MACRA Made Easy for 2018

MACRA Made Easy for 2018 A presentation on Merit Based Incentives by QVHSystems TM Michael Sexton M.D. Chief Executive Officer, QVHSystems Dr. Sexton brings his 40 years of experience as a physician practicing accountable care and physician leader at the state and national levels to lead QVH Systems. Dr. Sexton understands the need for innovative, affordable solutions for physicians and other health professionals faced with the transformation to value-based payment. msexton@qvhsystem.com 1

QVHSystems TM Catherine I. Hanson Chief Strategy Officer, QVHSystems Catherine I. Hanson is a nationally recognized healthcare attorney and accomplished advocate for physicians and other healthcare professionals. Ms. Hanson has concentrated her practice on helping physicians navigate the changes required by the evolving health care delivery and payment system and understands how to assist clients develop appropriate organizational strategies, aligned with their goals and values. She is also skilled at navigating the complex interpersonal, political and regulatory environments required to achieve success in the current healthcare environment. chanson@qvhsystem.com MACRA Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), commonly called the Permanent Doc Fix, is a United States statute. It changes the payment system for doctors who treat Medicare patients. It revises the Balanced Budget Act of 1997. It was the largest scale change to the American health care system following the Affordable Care Act ("ObamaCare") in 2010. 2

MACRA Under MACRA, the Secretary of the Department of Health and Human Services (DHHS) is tasked with implementation of a Merit Based Incentive Payment System (), an incentive program that consolidates three incentive programs into one, for eligible physicians. The legislation also allows for Advanced Alternative Payment Models (AAPMs). MACRA Helping physicians find their way 3

MACRA Overview Charting a practice specific path Avoid the penalty Maximize potential bonus Quality Advancing Care Information (ACI) Improvement Activities Cost (Resource use) Complicating factors Performance Reporting MACRA Overview Merit-based Incentive Payment System Started January 1, 2017 for 2019 payment year Consolidates PQRS, MU and VM Phases in penalties and bonuses: 4% 5% 7% 9% 2019 2020 2021 2022 and beyond QVHSYSTEMS TM Copyright September 2017, QVH Systems, LLC All rights reserved. 4

MACRA Overview Payment Updates Zero for 2020-2025 but +5% incentive payment if in an Advanced APM (2019-2024) 2026 and beyond, 0.75% if in APM, 0.25% for all others MACRA Overview Profiles physicians and other Eligible Clinicians (ECs) on 4 domains: Quality Advancing Care Information (ACI - HIT use) Improvement Activities Cost (Resource Use) Publishes each clinician s results on Physician Compare 5

MACRA Overview 15Point threshold in 2018 Imposed penalty on every clinician who scores below the median except in 2018 where threshold is set at 15 points Winners 1 ST Those who score above the threshold get a bonus Budget neutrality applies base bonus pool is funded by those who pay penalties Budget neutrality capped at a scaling factor of 3 (base bonus cannot exceed 300% of the maximum penalty) 6

Winners 1 ST Additional $500 million/yr. for those with exceptional performance - those performing from the 25th percentile above the threshold (70 points in 2018) 2020 Theoretical maximum bonus = 25% (15% (3x5%) + 10% Exceptional performance) Losers LAST Those who score below the threshold get a penalty 2020 penalty = 5% Medicare fee schedule reduction Future years Penalties scale up to 9% by 2022 Full penalty applies to everyone in the bottom quartile below the threshold 7

Details adjustment applied to all Part B services CMS predicting nearly $150 million will be transferred from the losers to the winners in 2020 VM experience suggests early adopters may receive significant bonuses 8

Avoiding the 5% Penalty? Child s Play Be exempt Have 200 Medicare fee-for-service patients or Receive $90,000 in Medicare Part B revenue 9

Avoiding the 5% Penalty? Child s Play If you are not exempt, you need only score 15 points Complete the Improvement Activities, or If you are a solo or small practice, report 4 Quality measures once for 4 patients, or Achieve the ACI base score and report 3 Quality measures once for 3 patients (or none for small practices) and Report by the March 31, 2019 deadline Timeline Don t wait til the last minute 10

2020 Payment Adjustments Adjustment Factor + Additional Adjustment Factor ADJUSTMENT FACTOR Performance Threshold = 15 Adjustment Factor FINAL SCORE ADJUSTMENT FACTOR Future Payment Adjustments Performance Threshold = 60 Adjustment Factor + Additional Adjustment Factor Adjustment Factor COMPOSITE PERFORMANCE SCORE Illustration example of Adjustment Factor based on Composite Performance Scores (CPS) QVHSYSTEMS TM Copyright September 2017, QVH Systems, LLC All rights reserved. 11

Practice Expense Inflation THE GAP (Why you can t settle for avoiding the penalty.) 31% 24% 16% 9% 2% 0.5% 0.5% 0% 0% 0% 0% 0% 0% Practice Cost Increase Compounded Fee Schedule Adjustment Stakes Are High! Not just Medicare LAST Half will lose each year s Marathon can you afford to sit out a year of training? All patients and payers can see your scores Would you pick a 3 or an 83 Commercial payers aren t far behind 12

Maximizing Bonus Make a plan Pick the quality measures you will do best on Pick a reporting mechanism claims, registry or EHR CMS Web Interface or QCDR alternatives Understand what s required for ACI Pick your improvement activities Decide whether to report as a group Maximizing Bonus Perform on Quality for the full year and for 90 days for ACI and Improvement Activities Report on all required measures and bonus opportunities by the 3/31/2019 deadline 13

Group Reporting Must report and be scored as a group across all 4 categories Each Eligible Clinician (EC) gets the same score based on group s aggregated performance Same fee schedule adjustment applied to all 2020 claims Cannot use Claims-based Quality Measures Groups of 25 can use the CMS Web- Interface (6/30/2018 registration deadline) Individual Reporting Each EC must report separately Each EC gets a fee schedule adjustment applied to all 2020 claims based on his or her individual score Can use Claims-based Quality Measures Cannot qualify for unless individual practice exceeds low-volume threshold 14

Reporting Option Pros & Cons Group Reporting Pros Less administrative burden Less internal divisiveness Can include PTs, etc. for education Participation and Bonus opportunity for individual EC s below the low-volume threshold Group Reporting Cons Can t tailor measures to different specialties Can t use claims to report Quality 2018 50 PERCENT Measure Name Measure Type Submission Method Measure title 1 Outcome (or interim outcome) measure Points Based on Performanc e Total Possible Points Potential High Priority Bonus points (3-10) 10 0 (required) 1 Measure title 2 High priority measure (3-10) 10 0 (required if 1 outcome is N/A) Measure title 3 Outcome or patient experience measure (3-10) 10 2 1 Measure title 4 High priority measure (3-10) 10 1 1 Measure title 5 Measure type (3-10) 10? 1 Measure title 6 Measure type (3-10) 10? 1 All-cause Hospital Readmission Claims no data submission None (3-10) 10 N/A N/A Total? 70?? Potential CEHRT Bonus points Cap applied to Bonus Categories (10% each x total possible points) (up to 7) (up to 7) Total with high priority and CEHRT Bonus? (up to 84) 15

Maximizing Quality Score Pick all required measures If < 6 measures available, report on all available measures (in your submission method - at least 1) Each measure will be more heavily weighted/fewer potential bonus points) STEP 1 Consider reporting on > 6 measures (only highest 6 counted including at least 1 mandatory outcome/high priority measure) STEP 2 Maximizing Quality Score Pick measures where you ll excel 1-10 points for each scored measure For > 1, (> 3 for solo/small practices) you must report On at least 60% of your patients, regardless of payer (except claims/wi) For the full year A minimum of 20 cases A measure that has a benchmark Only 1 submission method (except CAHPS) 16

Controlling High Blood Pressure Measure ID 236 Submission Method Measure Type Claims Process 57.69-63.44 EHR Process 50.00-55.39 Registry/ QCDR Process 51.00-58.20 Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Topped Out 63.45-68.28 55.40-59.72 58.21-63.56 68.29-72.78 59.73-63.59 63.57-68.27 72.79-77.06 63.60-67.38 68.28-72.40 77.07-81.47 67.39-71.00 72.41-76.69 81.48-86.75 71.01-75.33 76.70-82.75 86.76 93.42 75.34 80.89 82.76 91.06 >= 93.43 No >= 80.90 No >= 91.07 No Decile Below Decile 3 Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Number of Points Assigned for the 2017 Performance Period 3 points 3-3.9 points 4-4.9 points 5-5.9 points 6-6.9 points 7-7.9 points 8-8.9 points 9-9.9 points 10 points Maximizing Quality Score STEP 3 Take advantage of bonus points High priority measures 2 points for each additional outcome or patient experience measure over required minimum 1 point, for each additional patient safety, care coordination, efficiency or appropriate use measure over required minimum Capped at 10% of potential performance score (7 points if 70 points possible) Electronic end-to-end reporting 1 point for each measure reported electronically (not claims) 17

Maximizing Quality Score Report on performance for the full year Improvement points Assuming you at least test reported in 2017, you fully report in 2018 and your score improves, you can improve your score up to 10%. STEP 4 Final Quality Score Total points earned/total points possible (not counting bonus or improvement points),+ bonus and improvement points, capped at 100 points ACI 2018 25 PERCENT Advancing Care Information (HIT Activity) 2014 CEHRT Complete HIPAA Security Risk Analysis and any necessary remediation Base Score Performance score HIT category score Required Y Eprescribing Report required None Provide Patient Access Report required Up to 20 View, download or transmit PHI Not required Up to 10 Patient-Specific Education Not required Up to 10 Secure Messaging Not required Up to 10 Health Information Exchange Report required Up to 20 Medication Reconciliation Not required Up to 10 Report to an Immunization, Syndromic Surveillance Not required 10 points or other Specialized Registry Bonus points (up to 20) Report to one or more additional public health or clinical data registries 5 points Use CEHRT to perform improvement activities 10 points Total Potential ACI points 50 points 105 points 100 points Total Potential ACI category score 12.5 points 12.5 points 25 points None 18

Maximizing ACI score Achieve the base score Achieve at least 50 points for performance Report on optional measures in addition to the required measures if they will generate points Perform all activities at least some of the time Take advantage of bonus points Report to a second public health registry 5 points Perform an improvement activity using CEHRT 10 points Use 2015 CEHRT only 10 points Perform for at least 90 days and report as required Improvement Activities 2018 15 PERCENT Activity Name Subcategory Points Earned Potential Points PCMH or other recognized patient-centered practice 40 40 APM participation maximum maximum Activity 1 high priority 20 20 Activity 2 medium priority 10 10 Activity 3 medium priority 10 10 Totals [total] 40 19

Maximizing Improvement Activities score Pick activities that generate the required points (20 or 40) Pick activities that you will be able to accomplish Choose one that also generates ACI bonus points if feasible Perform for at least 90 days and report as required Cost (Resource Use) 2018 10 PERCENT Measure Name Cases AVG $ Cost Median $ Cost Points Awarded Measure 1 TCPP (20) 10 Measure 2 MSPB (35) 10 Total Performance Score Improvement Score Total score Total 10 earned/total # of measures Total 01 earned/total # of measures Total earned/ total # of measures Total Possible 10 Note: Points based on decile of risk adjusted, standardized cost. Total score will be the average of all individual measure scores. 20

Maximizing Cost score Obtain and study your QRUR and sqrur Look for opportunities to be more efficient Avoid unnecessary hospitalizations and SNF days Increase medication adherence Increase patient engagement Maximize prevention Learn how Medicare risk adjusts payments and quality scores ICD coding as important as CPT coding Do you know which diagnoses have RAF value? Improvement points = up to 10% 2018 Score Domain Weight Possible points Earned points Potential score Earned score Quality 50% 60-70 + bonus pts 50 HIT-Advancing Care 25% 155 25 Information Clinical Practice 15% 40 (20) 15 Improvement Resource Use 10% 10x (number of 10 scored measures Bonus Points Small Practice Bonus 5% 5 5 Complex Patient Bonus 5% 5 5 Total 100% 100 21

Complications Exemptions Low-volume threshold $90,000 Medicare Part B allowed changes or 200 Part B Medicare beneficiaries New to Medicare Never enrolled in PECOS or submitted Medicare claims Not Eligible not an MD, DO, DPM, OD, DDS, DC, PA, NP, CPNA or other nurse specialist Qualifying or Partially Qualifying APM Participants Complications Modifications Specialty Non-patient facing 100 patients-facing encounters For group 75% of group s NPIs qualify as non-patient facing Hospital-Based 75% of services provided in POS 19, 21, 22 or 23 ASC-Based 75% of services provided in POS 24 Small practice < 16 clinicians 22

Complications Modifications Rural or HPSA No say over HIT No internet EHR? If yes, 2014 or 2015 certified PCMH or other patient-centered practice Etc. Next Steps After you complete your Plan. 23

Reporting to CMS STEP 1 Once you have decided what quality measures and the other activities you will track, you have 2 more decisions to make: What performance reporting period to use How you are going to report your performance to CMS Choosing a reporting period For 2018, to receive more than minimum scores, you must report for Quality for the full year and ACI and Improvement activities for at least 90 consecutive days STEP 2 Different reporting periods for each category are OK. Many practices may do best by selecting October 1- December 31 for the ACI and Improvement Activity categories. 24

Choosing a reporting option 3 principle issues: Cost Administrative burden Likely result STEP 3 4 potential reporting options, depending on the category: EHR vendor Qualified Clinical Data Registry (QCDR) Qualified Registry Direct to CMS (Claims, CMS Web- Interface, Attestation) Alternative APMs MACRA s other path Alternative Payment Models 25

ACO An Accountable Care Organization (ACO) ties payments to quality metrics and the cost of care. An ACO consists of a group of health-care practitioners who agree to be accountable to patients and third-party payers for the quality, appropriateness and efficiency of their services. Medicare Shared Savings Program (MSSP) ACOs agree to be accountable to CMS for the quality, cost, and overall care of Medicare beneficiaries. MSSP-ACO Benefits No downside risk and opportunity for performance bonus Stay where you are, with your current EHR Fraud and abuse, antitrust and liability protections Continue or expand Medicare FFS revenue Improve the quality of care for your patients Position yourself for the future Significant Assistance 26

MSSP-ACO Assistance Without ACO Must report on all 3 performance categories Must report quality performance for 60% of all patients Must complete and report on improvement activities With ACO Only report 1 performance category - ACI Report on only your share of random sample of the ACO s Medicare patients selected by CMS ACO participation completes improvement activity obligation Subject to the Cost category Specialists generally must report on 6 quality measures Exempt from the Cost category Specialists only subject to the Web-Interface measures Advanced Alternative Payment Models (AAPMS) Additional AAPM benefits for 2019-2024 Not subject to 5% bonus on prior year s estimated aggregate payment amounts Paid in lump sum at the beginning of the year This bonus is paid on Part B FFS payments only Bonus does not impact shared savings calculations 27

Advanced Alternative Payment Models (AAPMS) Services must be provided through an eligible alternative payment entity which: Requires use of CEHRT Provides incentives based on quality measures comparable to measures Bears more than nominal financial risk Exceptions: Medical Homes Physician-Focused Payment Models APM Thresholds for 5% Bonus (Qualified Participants (QPs)) Medicare only 2019-2020 25% of revenue 2021-2022 50% of revenue 2023 75% of revenue All payers 2021-2022 50% all payer revenue + 25% Medicare 2023 75% all payer revenue + 25% Medicare 28

The Merit-Based Incentive Payment System () Navigator is an on-line tool that makes it easy to develop a plan for success. By automating the process of planning for implementation at the individual clinician and practice level, the Navigator eliminates the substantial expense that would otherwise be incurred trying to understand and then figuring out how to respond. The tool allows clinicians and their practice administrators to focus their resources on making a successful transition to this new payment system the steps required to perform well on the Itinerary/Plan they create rather than on struggling to decipher complex regulatory requirements. The Advanced Integrated Registry (AIR ) is a Centers for Medicare and Medicaid (CMS) approved Qualified Registry designed to help Eligible Clinicians do well. Supporting all three reportable categories - Quality, Advancing Care Information and Improvement Activities - the AIR is an affordable, flexible tool which accepts uploads of data from claims, standard HL7 EHR exports, spreadsheets and web-form. A workflow tool, AIR makes it easy to 1) identify patients who are likely qualified for each measure, 2) learn the steps necessary to fill gaps and 3) record success. 29

The ACE Portal provides information physicians, Medical Directors and other members of the care team need at the point of care for coordinating care and optimizing treatment. The tool displays the information clinicians need at the point of care, makes secure communications easy and provides the analytics required to allow clinicians to better manage their patient population. Questions 30

msexton@qvhsystem.com Michael Sexton M.D. Chief Executive Officer, QVHSystems chanson@qvhsystem.com Catherine I. Hanson Chief Strategy Officer, QVHSystems QVHSYSTEMS TM Copyright September 2017, QVH Systems, LLC All rights reserved. 31

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