MACRA Quality Payment Program

Transcription

1 The American College of Surgeons Resources for the New Medicare Physician System

2 Table of Contents Understanding the... 3 Navigating MIPS in MIPS Reporting: Individuals or Groups : The Transition Year... 7 Pick Your Pace for the Transition Year MIPS Reporting: Pathway toward Potentially...13 Receiving a Positive Update The MIPS Final Score and Updates...16 Support for Rural Surgeons and Individual or...20 Small Group Practices Glossary of Acronyms and Terms

3 Understanding the 1 (QPP) a. Operationalization of the Medicare Access and CHIP Reauthorization Act (MACRA) i. Legislation passed in April 2015 b. Replaces the Sustainable Growth Rate (SGR) c. Represents a major change in Medicare physician payment d. Advances the policy goal of value over volume 2 Two Tracks in the QPP a. Advanced Alternative Models (A-APMs) i. Object of ongoing policy development efforts by ACS ii. Few surgeons expected to participate in APMs initially b. Merit-based Incentive System (MIPS) i. MOST SURGEONS EXPECTED TO PARTICIPATE VIA THIS PATH ii. Streamlines Medicare s three prior quality programs into one new system and adds another category 3 MIPS a. Four Components i. ii. Cost (no weight Year 1) iii. Advancing Care Information (ACI) iv. Improvement Activities 4 Component a. Replaces PQRS reporting b. Many measures used in PQRS also applicable c. Reporting requirements modified i. Fewer measures required ii. Report on six measures (previously was nine), including one outcome measure or another high-value measure if outcome measure not available iii. Measures may be chosen from: 1. MIPS measures list 2. MIPS specialty-specific measures set 3. QCDR measures 5 Cost Component a. Replaces Value-Based Modifier b. CMS will make calculation based on available claims data c. NO REPORTING REQUIREMENTS d. NO WEIGHT IN YEAR 1 6 Advancing Care Information (ACI) Component a. Modifies and replaces current electronic heath record program (also known as Meaningful Use) b. Score derived in two parts i. Base score = 50% 1. Four or five measures depending on the edition of CEHRT 3 ii. Performance score only applicable to those who achieve Base score 1. Based upon level of performance on SUBSET of measures required for Base score 7 Improvement Activities a. New category b. Choose from a list of more than 90 activities c. Each activity is assigned a point value i. High value = 20 points ii. Medium value = 10 points d. Total of 40 points needed to achieve FULL CREDIT i. Some rural and small practices need to perform only one highvalue or two medium-value activities to earn FULL CREDIT ii. Small practice = 15 or fewer providers e. Reporting for 1st Year = ATTESTATION 8 MIPS Final Score a. Derived as composite from performance in three components b. Weighted by category i. Year 1 1. Component - 60% 2. Advancing Care Information (ACI) - 25% 3. Improvement Activities - 15% 4. Cost - 0% c. Percentages subject to change in later years

4 Navigating MIPS in 2017 The new Merit-based Incentive System (MIPS) has taken a number of steps to streamline reporting and make it easier to avoid penalties and achieve positive updates. MIPS also includes tools to help small and rural practices successfully compete with larger practices. However, over time penalties for nonparticipation or poor performance will grow. Therefore, it is critically important that all surgeons make a plan for how they can best participate and succeed in the new program. Because Medicare reporting requirements can seem burdensome and confusing, this document was created with the intent of explaining the MIPS program. The goal is to guide Fellows through the process of choosing the level of participation that is right for their individual practice. Knowing what options are available is vital to navigating the new reporting requirements and, ultimately, achieving the best possible financial outcomes. Background on MIPS and Its Components MIPS began measuring performance in The data reported in 2017 will be used to adjust payments in MIPS took the Physician Reporting System (PQRS), the Value-Based Modifier (VM), and the EHR Incentive commonly referred to as Meaningful Use (EHR-MU), added the new component Improvement Activities, and combined them to derive a composite MIPS Final Score. The components of the Final Score are known as (formerly PQRS), Cost (formerly VM), Advancing Care 4

5 Information (ACI) (formerly EHR-MU), and Improvement Activities. The weights for the individual components of the Final Score for the first year of the MIPS program are represented in the Figure Performance Category Weights Though the Centers for Medicare & Medicaid Services (CMS) has chosen not to provide any weight to the Cost component during the first year of the program, those who report data will receive feedback reports on their performance in the Cost component. 5

6 MIPS Reporting: Individuals or Groups If you submit Merit-based Incentive System (MIPS) data as an individual, your payment adjustment will be based on your individual performance. A Final Score is calculated using the data submitted for, Advancing Care Information (ACI), and Improvement Activities. Data for each of these three MIPS categories may be submitted through an electronic health record (EHR), registry, or a qualified clinical data registry (QCDR). data may also be submitted through the routine Medicare claims process. Data for Improvement Activities and the ACI category may also be submitted through the CMS web portal. Surgeons who submit MIPS data as part of a group practice, under a single Taxpayer Identification Number (TIN), will receive the MIPS Final Score and corresponding payment adjustment in accordance with the assessment made for their group practice (a single MIPS Final Score and corresponding payment adjustment is made for all individuals within the group). Those who choose to report as a group for any of the reporting requirements must report as a group for all of the remaining components of MIPS. It is important to have an idea of one s current preparedness and previous status with the Medicare programs that formed the basis for the components of MIPS, as those who performed well in the Physician Reporting System (PQRS) and the Electronic Health Records Incentive (also known as Meaningful Use, or EHR-MU) are more likely to be successful in MIPS. Accordingly, we recommend that all Fellows take a few simple steps. First, it is crucial to check the edition of one s certified EHR technology to see that it is either a 2014 or 2015 edition. One of those two editions is required to participate in ACI. In addition, it is also critically 6

7 important to become familiar with the available measures and the data submission methods available to your practice, including consideration of the use of a registry or a QCDR. We recommend that Fellows review the measure benchmarks found at qpp.cms.gov/resources/education in order to optimize their quality score. 2017: The Transition Year The Centers for Medicare & Medicaid Services (CMS) designated 2017 as a transition year and has provided a clear pathway to avoid penalties. In addition, CMS has reduced the reporting requirements in 2017 for those who wish to fully participate in preparation for the future or those practices whose goal is the achievement of a positive payment update. It is important to note that the funds available for positive payment updates are derived from the penalties assessed on those who choose NOT to participate. Accordingly, by making it easier to avoid penalties in the first year, CMS has also reduced the amount of funds available for positive incentives. Surgeons should bear this fact in mind when planning their course of action and attendant resource requirements for Participating to Avoid Penalties For 2017, CMS instituted options to allow surgeons to Pick Your Pace for participation in the Merit-based Incentive System (MIPS). Those who choose not to participate at any level will receive the full negative payment adjustment of 4 percent in However, it is noteworthy that 7

8 a 4 percent negative payment adjustment is less than half of the negative adjustments associated with the Physician Reporting System (PQRS), Value-Based Modifier (VM), and Meaningful Use programs in To avoid the 4 percent penalty, CMS only requires that surgeons test their ability to report data in any of three reporting components, namely, Advancing Care Information (ACI), or Improvement Activities. Information for the Cost component is derived automatically and has no reporting requirement. Specifically, to avoid a penalty, surgeons must simply report one quality measure for a single patient, attest to participating in an approved Improvement Activity for at least 90 consecutive days, or complete the base score requirements for ACI. Participating to Prepare for Future Success Those who wish to attempt to achieve a higher score must report data for 50 percent of all patients seen (for ALL payors) for any period of 90 consecutive days. Accordingly, one could begin as late as October 2, However, CMS encourages reporting for the full year. How data are reported depends upon the circumstances of an individual s practice, as there are multiple methods (electronic health record, registry, or qualified clinical data registry) for submitting data to CMS. It should be noted that data can also be submitted on an individual basis or as a group. 8

9 Pick Your Pace for the 2017 Transition Year Option 1: Test the MIPS Submit a minimum amount of 2017 data (for example, one quality measure or one Improvement Activity for any point in 2017) to Medicare to avoid a 4 percent Medicare Part B penalty in This option is for surgeons who may be unfamiliar with quality reporting and want to test it out or for those who only want to do the minimum amount of reporting to avoid the penalty, recognizing they will not be eligible for an incentive payment. The Centers for Medicare & Medicaid Services (CMS) defines a minimum amount of data as: 1 measure; OR 1 Improvement Activity; OR The required Base score Advancing Care Information (ACI) measures Option 2: Participate in MIPS for Part of the Year Surgeons may submit data to Medicare for a continuous 90-day period in 2017 to avoid the penalty and possibly earn a small incentive payment. If surgeons are not ready to start reporting to the Merit-based Incentive System (MIPS) on January 1, they can start anytime between January 1 and October 2. This option allows flexibility to those who want to participate in the program but prefer to report for a shorter period of time. 9

10 By reporting for a 90-day minimum, surgeons will be eligible for at least a neutral adjustment, if not a small positive adjustment. Positive adjustments are based on performance, not the amount of information or length of time providers reported. However, reporting for a longer period of time is the best way to earn the maximum positive adjustment, because surgeons can track their performance and improve. Partial participation in MIPS means that surgeons should meet at least the following criteria: Six measures for at least 90 consecutive days on 50 percent of all-payor applicable patients (50 percent of applicable Medicare patients for claims reporting), AND Four medium-weighted or two high-weighted Improvement Activities for 90 consecutive days, AND Report ACI measures for at least 90 consecutive days Surgeons can choose different 90-day reporting periods for each performance category, including, Improvement Activities, and ACI. 10

11 Option 3: Fully Participate in MIPS Surgeons can submit up to a full year of 2017 data to Medicare to be eligible for a positive payment adjustment, based on performance. Full participation in MIPS means that surgeons should at least meet the following criteria: Six measures for up to a full year on 50 percent of all-payor applicable patients (50 percent of applicable Medicare patients for claims reporting), AND Four medium-weighted or two high-weighted Improvement Activities for 90 consecutive days, AND Report ACI measures for up to a full year Reporting for up to a full year is the best way to get the maximum positive payment adjustment. Not only does full participation allow surgeons to track their performance over a longer period of time, it also expands the number of available measures for surgeons while better preparing them for future years of the QPP, which will likely require full-year participation. 11

12 Option 4: Participate in an Advanced APM An Alternate Model (APM) is a payment approach that provides incentive payments for the provision of high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. Advanced APMs are a subset of APMs that let practices earn higher incentives for taking on additional financial risk for the outcome of their patients. Surgeons who receive 25 percent of Medicare payments or see 20 percent of Medicare patients through an Advanced APM in 2017 could earn a 5 percent incentive payment in The American College of Surgeons (ACS) is currently working to expand the Advanced APM options for surgeons for future years. For more information, please visit Option 5: Do Not Participate Not participating in the in 2017 will result in a 4 percent Medicare Part B penalty in

13 MIPS Reporting: Pathway toward Potentially Receiving a Positive Update Reporting for To maximize performance on the score, data must be submitted for 50 percent of all patients seen (for ALL payers, except those who report by claims) for at least a 90 consecutive day period on a minimum of six measures, including one outcome measure. Another high-priority measure may be substituted if an outcome measure is not available. Measures can be chosen from the MIPS measures list, a MIPS specialty-specific measure set, or QCDR measures. Those who do meet the reporting requirements and perform well on the measures can receive up to 60 points toward their MIPS Final Score. For those who intend to simply avoid penalties for the first year of the MIPS program in 2017, reporting a single measure for a single patient will earn the three points necessary to meet the performance threshold prescribed by Centers for Medicare & Medicaid Services (CMS) to avoid a penalty. Bonus points are also available by reporting on additional outcome measures, high-priority measures, and end-to-end reporting measures using certified EHR technology (CEHRT). Reporting for ACI The Advancing Care Information (ACI) component is worth 25 percent of the MIPS Final Score. The assessment for ACI is a composite score composed of two parts: a Base score and a Performance score. To receive credit for the ACI component in 2017, one must have either 2014 or 2015 edition certified electronic health record technology (CEHRT). According to current regulations, only those with 2015 edition technology will qualify to receive credit for ACI beginning in

14 The Base score is an all-or-nothing threshold and accounts for 50 percent of the total score for the ACI component. Achieving the Base score is required before any score can be accrued for the performance portion. Achieving the Base score is also one of the options prescribed by CMS sufficient to avoid any MIPS penalties in If the Base score is achieved, one will not receive a penalty, even if, Improvement Activity, or additional ACI data are not submitted. The ACI measures are intended to ensure that certified EHRs are being used for core tasks such as providing patients with online access to their medical records, exchanging health information with patients and other providers, electronic prescribing, and protecting sensitive patient health information through a Security Risk Analysis. Once all of the measures for the Base score have been met, clinicians are eligible to receive credit for performance on both a subset of the Base score measures and on a set of additional optional measures. Bonus points are also available by reporting certain Improvement Activities via a certified EHR. Reporting for Improvement Activities While Improvement Activities (IA) is a new category, surgeons are familiar with many of the activities included, such as maintenance of certification (MOC), use of the American College of Surgeons (ACS) Surgical Risk Calculator, participation in a qualified clinical data registry (QCDR), and 14

15 registration with their state s prescription drug monitoring program (PDMP). Each activity is assigned either a point value of 20 points (high value) or 10 points (medium value). The reporting requirement for the IA is fulfilled by simple attestation via either a registry, QCDR, or a portal on the CMS website. To receive full credit, most surgeons must select and attest to having completed between two and four activities for a total of 40 points. For small practices, which CMS defines as those with fewer than 15 providers or those in rural practices, CMS has stated that to achieve full credit only one high-value or two medium-value activities are required. Those who fulfill the requirement will receive 15 points toward the MIPS Final Score. For those whose goal is simply to avoid a penalty in the first reporting year of MIPS, they can attest that they have completed a single activity for 90 days. For those seeking further information, the ACS website () offers additional fact sheets and informational videos on the MIPS program. Additionally, the official CMS website for the QPP ( is a great resource for learning about and selecting quality measures, ACI measures, and Improvement Activities for reporting in

16 The MIPS Final Score and Updates Beginning in 2017, participants in the Merit-based Incentive System (MIPS) will begin reporting quality measures that will result in payment updates (positive, negative, or neutral) starting in Similar to the past Physician Reporting System (PQRS) and Valuebased Modifier (VM) programs, payments are applied two years after the performance year. The information reported to the Centers for Medicare & Medicaid Services (CMS) in various categories (, Advancing Care Information [ACI], Improvement Activities, and Cost) will be combined into a single MIPS Final Score, which will be compared with a threshold to determine each provider s update. The maximum payment updates, the category weights, and the threshold will all vary over time. This document looks at how those pieces will fit together to affect Medicare payments. Component Weights For the 2017 performance year,, ACI, and Improvement Activities performance will account for 60, 25, and 15 percent of the total MIPS Final Score, respectively. For the first year the Cost category carries no weight, although providers will still receive information on their resource use relative to other providers. By 2019, and Cost are set to be equally weighted at 30 percent, with ACI and Improvement Activities continuing to account for 25 and 15 percent, respectively. Also of note, once 75 percent of physicians are classified 2017 Performance Category Weights 16

17 as meaningful users of electronic health records (EHR) technology, the ACI component weight can be reduced to as low as 15 percent, with the remainder distributed among the other categories. Please see the facs.org and qpp.cms.gov websites for specific information on measures, reporting methodologies, and scoring within each of the components. The MIPS Final Score and Adjustments Each year, provider performance in the four categories will be adjusted based upon that category s weight and combined into a final score between 0 and 100. This final score will then be compared against a performance threshold: If the score is above the threshold, the provider will be eligible for a positive update. If the score is equal to the threshold, the update will be neutral. If the score is below the threshold, payments will be reduced. In general, the maximum positive and negative updates are 4 percent for the 2019 payment year (based on 2017 performance) and will grow annually until they reach +/- 9 percent for 2022 and future years. For the first six years of the program, MIPS providers with the very highest 17

18 performance scores (typically those in the top three quartiles above the performance threshold) will be eligible to receive an additional positive update of up to 10 percent. Up to $500 million per year is available for these additional updates. The Performance Threshold The performance threshold will typically be the average of a prior performance period, but due to the lack of historical data, the Secretary of Health and Human Services has discretion in setting the threshold for the first two years. For the 2017 performance year, the threshold is set at 3, meaning that any provider who reports a single quality measure for a single patient, participates in a single Improvement Activity for 90 consecutive days, or completes the ACI Base score requirements will be at or above the performance threshold and therefore avoid penalties (for more information on the 2017 transition requirements, visit facs.org/advocacy/qpp/videos and view the Pick Your Pace video). This is expected to exempt a significant number of providers from penalties in the 2017 performance period, which CMS has designated as a transition year. However, since MIPS is mostly a budget-neutral payment system (in other words, negative updates are used to offset positive updates), positive updates for eligible providers may be small in the first year. 18

19 A Single Update versus Multiple Penalty s While the MIPS program s scoring system may seem complex, it effectively replaces multiple programs with potential penalties of 10 percent or more and very little upside potential (the PQRS, the Meaningful Use or EHR-MU, and the VM) with a single update mechanism with a much greater opportunity for positive payment adjustments. The ACS is committed to helping surgeons understand and succeed in the new payment system, and we will continue to update with new resources and information as it becomes available. 19

20 Support for Rural Surgeons and Individual or Small Group Practices If you are a solo practitioner or in a small group practice of 15 or fewer members, particularly if you practice in a rural or shortage area, you may be eligible for technical assistance or subject to reduced requirements designed to help you succeed in the (QPP). The U.S. Department of Health and Human Services (HHS) will be awarding $20 million for each of the first five years of the QPP to organizations tasked with helping small practices succeed. These funds will be allocated nationwide but with priority given to rural areas, designated health professional shortage areas (HPSAs), and medically underserved areas (MUAs). This money will be allocated to provide direct outreach and technical assistance, such as helping practices decide which quality measures to report, providing advice on electronic health record selection and implementation, and discussing how to improve your Merit-based Incentive System (MIPS) Final Score by receiving credit for Improvement Activities you may already be participating in. Help will also be provided to those interested in exploring participation in Alternative Models (APMs). There are also certain scoring advantages for small practices built into the MIPS scoring criteria. Specifically, small practices, rural practices, or practices located in geographic HPSAs can receive full credit in the Improvement Activities component of MIPS by attesting to a single highweighted or two medium-weighted activities (half the requirement of larger practices). 20

21 In addition, small practices may be excluded from MIPS altogether if they do not see many Medicare patients or if they receive a low amount of Medicare Part B payments. If you see fewer than 100 Medicare patients annually or submit less than $30,000 in Medicare claims, you are not eligible to participate in MIPS and therefore not eligible for its incentives or subject to its penalties and reporting requirements. In the future, small practices with 10 or fewer clinicians will be allowed to form virtual groups to streamline and increase the efficiency of the MIPS reporting requirements. Due to technological barriers associated with this new reporting method and the steps taken by CMS to shelter practices from penalties in the 2017 transition year, CMS has decided not to implement this option for at least the first year of the QPP. The American College of Surgeons (ACS) will continue to monitor the awarding of technical assistance funds and the development of the virtual group reporting option for small practices. Please check the ACS website, facs.org, for additional information as it becomes available. 21

22 Glossary of Acronyms and Terms ACI Advancing Care Information Component of MIPS representing a modified version of the Electronic Health Record (EHR) Incentive or Meaningful Use that serves to measure the extent to which physicians are actively engaged in the use of certified EHR technology. The Office of the National Coordinator for Health Information Technology (ONC) establishes the standards, implementation specifications, and certification criteria that determine whether an EHR is certified for the EHR Incentive and the upcoming ACI component of MACRA. APM Alternative Model Physician payment models that base the payment provided on value (quality/cost) and thereby differ from traditional Fee-For-Service (FFS) payment models. A-APM Advanced Alternative Model For purposes of MACRA and the QPP, a payment model that incorporates quality metrics, use of certified EHR technology, and either provider assumption of greater than nominal financial risk or provision of service in a medical home model. Certain Advanced APM participants may be excluded from the MIPS payment adjustment. CEHRT Certified Electronic Health Record Technology An electronic health record certified for use in the EHR Incentive and the upcoming ACI component of MACRA. The Office of the National Coordinator for Health Information Technology (ONC) establishes the standards, implementation specifications, and certification criteria. CHIP Children s Health Insurance A federally funded health insurance program that covers certain low-income children. CMS Centers for Medicare & Medicaid Services Federal agency within the Department of Health and Human Services responsible for administering the Medicare and Medicaid programs. EHR Incentive (also known as Meaningful Use) A CMS quality program used to determine if eligible professionals are actively engaged in the use of certified electronic health record technology. Currently, physicians can be penalized for failing to meet Meaningful Use requirements. Starting in 2017, the Meaningful Use program is modified and forms the basis for the Advancing Care Information (ACI) component of the MIPS program. IA Improvement Activities A new category of activities created by MACRA as a means of providing credit to physicians participating in the MIPS program, which measures efforts to improve their practice or their work toward participation in an APM. 22

23 Medicare Access and CHIP Reauthorization Act Legislation enacted in April 2015 that repealed the sustainable growth rate (SGR) and set the stage for the new Medicare physician payment program, the (QPP). In addition to other policies, the bill also included extensions of CHIP and other health provisions. MIPS Merit-based Incentive System The new fee-for-service payment system created by MACRA that will base annual payment updates on four factors:, Resource Use, Advancing Care Information (ACI), and Clinical Practice Improvement Activities (CPIA). PQRS Physician Reporting System A CMS quality reporting program for individual physicians and group practices. Currently, physicians Medicare Part B payments are penalized for failure to report PQRS quality measures. Starting in 2017, PQRS will be used as the basis for the component of MIPS. QCDR Qualified Clinical Data Registry A registry, approved by CMS following a qualification process, that functions to collect clinical data for the purpose of patient and disease tracking in order to foster improvement in the quality of care provided to patients. CMS may allow QCDRs the flexibility to define which quality measures participating physicians would choose to report. QPP The new CMS Medicare physician payment program. The QPP represents the operationalization of the MACRA legislation and is scheduled to go into effect on January 1, The QPP consists of two tracks, the Advanced Alternative Model (APM) and the Merit-based Incentive System (MIPS). SSR Surgeon Specific Registry The Surgeon Specific Registry (SSR) is a web and mobile software application and database that allows surgeons to track their cases and outcomes in a convenient, easy-to-use manner. Built on the ACS Case Log system, the SSR is available to facilitate PQRS reporting for 2016 and reporting of the MIPS component in VM or VBM Value-Based Modifier A CMS quality program used to measure the value of care by comparing quality and cost. Currently, payments may be adjusted up or down depending on each individual provider s quality and resource use report. Starting in 2017, the VM will be used as the basis for the Resource Use component of MIPS. 23

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