Quality Payment Program Final Rule Year 2: What s Coming in the New Year! Michelle Brunsen and Sandy Swallow December 6, 2017 1 This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW- QIN-D1-12/04/17-2481
Today s Agenda Overview of 2018 Quality Payment Program (QPP) Key changes to the Merit-Based Incentive Payment System (MIPS) for 2018 Retroactive changes for 2017 Eligibility and participation options Timelines and important dates Incentives and penalties Significant Hardship Exceptions Your questions! 2
Quality Payment Program Year 2 Timeline Proposed Rule published 6/30/2017 Final Rule Year 2 released 11/2/2017 Effective January 1, 2018 Comments accepted through 5 pm EST January 2, 2018 Submit electronic comments to http://www.regulations.gov Follow the Submit a comment instructions Refer to CMS-5522-FC when commenting on issues in the Final Rule Refer to CMS-5522-IFC when commenting on issues in the interim final rule 3
Quality Payment Program Year 2 (2018) A Second Year to Ramp Up Build upon the iterative learning of year 1 Prepare for more robust year 3 4
MIPS Eligible Clinicians 2018 MIPS Eligible Clinicians Physicians MD, DO Dentist Podiatrist Optometrist Chiropractor Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse Anesthetists Eligible Clinicians Excluded from MIPS Clinicians at or below the Low Volume Threshold Eligible Clinicians newly enrolled with Medicare aapm Qualified Participants (QPs) aapm Partial QPs who choose not to report Temporary Excluded Credentials Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician or Nutritionist Physical or Occupational Therapist Speech-Language Pathologist Audiologist 5
MIPS Eligible Clinicians 2018 Low-Volume Threshold (LVT) Exclusion and Opt-In Option 6 < $90,000 Medicare Allowable Charges OR < 200 Part B-enrolled beneficiaries Excludes an additional 134k Clinicians Two data runs to determine eligibility Each period Sept. 1 Aug. 31 with 30-day claims run out 1 st period ending in the calendar year 2 years prior to performance year 2 nd period ending in the calendar year 1 year prior to performance year Applied at the submitting entity level: individual or group LVT Opt-in option for 2019 not finalized Concerns CMS may not be ready to operationalize Revisit in 2018 NPRM
MIPS Reporting Options 2018 7
MIPS Reporting Options for 2018 Inclusion of Virtual Groups Additional participation option Solo practitioners and groups of < 10 clinicians come together to participate as a group regardless of location or specialties Qualified non-patient facing clinicians eligible Most MIPS group policies apply Must exceed the LVT to participate Elect to participate and go through an election process Election period Oct. 1 Dec. 31, 2017 Submit application Establish a formal written agreement Resources on QPP website Virtual Group Toolkit Virtual Group Fact Sheet 8
MIPS Incentives and Penalties 2018 9
MIPS Performance Thresholds 2018 Performance Threshold Modest increase to 15 points Allows multiple avenues to exceed. Some examples: Report all Improvement Activities Meet Advancing Care Information base score and submit 1 Quality measure Meet Advancing Care Information base score and submit one medium-weight Improvement Activity Submit 6 Quality measures that meet data completeness criteria Requires more engagement Helps ramp up to more stringent requirements in Year 3 10 Performance Threshold Exceptional Bonus Threshold Exceptional Performance Bonus 2017 2018 Mature 3 15 60 70 70 70-80 $500m 1-10% $500m 1-10% $500m 1-10%
MIPS Submission Mechanisms and Deadlines Only allowed 1 data submission mechanism per performance category Multiple submission mechanism options starting in 2019 Mechanism Deadline Qualified Registry QCDR EHR/Data Submission Vendor March 31 Attestation (ACI and IA) 11 Claims Web Interface March 1 (60 day claims run-off) 8 week submission window between Jan. 2 and Mar. 31 TBD
MIPS Performance Category Weights 2018 Performance Year Quality Cost Advancing Care Information Improvement Activities 2017 60% 0% 25% 15% 2018 50% 10% 25% 15% 2019 30% 30% 25% 15% 2020 30% 30% 25% 15% Complex re-weighting protocols Hardship Exemption Applications can now apply to any/all Categories 12
MIPS Performance Period Requirements 2018 Performance Category Quality Cost Advancing Care Information Improvement Activities Performance Period 1 Full Year 1 Full Year 90-Day Minimum to 1 Full Year 90-Day Minimum to 1 Full Year 13
Performance Category Requirements 2018 14
MIPS Quality Performance Category 2018 Quality Measure Submission Requirements 6 measures including 1 Outcome or High Priority Measure Fewer than 6 measures? Partial credit awarded for partial submission Measure groups still available Claims/Qualified Registry Only Eligible Measure Applicability (EMA) the new MAV test Or Web Interface Submission (groups 25 or more) If a quality submission is made 1 Administrative Claims Measure: All Cause Readmissions Medicare Calculates from claims Only if Group size >15 and > 200 attributed hospitalizations 15
MIPS Quality Performance Category 2018 Data Completeness > 60% reporting rate required All payer data for: (at least one measure must contain data on one Medicare patient) Registry QCDR EHR Medicare beneficiary data only for: Claims Web Interface Finalized the same criteria for 2019 16
MIPS Quality Performance Category 2018 Expanded the Measure Stratification Classes Class 1 Complete: 3-10 points 60% reporting rate 20 case minimum Has a benchmark Class 2 < 20 Cases or No Benchmark: 3 points Class 3 < 60% Reporting Rate: 1 point (3 for small practices) 17
MIPS Quality Performance Category 2018 New Scoring Language Measure Achievement Points Total Measure Achievement Points (TMAP) Measure Bonus Points Total Measure Bonus Points (TMBP) Total Available Measure Achievement Points (TAMAP) Scoring equation (TMAP + TMBP)/TAMAP = Total Quality Performance Category Score Quality Performance Category Percent Score when expressed as a percent 18
MIPS Quality Performance Category 2018 Topped Out Measures Defined: Majority of clinicians near top of the distribution Little room for improvement Little basis for comparison 45% of measures are topped out 6 measures identified 4-year lifecycle protocol 19
MIPS Quality Performance Category 2018 4-year lifecycle years 1. Identify as TOM 2. Special scoring applied 7-point Cap 3. Consider removal through rulemaking 4. Removal decisions made through rulemaking Measure # Preoperative Care: Selection of Prophylactic Antibiotic Melanoma: Overutilization of Imaging Studies in Melanoma Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis Image Confirmation of Successful Excision of Image-Localized Breast Lesion Optimizing Patient Exposure to Ionizing Radiation: 21 224 23 262 359 Chronic Obstructive Pulmonary Disease (COPD): Inflated Bronchodilator Therapy 52 20
MIPS Quality Performance Category 2018 CAHPS for MIPS Voluntary option for groups CAHPS for ACOs required for ACOs Must use an approved vendor Counts for 1 quality measure 1 Patient experience measure (2 bonus points) 1 High Priority Measure Survey period is minimum of 8 weeks between Nov. 1 and Feb. 28 Must self-nominate by June of Performance Year 21
MIPS Quality Performance Category 2018 Quality Category Improvement Bonus Full current year participation required Comparison only to previous year data at category level If previous year Quality score < 30, then 30% is used as comparison Will convert data for comparison if entities do not match Calculated as Capped at 10% points Category Percentage Scores without Bonus Points Based on statistically significant changes (This Yr. Score Last Yr. Score/Last Yr.) 22
MIPS Cost Performance Category 2018 Cost Category Dynamics 10% weight; 30% 2019 2 Cost Measures Total per capita costs for all attributed beneficiaries Attributed to the Provider/Practice source of Plurality of Primary Care Services All Part A and Part B costs 20 Case Minimum Medicare Spending per Beneficiary (Inpatient) Attributed to the Provider/Practice source of the Plurality of Inpatient Services Costs included 30 days pre-admission to 30 days post-admission 35 Case Minimum NO Episode Measures 23
MIPS Cost Performance Category 2018 Cost Category Improvement Bonus Measure level analysis Must have data in prior year Same measure Same entity level Both sets meet data sufficiency minimums Can only be positive Max of 1% point Cost improvement score = (measures with significant improvement-measures with significant decline)/measures) *1% point (Cost Achievement Points/Available Cost Achievement Points) + (Cost Improvement Score) = (Cost Performance Category Percent Score) 24
MIPS Advancing Care Information Performance Category 2018 ACI Category Dynamics Maintains a 25% weight Scoring the same: Base + Performance + Bonus Reporting period: minimum of continuous 90- day up to full year Allow use of 2014 or 2015 CEHRT or combination 10% point bonus for exclusive use of 2015 CEHRT Rule is silent on CEHRT requirements for 2019 25
MIPS Advancing Care Information Performance Category 2018 ACI Category Exceptions Hospital-based clinicians Non-patient facing clinicians Ambulatory Surgery Center (ASC)-based clinicians 26
MIPS Advancing Care Information Performance Category 2018 ACI Category Clarification/Corrections Meaningful user = any provider with an ACI Category Score > 75% Timely for Patient Access = 4 business days after data available to EC Applied Retroactively to 2017 VDT action clarified the actions in the measure as being taken by the patient or the patient-authorized representatives rather than the MIPS EC Summary of Care document can be generated by any support staff, not just clinician Minor verbiage corrections to: Patient Access, Patient Education, Health Information Exchange & Medication Reconciliation 27
MIPS Advancing Care Information Performance Category 2018 ACI Category Clarifications/Corrections Same minimum for any reporting period 90 to 365 days Specific exceptions to e-prescribing and HIE Base Point Measures - Retroactive to 2017 Generate fewer than 100 prescriptions in a reporting period Generate fewer than 100 outgoing transitions of care in a reporting period Receive fewer than 100 incoming TOC in a reporting period 2015 CEHRT measures Applies to never-before-encountered patients 28
MIPS Advancing Care Information Performance Category 2018 ACI Category Dynamics Reporting to Public Health Agency (PHA) or Clinical Data Registry (CDR) 10% points for electronically reporting to any single PHA or CDR Bonus score of 5% points for reporting to at least one additional PHA or CDR Bonus registry must be different than the performance registry 29
MIPS Improvement Activities Performance Category 2018 IA Category Dynamics Maintains 15% weight Finalized more activities (112) and changes to existing activities 30 CEHRT IA measures available (extra credit in ACI) Performance period minimum of continuous 90- day up to including full year Continue double points for small practices, rural or HPSA and non face-to-face 30
MIPS Improvement Activities Performance Category 2018 IA Category PCMH Adjustment Language adjusted to include status of Recognized as equivalent to Certified 50% threshold for number of practice sites within TIN with PCMH recognition for full credit Must attest to receive credit 31
MIPS Scoring Additions for 2018 New Bonus opportunities! Improvement Bonus Quality: applies to category-level (1-10% points) Cost: applies to measure-level (1% point) Applies at Final Score Level Add 5-point Small Practice bonus (< 15 clinicians) Add 5-point Complex Patient bonus (dual eligibility ratio and HCC risk score) Based on Risk Score year prior to performance period Patient attribution overlapping performance year (Sept.- Aug.) Electronic Flow Limit to 10% of denominator Scoped for the first 2 years only All but Claims Submission Measure 32
MIPS Hardship Exceptions Significant Hardship Exception by Application Due by December 31 st starting in 2017 Applicable to Individuals, Groups, Virtual Groups Expanded to apply to any one or more performance categories Results in Re-weighting 5 year limitation removed Supported reasons for approval include: Significant hardship for small practice Insufficient internet connectivity Extreme and uncontrollable circumstances Lack of control over the availability of CEHRT Lack face-to-face patient interaction Decertified EHR technology Good faith effort to migrate to CEHRT Annual Renewal limitation to 5 years 33
Significant Hardship Exceptions Automatic Extreme and Uncontrollable Circumstance Policy Interim (emergency) final rule Automatic exception without having to submit an application The Hurricanes Harvey, Irma and Maria Rule Northern California Wildfires Disaster Exceptions/Exemptions Final Score = Performance Threshold Data accepted and scored if submitted 34
MIPS Special Provider Populations for 2018 Automatic Identification CMS will automatically identify the following status with access through QPP website: Low Volume Small Practice Rural and HPSA Clinicians and Practices Non-Patient Facing Clinicians and Practices Hospital Based Clinicians and Practices Ambulatory Surgical Center Based Clinicians and Practices Facility-Based Clinicians and Practices (not available until 2019) Extreme and Uncontrollable Circumstances 35
MIPS Special Provider Populations for 2018 Small Practices Status Applicable to: Eligibility for technical assistance Improvement Activity requirement ACI Hardship Exception Small Practice Bonus Low Volume Exclusion if meet criteria Virtual Group option if meet criteria 3 Point floor on Quality Measures 36
MIPS Special Provider Populations for 2018 Special Status Applicable to: Special Status Activity Rural and HPSA Improvement Activity Points doubled Non-Patient Facing Hospital-Based ASC-Based Improvement Activity Points doubled Advancing Care Information (ACI) Automatically reweighted Scored if submitted Advancing Care Information (ACI) Automatically reweighted Scored if submitted Advancing Care Information (ACI) Automatically reweighted Scored if submitted 37
Hierarchy for Final Score More than one Final Score is associated with a TIN/NPI? 38 Example TIN/NPI has more than one APM Entity final score TIN/NPI has an APM Entity final score and also has an individual score TIN/NPI has an APM Entity final score that is not a virtual group score and also has a group final score TIN/NPI has an APM Entity final score and also has a virtual group score TIN/NPI has a virtual group score and an individual final score TIN/NPI has a group final score and an individual final score, but no APM Entity final score and is not in a virtual group Final Score Used to Determine Payment Adjustments The highest of the APM Entity final scores APM Entity final score APM Entity final score APM Entity final score Virtual group score The highest of the group or individual final score
Hierarchy for Final Score No Final Score is associated with a TIN/NPI? MIPS EC (NPI1) TIN A/NPI 1 90 TIN B/NPI 1 TIN C/NPI 1 70 Performance Period Final Score N/A (NPI 1 was not part of TIN C during the performance period) TIN/NPI Billing in MIPS Payment Year (yes/no) Yes (NPI 1 is still billing under TIN A in the MIPS payment year) No (NPI 1 has left TIN B and no longer bills under TIN B in the MIPS payment year) Yes (NPI 1 has joined TIN C and is billing under TINC in the MIPS payment year) Final Score Used to Determine Payment Adjustment 90 N/A (No claims are billed under TIN B/NPI 1) 90 (No final score for TIN C/NPI 1. Use the highest final score associated with NPI 1 from the performance period) 39 Table 31; page 778
Continue the Dialogue CMS wants to hear from you! How to comment on the Final Rule: Electronically through Regulations.gov Regular mail Express/overnight mail Hand or courier Submit comments by Jan. 2, 2018 QPP Final Rule Year 2 40
Takeaways for You! Create a strategy to manage Cost in 2018 If you are in a small practice, check the revised lowvolume thresholds and learn more about virtual groups before deadline. Understand the changes to the categories/weighting, the increase in minimum participation to avoid a penalty, the new data completeness threshold and more. Plan to continuously improve. Scores in the 70-80 range may not exceed the performance threshold in the future. Reach out to Telligen QIO or SURS for assistance 41 CMS continues to support these programs
THANK YOU! Telligen Sandy Swallow 515.223.2105 sswallow@area-d.hcqis.org Michelle Brunsen 515.453.8180 mbrunsen@telligen.com Websites www.telligenqinqio.com www.telligenqpp.com www.qpp.cms.gov 42