CMS Quality Payment Program: Performance and Reporting Requirements

CMS Quality Payment Program: Performance and Reporting Requirements Session #QU1, February 19, 2017 Kristine Martin Anderson, Executive Vice President, Booz Allen Hamilton Colleen Bruce, Lead Associate, Booz Allen Hamilton 1

Speaker Introduction Kristine Martin Anderson, MBA Executive Vice President Booz Allen Hamilton Add Speaker Photo Here Colleen Bruce, JD Lead Associate Booz Allen Hamilton 2

Conflict of Interest Kristine Martin Anderson, MBA Has no real or apparent conflicts of interest to report. Colleen Bruce, JD Has no real or apparent conflicts of interest to report. 3

Agenda Quality Payment Program (QPP) Overview Advanced Alternative Payment Models (Advanced APMs) Merit-based Incentive Payment System (MIPS) Participation Payment Adjustment Composite Performance Score Measure Selection Performance Feedback Next Steps 4

Learning Objectives 1. Review the MIPS quality reporting requirements for EHR users 2. Identify performance thresholds for APM requirements 3. Explain how alternative payment model quality measure sets that do not qualify as a QPP APM (for example, CMS ACO 1's from 2016) align with the MIPS quality measure sets 5

An Introduction of How Benefits Were Realized for the Value of Health IT The QPP advances use of health IT overall by encouraging providers to use EHRs, and also through specific components of the program, such as the Advancing Care Information. The QPP will support all five kinds of value of Health IT. 6

QPP Overview Aims of the QPP: Care improvement through focus on better outcomes, decreased provider burden, and preservation of independent clinical practice Adoption of Alternative Payment Models that align incentives across health care stakeholders Advancement of existing Delivery System Reform efforts The QPP rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS 7

Advanced Alternative Payment Models (Advanced APMs) Advanced APMs allow physicians and other clinicians to deliver coordinated, customized, high-quality care to their patients within a streamlined payment system. Advanced APMs must: Require participants to use CEHRT Provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS Either require that participating APM entities bear risk for monetary losses of a more than nominal amount, or be a Medical Home Model expanded under section 1115A(c) of MACRA 8

Advanced Alternative Payment Models (Advanced APMs) Qualifying APM participants (QPs) are eligible clinicians (ECs) in an Advanced APM who have a certain percentage of patients or payments through an advanced APM. QPs are excluded from MIPS and receive a 5% incentive payment per year beginning in 2019 through 2024. QPs will receive the annual 5% lump-sum bonus based on their Medicare Part B payments from the previous year s claims. This bonus will be in addition to the incentive paid through existing contracts with the Advanced APM. Beginning in 2026, QPs will qualify for a 0.75% increase in your Medicare Part B PFS payments. Two thresholds for the level of participation in Advanced APMs to become a QP: Medicare Option Applicable beginning in payment year 2019 based on Part B payments for covered professional services or counts of patients furnished covered professional services under Part B All-Payer Combination Option Applicable beginning in payment year 2021, utilizes the Medicare Option as well as an EC s participation in Other Payer Advanced APMs 9

Merit-based Incentive Payment System (MIPS) The MIPS program consolidates components of three existing programs to ease clinician burden: PQRS Quality Performance and Improvement Value Modifier Resource Use Meaningful Use Advancing Care Information MIPS adds a fourth component to promote ongoing improvement and innovation in clinical activities Clinical Practice Improvements MIPS offers clinicians the flexibility to demonstrate performance through activities and measures that are most meaningful to their practice 10

Participation Eligible clinicians (ECs) who are not QPs (i.e. EC who does not participate in an APM) must participate in MIPS in 2017 or face a 4% penalty in 2019 MIPS ECs include: Clinicians billing at least $30,000 to Medicare Part B who do not participate in a qualified APM 11

Participation During the 2017 transition year, ECs have four options for participation in the QPP: No Participation Test Participation Partial Participation Full Participation Failure to submit any data in 2017 will result in a 4% negative payment adjustment ECs submitting the minimum amount of 2017 data to Medicare (e.g., one quality measure or one improvement activity at any point in 2017) will avoid the negative payment adjustment (payment adjustment of 0%) ECs who submit data for a 90-day period in 2017 may earn a neutral or small positive payment adjustment (positive payment adjustment up to 4%). ECs submitting a full year of data in 2017 may earn a moderate positive payment adjustment (positive payment adjustment up to 10%). 12

Payment Adjustment Application of payment adjustments under PQRS, VM, and EHR- MU will sunset Dec. 31, 2018 MIPS and APM incentive payments begin January 1, 2019, based on performance in 2017 Under MIPS, eligible clinicians can receive positive, negative or zero payment adjustment APM Participants can receive a 5% incentive payment for 6 years CMS will apply the MIPS payment adjustment at the TIN/National Provider Identifier (NPI) level 13

Payment Adjustment Maximum Adjustments for MIPS through 2022 14

Composite Performance Score To calculate a single MIPS composite performance score, CMS will factor in performance in four weighted categories on a 0-100 point scale: 15

Composite Performance Score To calculate a single MIPS composite performance score, CMS will apply the following weights: Performance Category 2019 2020 2021 Quality 60% 50% 30% Cost 0% 10% 30% Clinical Practice Improvement Activities 15% 15% 15% Advancing Care Information 25% 25% 25% 16

Quality Performance Score MIPS quality measures will be collected January 1, 2017- December 31, 2017 and submitted to CMS by March 30, 2018 for the 2019 payment adjustment Individual ECs, small groups, and specialists may report measures via: Claims Qualified Clinical Data Registries (QCDR) Registries CERT Large groups (25 ECs or more) can report measures using the CMS Web interface EXCEPTION: The CMS Web Interface can only accept Medicare patient quality data. If a group does not have an adequate sample of Medicare patients, they must report using one of the small group reporting methods 17

Quality Performance Score In 2017, individual or small practice ECs have options for reporting quality measures: Failure to report will result in a 4% negative payment adjustment Reporting one quality measure for 90 consecutive days will allow the EC to avoid a negative payment adjustment in FY19 Reporting six quality measures including one outcome measure (or one specialty-specific measure set), for 90 consecutive days will allow the EC to avoid a negative adjustment or gain a small positive adjustment Reporting six quality measures including one outcome measure (or one specialty-specific measure set,) for the full reporting year (January 1- December 31, 2017) may earn the EC a moderate positive payment adjustment Successful participation in an approved APM will produce a moderate positive payment adjustment and an additional 5% bonus 18

Quality Performance Score If the EC chooses to report more than the minimum: MIPS ECs will receive 1-10 achievement points for each scored quality measure based on performance compared to applicable measure benchmarks Minimum case requirements for quality measures are 20 cases, with the exception of the all-cause readmission measure which has a minimum case requirement of 200 cases CMS totals scores for the 6 required quality measures submitted along with bonuses to determine the total Quality Performance Score 19

Quality Performance Score Large groups must register by June 30, 2017 to use the CMS Web Interface for administration of the CAHPS for MIPS survey Groups of 25 or more MIPS-eligible clinicians must report on all 15 measures included in the CMS Web Interface, which align with the MSSP Level 1 Quality Measure Set Large groups must report on the first 248 consecutively ranked beneficiaries in the sample for each measure/module If the sample of eligible assigned beneficiaries is less than 248, then the group must report on 100% of assigned beneficiaries Groups must capture quality performance data for the full calendar year (January 1, 2017-December 31, 2017) The CMS Web Interface submission will occur during an eight-week period following the close of the performance period, and will begin no earlier than January 1 and end no later than March 31 20

Cost Performance Measures CMS does intend to calculate performance on cost measures in 2017, but will provide this information to clinicians in performance feedback Beginning in 2018, the cost performance category contribution to the final score will gradually increase from 0% to 30% 21

Clinical Practice Improvement Most QPP participants will be required to attest that they completed up to four improvement activities for a minimum of 90 days each Groups with 15 or fewer participants or eligible clinicians in a rural or health professional shortage area must attest to completion of two improvement activities for a minimum of 90 days Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model will automatically earn full credit for clinical practice improvement 22

Clinical Practice Improvement Examples of clinical practice improvement activities include: Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes Routine and timely follow-up to hospitalizations, ED visits, and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team After an improvement activity's first year in use, CMS will evaluate the activity to see if and when the activity is suitable for pubic reporting 23

Advancing Care Information MIPS ECs are required to report five measures for the Advancing Care Information Performance Category Reporting on all five required measures will earn the clinician 50%. Reporting on the optional measures will allow the clinician to earn a higher score. For 2017, a bonus score will be awarded for improvement activities that utilize CEHRT and for reporting to public health or clinical data registries. Measure sets will depend on the EC s version of CEHERT (i.e., 2014 or 2015) 24

Advancing Care Information Advancing care information measures include: At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or provider 1. Creates a summary of care record using CEHRT; and 2. Electronically exchanges the summary of care record. 25

Bonus Points Bonus points are available when two or more high priority measures are reported The following categories of measures will qualify for a bonus: Outcomes (2 points) Patient Experience (2 points) Reported appropriate use, patient safety, efficiency, and care coordination measures (1 point) Bonus will not exceed 5% of the total quality score Bonus points are available for using CEHRT systems to capture and report measures 26

Bonus Points Groups participating in the AHRQ Quality Consumer Assessment of Health care Providers and Systems (CAHPS) for MIPS will receive a bonus point In absence of a relevant outcome measure, CAPHS participation meets the requirement to report at least one high priority measure For the performance period, groups participating in the CAHPS for MIPS survey measures must use a CMS approved survey vendor to transmit survey measure data 27

Measure Selection Quality measures will be selected annually through a call for quality measures process, and a final list of quality measures will be published in the Federal Register by November 1 of each year Only measures submitted before June 1 of each year will be considered for inclusion in the annual list for the performance period beginning two years after the measure is submitted CMS will establish an Innovation Center quality measure review process for measures that are not NQF-endorsed or included on the final MIPS measure list 28

Measure Selection The QPP emphasizes the application of outcome-based measures, as well as global measures (e.g., global outcome measures and population-based measures) for purposes of quality performance improvement In future years, CMS hopes to create a balanced portfolio that includes outcome measures and introduces efficiency measures CMS is particularly interested in developing outcome measures for chronic conditions (such as diabetes care and hypertension management) as it is difficult to measure the many factors that affect the care and outcomes of patients with chronic conditions 29

Performance Feedback In the initial years, CMS will provide performance feedback to participating providers on an annual basis In future years, CMS aims provide performance feedback on a more frequent basis, and provide feedback on the performance categories of improvement activities and advancing care information Performance feedback will be made available using a web-based application 30

Next Steps for Providers Empanel and risk adjust patients. Identify highest risk patients and tailor care based on risk level. Standardize care delivery and promote adherence to clinical best practice through the use of clinical decision support BPAs. Monitor bundle utilization and outcomes through the use of analytics dashboards. Review interventions, workflow, and bundle utilization when performance stagnates. Leverage patient portals to change patient behavior for chronic disease management. Select CQMs that will best achieve the goals of the program while improving patient care. 31

Sources 81 FR 77008 Department of Health and Human Services, Centers for Medicare and Medicaid, Executive Summary: Medicare Program; Merit-Based Incentive Program (MIPS) and Alternative Payment Model (APM) Incentive Under Physician Fee Schedule, and Criteria for Physician-Focused Payment Models (October 14, 2016) Frequently Asked Questions: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (December 2016) 32

Questions Questions? Contact Colleen Bruce, Lead Associate, Booz Allen Hamilton Bruce_colleen@bah.com Remind attendees to complete online session evaluation 33