MACRA Implementation. Michael Schweitz, MD Chair, Federal Advocacy Committee Coalition of State Rheumatology Organizations

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1 MACRA Implementation Michael Schweitz, MD Chair, Federal Advocacy Committee Coalition of State Rheumatology Organizations

2 Disclaimer Materials are provided without warranty and based on current understanding of the draft proposals. Proposals are subject to change.

3 MACRA Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Enacted into law on April 16, 2015 Repealed the flawed Sustainable Growth Rate (SGR) formula Established a two-track Medicare physician payment system Merit-Based Incentive Payment System (MIPS) Alternative Payment Models (APMs)

4 MACRA & CMS Notice of Proposed Rulemaking released on April 27, 2016 Implements certain MACRA provisions through a unified framework called the Quality Payment Program Reflects stakeholder feedback through multiple comment opportunities 2016 Medicare Physician Fee Schedule Request for Information on MIPS/APMs Request for Comment on MACRA Episode Groups Other formal and informal feedback solicitations

5 Medicare s Quality Payment Program MIPS Consolidates existing physician-focused Medicare quality improvement programs Creates a composite performance score (CPS) to inform physician payment based on four weighted categories Quality (PQRS) Advancing Care Information (EHR/MU) Cost (Resource Use/VM) Clinical Practice Improvement Activities APMs Physicians receiving a significant share of their revenues through an APM that involves financial risk and quality measurement APMs must also Bear more than nominal financial risk Require participants to use certified EHR technology Report on MIPS-like quality measures

6 Merit-Based Incentive Payment System (MIPS)

7 Most rheumatologists will be subject to MIPS

8 MIPS: Year 1* Quality (50%) Advancing Care Information (25%) Clinical Practice Improvement (15%) Cost (10%) Composite Performance Score (CPS) * CY 2019 payment adjustments based on CY 2017 performance

9 MIPS: Year 1 Quality pts. Report on six weighted quality measures (or a specialty measure set if available) One crosscutting measure One outcome/high quality measure Population health measures applied based on practice size ACI 100+ pts. Base Score (50 pts.): Provide numerator/denominator and yes for six objectives Performance Score (80 pts.): Report performance on measures from three objectives Bonus Point (1 pt.): Report on more than one public health registry (beyond the immunization category (exclusions apply))

10 MIPS: Year 1 CPI 60 pts. More than 90 weighted options in nine categories, including participation in APMs Measures range between pts. No minimum required; however, activity must have been performed for at least 90 days, if reported Cost Average of points across applicable measures Calculated based on Medicare claims 40+ episode-specific measures covering multiple specialties Part D drugs are not included

11 MIPS Quality & Rheumatology Proposed Allergy/Immunology/Rheumatology Specialty Measure Set Includes five Rheumatoid Arthritis (RA) measures RA: Tuberculosis Screening RA: Periodic Assessment of Disease Activity RA: Functional Status Assessment RA: Assessment and Classification of Disease Prognosis RA: Glucocorticoid Management

12 MIPS Quality & Rheumatology Rheumatologists must also identify and report One cross-cutting measure, such as Care Plan Documentation of Current Medications in the Medical Record Preventive Care and Screening: Tobacco Use CAHPS for MIPS Clinician/Group Survey One outcome or high priority measure, such as OA: Function and Pain Assessment

13 MIPS ACI Base Score = 50 pts. Protect Patient Health Information ( yes required) Electronic Prescribing (numerator/ denominator) Public Health/Clinical Data Registry Reporting (numerator/ denominator) Patient Electronic Access (numerator/ denominator) Coordination of Care Through Patient Engagement (numerator/ denominator) Health Information Exchange ( yes required) Report the numerator/denominator for measures within the following objectives: Electronic Prescribing Public Health/Clinical Data Registry Reporting Patient Electronic Access Coordination of Care Through Patient Engagement Report yes to measures in the following objectives: Protect Patient Health Information Health Information Exchange

14 MIPS ACI Performance on each measure in the following objectives will result in points toward the performance score Patient Electronic Access Coordination of Care through Patient Engagement Health Information Exchange Report to a registry beyond the immunization registry requirement for one additional bonus point Performance Score = 80 pts. Patient Electronic Access Coordination of Care through Patient Engagement Health Information Exchange Bonus Point = 1pt. Public Health/Clinical Data Registry Reporting

15 Potential MIPS CPIAs for Rheumatology? Expanded Practice Access Expanded hours in evenings and on weekends Provision of same-day or next-day access for urgent care Population Management Improve health status of communities/work with QIO Participation in a QCDR or other registries for quality improvement Care Coordination Managing care intensively through new diagnoses, injuries and exacerbations of illness Use pre-visit planning to optimize preventive care for patients with chronic conditions Beneficiary Engagement Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan

16 Potential MIPS CPIAs for Rheumatology? Patient Safety and Practice Assessment Achieving Health Equity Participation in Maintenance of Certification Part IV for improving professional practice Use of tools that assist specialty practices in tracking specific measures Seeing new Medicaid patients in a timely manner Participation in State Innovation Model funded activities Emergency Response and Preparedness Integrated Behavioral and Mental Health Participation in domestic or international humanitarian volunteer work (registered for 6 months) Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment

17 Potential MIPS CPIA for Rheumatology? Participation in APMs MIPS eligible clinicians and groups in a certified patientcentered medical home will receive 100 percent (or 60 points) toward their CPIA score MIPS eligible clinicians and groups participating in APMs can earn at least 50 percent (or 30 points) toward their CPIA score (unless they are QPs or Partial QPs in Advanced APMs and elected not to report MIPS information)

18 MIPS Cost & Rheumatology Osteoporosis Osteoporosis (Osteopor) episode is triggered by two (2) E&Ms with a principal or secondary diagnosis of any Osteoporosis trigger code occurring within 30 calendar days. This episode is intended to capture all services related to the medical management and treatment of Osteopor. Rheumatoid Arthritis Rheumatoid Arthritis (RA) episode is triggered by two (2) E&Ms with a principal or secondary diagnosis of any RA trigger code occurring within 30 calendar days. This episode is intended to capture all services related to the medical management and treatment of RA.

19 CPS above the performance threshold will yield a neutral or positive payment adjustment MIPS CPS MIPS eligible clinicians will receive a positive, negative or zero payment adjustment based on their composite score when compared to a benchmark CPS below the performance threshold will yield a negative payment adjustment

20 MIPS Payment Adjustments CY Potential Adjustments 2019 (Year 1) -4%; up to 12% + 10% %; up to 15% + 10% %; up to 21% + 10% 2022 & Beyond -9%; up to 27% + 10% Exceptional Performance An additional bonus (not to exceed 10%) will be applied to payments to eligible clinicians with exceptional performance where CPS is equal to or greater than an additional performance threshold, defined as the 25th percentile of possible values above the CPS performance threshold

21 MIPS Reporting Third party intermediaries may submit data for eligible clinicians in all categories Qualified Registries Qualified Clinical Data Registries (QCDR) CEHRT CMS Web Interface (groups of 25+) Certified Survey Vendors

22 MIPS Exclusions

23 Alternative Payment Models (APMs)

24 Not all APMs are created equal There are multiple alternative payment models (APMs) in Medicare, Medicaid, and the private sector MACRA emphasizes participation in certain APMs more than others Advanced APMs carry the most weight, as they help eligible clinicians become qualifying participants (QPs), avoid the MIPS, and earn a +5 percent financial incentive MIPS APMs carry considerable weight, as these APMs will give eligible clinicians an opportunity to earn significant points toward their clinical practice improvement activity (CPIA) score under MIPS Other non-qualifying Medicare APMs are in effect, but many of these were not proposed in the rule for purposes of becoming a QP or for earning credit under MIPS directly. However, these models could still be important in helping eligible clinicians reduce Medicare spending per beneficiary, thus potentially impacting the cost and resource use score under MIPS

25 MACRA APM Criteria

26 Advanced APMs These APMs have been proposed as Advanced APMs. Eligible clinicians that participate in an Advanced APM entity that reaches either the payment or patient threshold will be be considered qualifying participants (QPs), be exempt from MIPS, and earn the 5% incentive in Advanced APMs Comprehensive ESRD Care Model (large dialysis organizations (LDO)) Comprehensive Primary Care Plus MSSP ACO Track 2 MSSP ACO Track 3 Next Generation ACO Model Oncology Care Model (two-sided risk)

27 MIPS APMs These APMs have been proposed as MIPS APMs. Participation in these APMs may help you earn credit in the MIPS program under the CPIA category. MIPS APMs Some Advanced APMs Comprehensive ESRD Care Model (non- LDO) MSSP ACO Track 1 Oncology Care Model (one-sided risk)

28 Other non-qualifying Medicare APMs There are many other APMs in the Medicare program. Under the current proposal, these APMs will not help you become a QP nor earn you credit under the MIPS CPIA category. However, they may help reduce spending and impact your cost and resource use score under MIPS. Other non-qualifying APMs Bundled Payment for Care Improvement (BPCI) Models Comprehensive Care for Joint Replacement (CJR) Model Medicare Part B Drug Model

29 MACRA Payment Adjustments MPFS Updates % MPFS Update % MPFS Update 2026 & Beyond 0.25% or 0.75% MPFS Update MIPS Adjustment Current Programs Continue % OR +4% (x3)+10% % OR +5% (x3)+10% % OR +7% (x3)+10% 2022 & Beyond -9% OR +9% (x3)+10% APM Bonus % bonus 2025 & Beyond no bonus

30 MIPS Impact on Rheumatology Provider Type # of Physicians Allowed Charges (mil) % w/ neg. adj. % w/ pos. adj. Agg. Impact (neg. adj.) (mil) Agg. Impact (pos. adj.) (mil) Agg. Positive w/o ex. perf. Bonus (mil) Agg. Positive w/ ex. perf. Bonus (mil) Rheumatology 4,274 $ % 67.6% -$3 $13 $8 $5 Out of all Medicare specialties (except for pediatrics), rheumatology is expected to see the MOST physicians earn a positive adjustment under MIPS

31 MACRA Next Steps Upcoming timelines July 2016: CY 2017 MPFS Proposed Rule (likely to include MACRA discussion) November 2016: CY 2017 MPFS Final Rule and Final MIPS/APM Requirements January 1, 2017: Beginning of first performance period for MIPS

32 Resources MACRA Proposed Rule: 09/pdf/ pdf CMS s Quality Payment Program Slides: Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and- APMs/Quality-Payment-Program-MACRA-NPRM-Slides.pdf CMS s MACRA Web page: Initiatives-Patient-Assessment-Instruments/Value-Based- Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html