11/14/2016. A few simple questions. MACRA Regulations. Congress & CMS Game Changer MIPPA CMS Quality Publications

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1 A few simple questions Don t Lose Your Pants (or Your Sanity) Over MIPS An ODs Survival Kit for MACRA and Registries Jeff Michaels, OD, FAAO, Diplomate, American Board of Optometry Will Medicare funding last forever? Why? Aging of America? System paid on QUANTITY System relied on past success Congress & CMS Game Changer April 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Medicare severs Pay for Service Payments Service, Quality, EHR, Cost Goal 90% of all Medicare Fee for Service payments tied to QUALITY AND VALUE by 2018 MACRA Regulations Quality Payment Program (QPP) April 27, 2016 = Proposed Regulations pages! October 14, 2016 = Final(?) Regulations...2,398 pages! 2 paths to payment for Medicare Providers: 1. DEFAULT = Merit based Incentive Payment System (MIPS) 2. Advanced Alternative Payment Models (APMs) CMS Quality Publications MIPPA 2008 Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee for Service Program April 2007 Payments linked to quality and efficiency of care Evidence based outcomes Medicare Improvements for Patients and Providers Act of 2008 Section 131(d) requires the HHS Secretary to develop a plan to transition Medicare to a Value Based Purchasing program based on efficiency and quality It s the law 1

2 PPACA 2010 Patient Protection and Affordable Care Act Established a payment modifier that provides for differential payment to physicians under the physician fee schedule based on the quality of care $$ penalties in 2015 for not participating in PQRS CMS Game Changer 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) MACRA Proposals 3 different proposals included many of AOA s Medicare pay reform principles, but... Every single one still required at least 1 significant & sweeping change to protect optometry s physician recognition & ensure OD s continued full participation With the help of that army of advocates, AOA was ultimately successful in making key changes to the 3 separate bills being considered THANK YOU! AOA Keypersons AOA Volunteers Federal Relations Committee Federal Legislation and Keyperson Committee AOA PAC Committee AOA Board of Trustees AOA Staff (DC and St. Louis) 2015 MACRA Legislation Medicare s New Quality Payment Program (QPP) Permanently repealed SGR Annual fee schedule increase of 0.5% for July , then... In 2019, consolidates & expands the 3 existing incentive programs PQRS EHR MU Value Based Modifier MACRA = Quality Payment Program (QPP) Now 2 Ways to get paid by Medicare: 1) Merit based Incentive Payment System (MIPS) Is the Default payment/grading system for providers neutral legislation Pay increase or decrease to your TOTAL MEDICARE PAYABLES DELAYED payment adjustments up or down based on performance 2 years prior! 2) Advanced Alternative Payment Models (APMs) Must be a Qualifying APM Participant (QP) Must see a certain % of patients or payments thru an APM 2

3 Can IOpt Out of MIPS? To Qualify for 5% APM Bonus... Opt Out of MIPS: Low Volume Threshold Submit $30,000 in allowable charges, OR You see 100 Medicare patients in a year Can IOpt IN to MIPS if I m Under the Low Volume Threshold? NO!!! Payment Adjustments 2017 Performance 2019 payment adjustments 2018 Performance = 2020 payment adjustments 2019 Performance = 2021 payment adjustments 3

4 Dates to Remember January 1, 2017 MIPS starts October 2, 2017 Last day to start collecting data for 90 day period January 2, 2018 March 31, 2018 Dates to submit your data to CMS January 2019 When your payments change for 2017 performance For 2017 Transition Year (not sure yet about 2018) Your MIPS Grade is Weighted 2017 Performance 2019 Performance Overview of MACRA through 2022 YOUR SCORE above TPS earns BONUS : 60% Advancing Care Info (MU) 25% Clinical Practice Improvement: 15% : 0% : 30% Advancing Care Info (MU) 25% Clinical Practice Improvement: 15% : 30% CMS Weighted and Calculated Annual Threshold Performance Score (TPS) YOUR SCORE below TPS earns PENALTY Above the Curve for % or above is a Passing Grade for 2017 Performance 70% is an A+ for 2017 MIPS Bonus shares $500,000,000 Be Minimum? Don t set out to be The Minimum Avoiding NEGATIVE adjustment for your 2017 Performance is easy!!! It will get more difficult in 2 nd Year (2018) 4

5 Pre MIPS = 70 points for 2017 Transition Year Ends December 31, 2016 PQRS: Physician Quality Reporting System MU: Meaningful Use VBM: Value Based Modifier = 3 points for 2017 Transition Year MIPS Performance for ODs Starts January 2017 Old School PQRS MU VBM New School Advancing Care Information (ACI) Clinical Practice Improvement Activities (CPIA) Change is the law of life and those who look only to the past or present are certain to miss the future." -Pres. John F. Kennedy CMS now predicts... (assumption: 80% participation rate across all practice sizes) >90% of all MIPS eligible clinicians will receive a positive or neutral payment adjustment in the 2017 transition year (effective on 2019 Medicare payments) >80% of MIPS eligible clinicians in small & solo practices with 1 9 clinicians will receive a positive or neutral payment adjustment in 2017 transition year (effective on 2019 Medicare payments) $100 Million in technical assistance for small, rural, HPSA practices CMS Taking it Easy on us in 2017 Transition Year Transition Year for CY 2017 = 1 st Year of QPP/MIPS Lowering participation thresholds for CY 2017 Medicare goals for 2017: Allow us to learn MIPS Reduce our chance of negative payment adjustment Prevent us from losing our pants! Hope we don t run for the hills!! 5

6 QPP: Pick Your Pace for 2017 OPTION 1: Submit nothing = 4% negative payment adjustment on all Medicare fees for 2019 OPTION 2: Test QPP system & submit some QPP data after Jan 1, to ensure your system is working submit 1 Quality measure or 1 CPIA Avoid negative payment adjustment = neutral fee schedule for 2019 OPTION 3: Participate for part of calendar year 2017 Report 90 days on Quality, Technology Use (ACI), Practice Activities (CPIA) Could still qualify for small positive payment adjustment for 2019 QPP: Pick Your Pace for 2017 OPTION 4: Participate for full calendar year 2017 Begins Jan. 1, 2017 & continues all year Report on Quality, Technology Use (ACI), Practice Activities (CPIA) Could qualify for a modest positive payment adjustment OPTION 5: Participate in an Advanced Alternative Payment Model Must meet minimum payment percentage requirements for 2017 Will qualify for 5% incentive payment MIPS Payments for ODs Advancing Care Information Clinical Practice Improvement Activities MIPS Cheat Sheet 5 1 Done! Advancing Care Information Nothing! Clinical Practice Improvement Activities New, 1! MIPS Payments for ODs Advancing Care Information Clinical Practice Improvement Activities Quality is Still Driven by PQRS Ideology PQRS Optometry s start in the quality reporting arena 2007 Voluntary/bonus 2015 Penalty for not participating in 2013 (2 year delay) 6

7 PQRS for ODs The Good News? 40% 40 38% 35 32% ODs Submitting PQRS 30 28% ODs Paid for PQRS % 25 22% 20% 19% 20% 20% % 10 6% PQRS for ODs Hitting the Bottom Line! 2015: First PQRS Pay Reductions 20,282 ODs got a Medicare pay cut in 2015 Because you didn t submit 1 successful code in 2013 OMDs 28% receiving payment reduction in 2015 Just Do It! You have to get in the game! PQRS MU Registry use Not just CMS! Why Optometry? DID YOU KNOW? 20 medical conditions account for >95% of Medicare's costs? Medicare s Top 20 High-Impact Conditions Acute myocardial infarction (AMI) Alzheimer's Disease and related disorders Atrial fibrillation Breast cancer Cataract Congestive heart failure (CHF) Chronic kidney disease Colorectal cancer Chronic obstructive pulmonary disease (COPD) Diabetes Endometrial cancer Glaucoma Hip/pelvic fracture Ischemic heart disease Lung cancer Major depression Osteoporosis Prostate cancer Rheumatoid arthritis and osteoarthritis Stroke/transient ischemic attack (TIA) Why Optometry? We are on the FRONT LINE for many of Medicare s most cost exhaustive conditions! Grades provider from performance categories (60% of grade) Advancing Care Info (25% of grade) (0% of grade) Clinical Practice Improvement Activities (15% of grade) 7

8 Why PQRS: Glaucoma Gap in Care Why PQRS: Diabetes Gap in Care Glaucoma 2027F There is a significant gap in documentation patterns of the optic nerve for initial and follow up visits Even among glaucoma specialists!! Diabetes 2021F RAND Study Only 50% of diabetics get timely eye exams Only 19% had evidence of dilated eye exam! PQRS Under the Hood Claims Based Did You Get It All? If PQRS is to improve costs and outcomes, how do you improve the PQRS system? Or at least improve my payments! Automate PQRS! Registry based PQRS Diabetic Is your patient over 18? Under 75? Did you use correct CPT code? 99xxx vs 92xxx Did you use correct ICD code? Did you document Diabetic Retinopathy? Did you use proper PQRS code based on age and diagnosis? Registry Based Did You Get It All? Diabetic Is your patient over 18? Under 75? Did you use correct CPT code? 99xxx vs 92xxx Did you use correct ICD code? Did you document Diabetic Retinopathy? Did you use proper PQRS code based on age and diagnosis? Correlating Your EHR Exam to PQRS Codes electronic Clinical Quality Measures (ecqm) Matches your EHR data field to appropriate PQRS code If you click the correct boxes then a correlating PQRS applies 8

9 Surviving PQRS with Registries! PQRS: Documentation of Current Meds Example Diabetes Eye Exam Age xxx or 92xxx Diagnosis Diabetes Retina findings documented PQRS: POAG (Document ONH) What If I m Below 50%? Learn your ecqm report from your vendor!! Take Your F Codes! Streamline PQRS by using AOA MORE No F codes to remember! Automatically correlated to your exam findings and diagnostic procedures (ecqms) If It Looks Like a Duck Claims Based PQRS Dying duck! EHR Based PQRS Registry Based PQRS 9

10 PQRS Key Message! PQRS will still need to be submitted by you to CMS AOA MORE does not automatically send your PQRS to CMS AOA MORE will have a process set up to automate the process Submit after the reporting period ends (Dec 31) Jan Feb the following year Know the QUALITY 5 1 Done! You must have: 6 Quality Measures 5 Regular measures 1 outcomes measure 1 High Priority measure if no Outcomes measure is available Minimum of 20 patients per Quality Measure Know your patient population If you don t see 20 Glaucoma patients in a year, don t pick the Glaucoma Quality measures!!! Picking Quality Measures Take advantage of BONUS POINTS High priority measures = 1 Bonus point Extra outcome measure = 2 Bonus points You have to know: What are regular measures What are outcomes measures What are high priority measures If your EHR count these quality measures Quality 5 1 Done! Cheat Sheet DM eye exam (no retinopathy)* Diabetic Retinopathy Diabetic Ret letter to PCP! POAG* AMD exam* AMD AREDS counseling* Document meds! BMI measure BP Screening Close the referral loop! Tobacco Screening/Cessation* POAG 15% reduction!! BP control!! * Top 5 submitted in 2014 by ODs! High priority, get bonus point Double bonus if 2 nd Outcome measure Quality 5 1 Done! Cheat Sheet DM eye exam (no retinopathy)* Diabetic Retinopathy Diabetic Ret letter to PCP! POAG* AMD exam* AMD AREDS counseling* Document meds! BMI measure BP Screening Close the referral loop! Tobacco Screening/Cessation* POAG 15% reduction!! BP control!! Regular Measures Outcomes Measures High Priority Measures Quality 5 1 Done! Cheat Sheet DM eye exam (no retinopathy)* Diabetic Retinopathy Diabetic Ret letter to PCP! POAG* AMD exam* AMD AREDS counseling* Document meds! BMI measure BP Screening Close the referral loop! Tobacco Screening/Cessation* POAG 15% reduction!! BP control!! PICK 5 * Top 5 submitted in 2014 by ODs! High priority, get bonus point Double bonus if 2 nd Outcome measure * Top 5 submitted in 2014 by ODs! High priority, get bonus point 10

11 Quality 5 1 Done! Cheat Sheet Quality 5 1 Done! Cheat Sheet DM eye exam (no retinopathy)* Diabetic Retinopathy Diabetic Ret letter to PCP! POAG* AMD exam* AMD AREDS counseling* Document meds! BMI measure BP Screening Close the referral loop! Tobacco Screening/Cessation* POAG 15% reduction!! BP control!! PICK 1 OUTCOME DM eye exam (no retinopathy)* Diabetic Retinopathy Diabetic Ret letter to PCP! POAG* AMD exam* AMD AREDS counseling* Document meds! BMI measure BP Screening Close the referral loop! Tobacco Screening/Cessation* POAG 15% reduction!! BP control!! PICK 1 HIGH PRIORITY PICK 1 OUTCOME Quality 5 1 Done! Cheat Sheet DM eye exam (no retinopathy)* Document meds! Diabetic Retinopathy BMI measure Diabetic Ret letter to PCP! BP Screening POAG* Close the referral loop! AMD exam* Tobacco Screening/Cessation* AMD AREDS counseling* POAG 15% reduction!! BP control!! Regular Measures Outcomes Measures High Priority Measures MIPS Quality Pick 6 You can pick more than 6 CMS takes highest scoring (per category) Minimum 20 cases per measure Quality Scoring Rules for 2017 is 60% of your total MIPS score for points per measure (60 points total) Earned points based on % eligible times you successfully submit measure Must be over 50% of your patients Quality Scoring Rules for 2017 Submit on 6 measures including 1 outcome measure 0 10 points per measure You get 0 points if you do NOTHING You get 3 points minimum (in 2017) for submitting ANY data per measure You get 4 10 points if over 50% of your patients 11

12 Be Minimum in 2017? Submit 1 Quality Code on at least 1 patient Any Quality Measure! Any amount of times (1 or more) Submitting Codes occurs between Jan2 Mar31 of the following year Example: you documented medications on 1 patient! GUARANTEED NOT TO HAVE NEGATIVE PAY ADJUSTMENT (in 2019) MIPS Payments for ODs Advancing Care Information Clinical Practice Improvement Activities MIPS Cheat Sheet 5 1 Done! Advancing Care Information Nothing! Clinical Practice Improvement Activities New, 1! Advancing Care Information Think MU As of December ,608 ODs were paid for MU $327,685,425 Average $24,080 per OD Grades provider from performance categories (60% of grade) Advancing Care Info (25% of grade) (0% of grade) Clinical Practice Improvement Activities (15%) Advancing Care Information = Base Score Performance Score Bonus Score Base Score = 50 % Performance Score = 90 % Bonus Score = 15% The goal is to achieve 100 points More than 100 is possible! 12

13 Advancing Care Information Is your EHR Stage 2 compliant or Stage 3 compliant? 2014 certified (Modified Stage 2) 2015 certified (Stage 3)) ACI Score 2017 Base Score = 50 % Participation points Not graded by how well you do Performance Score = Up to 90% Graded by how well you do Bonuses = up to 15% Using a Registry like AOA MORE Specific CPIA activities Scoring over 100 = 100 points You can over achieve to ensure your maximum score ACI Base Score = 50% Protect PHI (Security Risk Assessment) erx Provide Patient Access Health Information Exchange ACI Performance Score = 90% Health Information Exchange 20%** Pt Electronic Access Provide Patient Access 20%** View, Download, Transmit 10% Patient Specific Education 10% Secure messaging 10% Medication Reconciliation 10% Immunization Registry 10% Bonus Scores up to 15% in Performance Score Using a registry besides Immunization 5% Must have a Base Score Specific Improvement Activities 10% We cover improvement activities later MIPS Payments for ODs Advancing Care Info Clinical Practice Activities 13

14 MIPS Cheat Sheet 5 1 Done! Advancing Care Information Nothing! Clinical Practice Improvement Activities New, 1! New School Cost for MIPS Nothing to submit by doctor Math done by CMS (data collection starts in 2017) Per Capita expenses for 10 episode based measures e.g. Diabetes Cost & Value was removed from MIPS calculation only for 2017 Will be 10% of the total MIPS score in 2018 Will be 30% of the total MIPS score in 2019 Get Your QRUR! To be replaced by MIPS Feedback Report MIPS Payments for ODs Advancing Care Information Clinical Practice Improvement Activities MIPS Cheat Sheet 5 1 Done! Advancing Care Information Nothing! Clinical Practice Improvement Activities New, 1! 14

15 Clinical Practice Improvement Activities (CPIA) New to the Quality Payment Program Activities in your practice that help the public Think of your role in Public Health Clinical Practice Improvement Activities (CPIA) You need 40 points for maximum CPIA score 10 point measures (Medium Weight) 20 point measures (High Weight) Points doubled for MOST ODs Select measures to reach 40 total points Heavily weighted to those using clinical registries Qualified Clinical Data Registry (QCDR) Pick Your CPIA Path Are you a Small practice or a Large practice? Your CPIA requirements depend on how big your practice is By Tax ID# Small Practice vs Large Practice Pick Your CPIA Path (by TIN) Small Office 15 or fewer CMS clinicians Rural Area Health Professional Shortage Area All activities are double points! Large Office More than 15 CMS clinicians Pick any combo to make 40 points Each is worth 10, 20 points PICK 1-4 TO ADD TO 40 POINTS Small Office: PICK 1-2 TO ADD TO 40 POINTS Large Office: PICK 1-4 TO ADD TO 40 POINTS High Weight (20 points each) Use AOA MORE to report local practice patterns 24/7 access to clinicians** Medium Weight (10 points each) Use AOA MORE to show outcome comparisons across specific population Use AOA MORE to promote standard practice uses Use AOA MORE to track patient safety (microbial keratitis) Close referral loop**: provide reports to referred from physicians Timely communication of test results Engage patients and families in decision making MIPS Cheat Sheet 5 1 Done! Advancing Care Information Nothing! Clinical Practice Improvement Activities New,1! 15

16 Pay Raise or Pay Cut? Annual Threshold Performance Score (TPS) It s the curve Depends on how others are doing Year #1: the curve is just a 3!! (& exceptional is 70) MIPS Final Score (0 100) Quality Score + Advancing Information Score + Clinical Practice Improvement Activities + Cost Score CMS Online Tool

17 NOTE: CMS will collect Cost data for providers starting in 2017, even though it won t count towards ours 2017 Transition Year MIPS Score. MIPS MATH + = Database Systematic collection of data Captures data that can be analyzed Analyze to improve care and outcomes Cancer registry 17

18 Registries Old School Immunization Registry Syndromic Surveillance Registry Specialized Registry AOA MORE New School Qualified Clinical Data Registry AOA MORE Clinical Feedback Glaucoma/Glaucoma Suspect (VF, OCT) Laser Outcomes PQRS satisfaction rate Medication Rx s ICD codes Constantly evolving Top Registry Users by Profession (2013) (Before AOA MORE) Specialty Eligible Professionals Eligible Professionals who Participated Percent of Eligible Professionals who Participated Answering Optometry s Questions: Kids under 5? Most common K ulcer? Diabetics? Myopia Progression Optometry advocating for Optometry!! 30,000+ ODs working together Registry Individual Measures Internal Medicine 76,041 5, % Physical/Occupational Therapy 49,006 5, % Family Practice 78,441 4, % Dermatology 9,791 3, % Nurse Practitioner 62,216 3, % Physician Assistant 50,626 2, % Other Eligible Professional 38,052 2, % Radiology 31,213 2, % Ophthalmology 17,468 1, % Cardiology 18,851 1, % 18

19 EHR PUSH Registry CMS/ PQRS/ etc Your cost to use AOA MORE? You DESERVE to be at the value based purchasing table $0 to members One of the most common registries for ODs costs over $3000 in the first year QUESTION: Am I automatically enrolled if my vendor is integrated? No. You must sign up to authorize your data integration Dashboard Screenshots 19

20 MIPS: A ROAD MAP TO SUCCESS Questions? JMichaelsOD@yahoo.com 20