MACRA: How is Podiatry Affected?

MACRA: How is Podiatry Affected?

Faculty Adam E. Fleischer, DPM, MPH Associate Professor Dr. William M. Scholl College of Podiatric Medicine Rosalind Franklin University of Medicine and Science Director of Research Weil Foot and Ankle Institute Chicago, Illinois

Faculty Disclosures Dr. Fleischer has disclosed no relevant financial relationships with any commercial interests.

Learning Objectives 1) Recognize how provider MIPS scores will be affected in the coming years. 2) Describe future trends for MIPS and APMs and their impact on podiatry. 3) Describe several Quality and Improvement reporting measures that are particularly well suited for podiatric physicians.

SGR MACRA (The Medicare Access and CHIP Reauthorization Act of 2015) Quality Payment Program MIPS APM

MIPS Score Highest possible score is 100 points EPs will receive either a positive or negative payment adjustment to the Medicare Part B fee schedule, based on their MIPS score Almost all podiatrists will report through MIPS first year MIPS = merit-based incentive payment system; EP = eligible professional.

Thresholds CMS set the Performance Threshold at 3 and the Exceptional Performance Threshold at 70, meaning that any clinician with a MIPS score of at least 3 which can be accomplished by submitting, for example, just one quality measure will avoid a negative adjustment, and those earning a score of at least 70 will be eligible for an Exceptional Performance Adjustment from the annual $500 million pool. CMS = Centers for Medicare & Medicaid Services

MIPS Adjustments 2019: -4% to +4% (based on 2017 score) 2020: -5% to +5% (based on 2018 score) 2021: -7% to +7% (based on 2019 score) 2022 : -9% to +9% (based on 2020 score)

MIPS Year 1 Mostly budget neutral Penalty no more than 4% Most positive adjustments no more than 4% (positive moved based on budget neutrality) Exceptional Performance (MIPS score of 70 or higher access to additional $500 million bonus pool)

Exclusions CMS proposes to exclude otherwise MIPS-eligible low-volume clinicians or groups who, during the performance period, either do not exceed Medicare billing charges of $30,000 or provide care for 100 or fewer Part B-enrolled Medicare beneficiaries. Newly Medicare-enrolled eligible clinicians Qualifying APM Participants (QPs) Certain Partial Qualifying APM Participants (Partial QPs) APM = alternative payment model

MIPS Two determination period options to meet 2017 low-volume threshold: 9/1/2015-8/31/2016 or 9/1/2016-8/31/2017

MIPS Participation Status Letter MIPS Participation Status Letter The Centers for Medicare & Medicaid Services is reviewing claims and letting practices know which clinicians need to take part in, the Merit-based Incentive Payment System. MIPS is an important part of the new. In late April through May, practices will get a letter from the. This letter will tell the participation status of each MIPS clinician associated with the Taxpayer Identification Number or TIN in a practice. Clinicians should participate in MIPS for the 2017 transition year if they bill more than $30,000 in Medicare Part B allowed charges a year AND provide care for more than 100 Part B-enrolled Medicare beneficiaries a year. The Quality Payment Program intends to shift reimbursement from the volume of services provided toward a payment system that rewards clinicians for their overall work in delivering the best care for patients. It replaces the Sustainable Growth Rate formula and streamlines the Legacy Programs Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare Electronic Health Records (EHR) Incentive Program. During this first year of the program CMS is committed to diligently working with you to streamline the process as much as possible. Our goal is to further reduce burdensome requirements so that you can deliver the best possible care to patients.

Check Your Status Online https://qpp.cms.gov/learn/eligibility

MIPS MIPS reporting is not limited to Medicare patients* (but some quality measures do have age ranges in their denominators, so pay attention to them) *Reporting the quality component by claims method is an exception

MIPS Score Performance Year 2017 Quality 60% ACI 25% Clinical Practice Improvement Activities 15% Cost 0% ACI = Advancing Care Information

CHOOSE YOUR COURSE OF PARTICIPATION Three options with regards to MIPS 3

MAXIMUM MIPS Clinicians can choose to report to MIPS for a full 90-day period (ideally, for the full year) and maximize the MIPS-eligible clinician s chances to qualify for a positive payment adjustment. In addition, MIPS-eligible clinicians who are exceptional performers in MIPS, as shown by the practice information that they submit, are eligible for an additional positive adjustment.

MODERATE MIPS Clinicians can choose to report to MIPS for less than the full-year 2017 performance period (but must report for a 90-day period at a minimum), and report more than one quality measure or improvement activity, or more than the required measures in the advancing care information performance category, in order to avoid a negative MIPS payment adjustment (and to possibly receive a positive MIPS payment adjustment).

MINIMUM MIPS Clinicians can choose to report one measure in the quality performance category or one activity in the improvement activities performance category, or report the required measures of the advancing care information performance category, and avoid a negative payment adjustment.

MINIMUM SCORE OF 3 For the 2017 transition year, if the measure is submitted but is unable to be scored because it does not meet the required case minimum (20), does not have a benchmark, or does not meet the data completeness requirement (at least 50% reporting rate), the measure will receive a score of 3 points.

WHAT ABOUT NO MIPS? -4% Four percent payment reduction on Medicare Part B Fee For Service Payments in 2019

MIPS Quality (60%) Choose 6 MIPS quality measures One must be an outcome measure (or, if no outcome is available, then a high-priority measure) All 6 must be reported by the same method

Quality Measures Submission Methods Claims 50% or more of Medicare Part B patients Registry 50% or more of all patients EHR 50% of all patients CMS Web Interface (groups of 25+) ALL SIX MUST BE SUBMITTED BY THE SAME METHOD

QPP.CMS.GOV

QPP.CMS.GOV

QPP.CMS.GOV

QUALITY MEASURES Claims Reporting 1. Documentation of current medications in the medical record* 2. Diabetes: Hemoglobin A1c (HbA1c) poor control - intermediate outcome 3. Pain assessment and follow up 4. Pneumococcal vaccination status for older adults 5. BMI screening and follow-up plan 6. Influenza immunization 7. Screening for high blood pressure and follow up 8. Tobacco screening and cessation intervention *High-priority measure BMI = body mass index

Six Recommended Measures to Report by Claims (Medicare Part B Patients Only) 1. Documentation of current meds in the medical record* 2. Pneumococcal vaccination status for older adults 3. BMI screening and follow-up plan 4. Influenza immunization 5. Screening for high blood pressure and follow up 6. Tobacco screening and cessation intervention *High-priority measure

How Points for Measures are Assigned (Claims Decile)

Documentation of Current Medications in Medical

Pneumococcal Vaccination Status for Older Adults

BMI Screening and Follow-Up Plan

Influenza Immunization Influenza Immunization

Screening for High Blood Pressure and Follow Up

Tobacco Screening and Cessation Intervention

KEY POINTS You are submitting by claims method, so the patient must be a Medicare Part B Fee for Service patient (not Medicare Advantage, Medicare HMO, etc) You must be seeing them for one of the denominatordesignated codes (essentially an E/M service) You must place the quality measure code on the claim form under Item 24 E/M = evaluation and management

QUALITY MEASURES Registry Reporting 1. Diabetes: Hemoglobin A1c (HbA1c) poor control - intermediate outcome 2. Diabetes: Medical attention for nephropathy 3. Diabetic foot and ankle care, peripheral neuropathy neurologic exam 4. Diabetic foot and ankle care, ulcer prevention examination of footwear 5. Documentation of current meds in the medical record 6. Immunizations for adolescents

QUALITY MEASURES Registry Reporting 7. Functional status change for patients with foot or ankle impairments outcome 8. Pain assessment and follow up 9. Pneumococcal vaccination status for older adults 10. Preventive care and screening: BMI screening and follow up plan 11. Preventive care and screening: Influenza immunization 12. Screening for high blood pressure and follow up 13. Preventive care and screening: Tobacco use: screening and cessation Intervention 14. Preventive care and screening: Unhealthy alcohol use: Screening and brief counseling

Six Recommended Registry Measures (All patients) 1. Diabetic foot and ankle care, peripheral neuropathy neurologic exam 2. Diabetic foot and ankle care, ulcer prevention examination of footwear 3. Documentation of current medications in the medical record* 4. Screening for high blood pressure and follow up 5. Preventive care and screening: Tobacco use: Screening and cessation intervention 6. Preventive care and screening: BMI screening and follow-up plan

QUALITY MEASURES EHR Reporting 1. Diabetes: Foot exam 2. Diabetes: Hemoglobin A1c (HbA1c) poor control (>9%) intermediate outcome 3. Diabetes: Medical attention for nephropathy 4. Documentation of current medications in the medical record* 5. Falls: Screening for future fall risk* 6. Pneumococcal vaccination status for older adults 7. Preventive care and screening: BMI screening and followup plan

QUALITY MEASURES EHR Reporting 8. Preventive care and screening: Influenza immunization 9. Preventive care and screening: Screening for high blood pressure and follow up documented 10. Preventive care and screening: Tobacco use: Screening and cessation intervention

QUALITY MEASURES When choosing quality measures, check minimum case requirements! Most minimum case requirements listed as 20

Advancing Care Information (Think Meaningful Use) In 2017, there are two measure set options for reporting. The option you use to submit your data is based on your electronic health record edition. Option 1: Advancing Care Information Objectives and Measures Option 2: 2017 Advancing Care Information Transition Objectives and Measures You can report the Advancing Care Information Objectives and Measures (Option 1): If you have technology certified to the 2015 edition; or If you have a combination of technologies from 2014 and 2015 editions that support these measures You can report the 2017 Advancing Care Information Transition Objectives and Measures (Option 2): If you have technology certified to the 2015 edition; or If you have technology certified to the 2014 edition; or If you have a combination of technologies from 2014 and 2015 editions

Advancing Care Information (25%) 4 Measures if using 2014 ONC- Certified EHR (Transition-Option 2)

Advancing Care Information (25%) 40% credit just for reporting the base measures Other 60% depends on performance and bonus measures No more clinical decision support rule No more CPOE CPOE = computer provider order entry

Total ACI Score Base Score + Performance Score + Bonus Points

ACI Base Score Base score: 10 points for reporting a measure Base score: Max 40 Need numerator to be 1 for each

MIPS ACI Base 4 Measures (Transition) Protect Patient Health Information (yes/no) MUST BE A YES OR RECEIVE A ZERO FOR ACI Electronic Prescribing At least one permissible prescription written by the MIPS-eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology. Provide Patient Electronic Access Health Information For at least one unique patient seen by the MIPS-eligible clinician: (1) The patient (or the patient s authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS-eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS-eligible clinician's certified EHR technology. Send a Summary of Care For at least one transition of care or referral, the MIPS-eligible clinician who transitions or refers their patient to another setting of care or healthcare provider: (1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.

ACI Performance Score Performance Score: Receive 1-10 points for each measure reported, based on performance of that measure Performance Score: Maximum 70 points

ACI Bonus Points 5 bonus points for reporting to any additional public health or clinical data registry 10 bonus points for achieving one Improvement Activity via CEHRT CEHRT = certified electronic health record technology

ACI Performance and Bonus Measures 1. Provide patient electronic access (additional 10%) 2. Health information exchange (additional 10%) 3. View, download, or transmit (VDT) (up to 10%) 4. Provide patient-specific education (up to 10%) 5. Secure messaging (up to 10%) 6. Medication reconciliation (up to 10%) 7. Immunization registry reporting (0 or 10%) 8. Syndromic surveillance reporting (5% bonus) 9. Specialized registry reporting (5% bonus)

ACI Score 100 or above on ACI = full 25 MIPS points

ACI Total Score Reporting Score + Performance Score + Bonuses = Total ACI Score If earn 100 (or more), get the full 25 MIPS score If earn less than 100, declines proportionately. It is not all or nothing! 50 ACI points means 12.5 MIPS points

Clinical Practice Improvement Activities (15%) List of more than 90 options Choose up to 4 activities if in a group of more than 15 clinicians Choose up to 2 activities if in a group of 15 or fewer clinicians

Clinical Practice Improvement Activities (15%) Medium weight = 10 points High weight = 20 points Activities are double-weighted if practice in a group of fewer than 15 clinicians Score needed for full CPIA credit 40 CPIA points means 15 MIPS points

QPP.CMS.GOV

Clinical Practice Improvement Activities (15%) 1. Registration in your state s prescription drug monitoring program - Medium 2. Implement fall screening & assessment program - Medium 3. Provide 24/7 access to a clinician who has real-time access to patient s medical record - High 4. Assess patient experience of care through surveys, advisory councils, and/or other mechanisms - Medium 5. Use decision support and standardized treatment protocols - Medium 6. Program to send reports back to referring clinician - Medium

Clinical Practice Improvement Activities (15%) 7. Collection and follow-up on patient experience and satisfaction data on beneficiary engagement - High 8. Collection and use of patient experience and satisfaction data on access - Medium 9. Consultation of the prescription drug monitoring program - High 10. Engagement of community for health status improvement - Medium 11. Engagement of patients, family, and caregivers in developing a plan of care - Medium

Clinical Practice Improvement Activities (15%) 12. Engagement of patients through implementation of improvements in patient portal Medium 13. Implementation of condition-specific chronic disease self-management support programs - Medium 14. Implementation of use of specialist reports back to referring clinician or group to close referral loop - Medium 15. Improved practices that disseminate appropriate selfmanagement materials - Medium 16. Use of decision support and standardized treatment protocols - Medium

Annual Registration in the Prescription Drug Monitoring Program Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months. Subcategory Name: Patient Safety & Practice Assessment Activity Weighting: Medium

Cost (0% in 2017) Calculated by claims review, so no additional reporting Higher points for more efficient resource use Not implemented in 2017, but CMS is supposed to give providers this analysis so they can anticipate 2018

APMs Exempt from MIPS payment adjustments Successful participation = 5% bonus and no MIPS adjustment Have to receive certain amount of payments or see certain number of patients through APM

APMs Advanced APMs are those in which clinicians accept risk for providing coordinated, high-quality care

APMA.org/MACRA

MACRA Made Easy Webinar Series MIPS in 2017 Advancing Care Information Quality Performance Category Improvement Activities Performance Category For other MACRA-related Resources visit APMA.org/MACRA APMA.org/MacraWebinars

Resources For more information on Quality measures: https://qpp.cms.gov/mips/quality-measures For more information on CPIA: https://qpp.cms.gov/mips/improvement-activities For more information on Advancing Care: https://qpp.cms.gov/mips/advancing-care-information Quality Payment Program (CMS Web Page): https://qpp.cms.gov

QUESTIONS