty associations 62 31

33 Quality Improvement Organizations for Small Practices (< 15) Alabama, Kentucky, Tennessee Atom Alliance (800) Arkansas TMF (866) Georgia Alliant Quality (678) Questions? 64 32