MACRA Implementation: A Review of the Quality Payment Program

MACRA Implementation: A Review of the Quality Payment Program Neal Logue, Kirk Sadur Centers for Medicare and Medicaid Services, Region IX, September 15, 2017

Disclaimer This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide..

Objectives for today Overview of CMS Priorities - Shifting from Volume to Value-Based payments - Program alignment and streamlining Health System Transformation: MACRA 2015 - Review of the Medicare Access and CHIP Reauthorization Act - The Quality Payment Program Final Rule Key updates and resources - Options for participation in 2017 - Opportunities for technical support 3

Key CMS Priorities in health system transformation 4

Origins of the Quality Payment Program: MACRA Bipartisan Legislation: the Medicare Access and CHIP Reauthorization Act, 2015 Increases focus on quality of care delivered Clear intent that outcomes needed to be rewarded, not number of services Shifts payments away from number of services to overall work of clinicians Moving toward patient-centric health care system Replaces Sustainable Growth Rate (SGR) SGR ELIMINATED BY MACRA 5

Medicare Payments Prior to MACRA Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. Services provided Medicare Fee Schedule Adjustments Final payment to clinician Physician Quality Reporting Program (PQRS) Value-Based Payment Modifier Medicare EHR Incentive Program 6

MACRA changes how Medicare pays clinicians. The Quality Payment Program policy will reform Medicare Part B payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system Services provided Medicare Fee Schedule Adjustments Final payment to clinician 7

https://qpp.cms.gov 8

The Timeline for the Quality Payment Program 2017 https://qpp.cms.gov 9

Quality Payment Program Strategic Goals Improve beneficiary outcomes Enhance clinician experience Increase adoption of Advanced APMs Maximize participation Improve data and information sharing Ensure operational excellence in program implementation Quick Tip: For additional information on the Quality Payment Program, please visit QPP.CMS.GOV 10

The Quality Payment Program The Quality Payment Program policy will: Reform Medicare Part B payments for more than 600,000 clinicians Improve care across the entire health care delivery system Clinicians have two tracks to choose from: 14

Introduction to the Merit-based Incentive Payment System (MIPS) 12

What is the Merit-based Incentive Payment System? Combines legacy programs into single, improved reporting program PQRS VM EHR Legacy Program Phase Out Last Performance Period PQRS Payment End 2016 2018 13

What is the Merit-based Incentive Payment System? Performance Categories Quality Cost Improvement Activities Advancing Care Information Moves Medicare Part B clinicians to a performance-based payment system Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice Reporting standards align with Advanced APMs wherever possible 14

When Does the Merit-based Incentive Payment System Officially Begin? Performance year submit Feedback available adjustment 2017 Performance Year Performance: The first performance period opens January 1, 2017 and closes December 31, 2017. During 2017, you will record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can provide care during the year through that model. March 31, 2018 Data Submission Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, 2018. In order to earn the 5% incentive payment for participating in an Advanced APM, just send quality data through your Advanced APM. Feedback January 1, 2019 Payment Adjustment Feedback: Medicare gives you feedback about your performance after you send your data. Payment: You may earn a positive MIPS payment adjustment beginning January 1, 2019 if you submit 2017 data by March 31, 2018. If you participate in an Advanced APM in 2017, then you could earn 5% incentive payment in 2019. 15

Who Participates in the Merit-based Incentive Payment System? 16

Eligible Clinicians: Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients a year. Quick Tip: Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function. These clinicians include: Physicians Physician Assistants Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetists 17

Who is excluded from MIPS? Clinicians who are: Newly-enrolled in Medicare Enrolled in Medicare for the first time during the performance period (exempt until following performance year) Below the low-volume threshold Medicare Part B allowed charges less than or equal to $30,000 a year OR See 100 or fewer Medicare Part B patients a year Significantly participating in Advanced APMs Receive 25% of your Medicare payments OR See 20% of your Medicare patients through an Advanced APM 21

Eligibility Scenario BILLING $30,000 100 To be eligible for the Quality Payment Program, a clinician must bill more than $30,000 AND see more than 100 Medicare beneficiaries. Quick Tip: And is the key to eligibility In the example provided in this incident where a clinician billed $29,000 and saw 101 patients, this clinician would be EXEMPT from the program because the clinician did not bill more than $30,000. BILLING $29,000 + = 101 EXEMPT From the Quality Payment Program 19

Non-Patient Facing Clinicians Non-patient facing clinicians are eligible to participate in MIPS as long as they exceed the low-volume threshold, are not newly enrolled, and are not a Qualifying APM Participant (QP) or Partial QP that elects not to report data to MIPS The non-patient facing MIPS-eligible clinician threshold for individual MIPS-eligible clinicians is < 100 patient facing encounters in a designated period A group is non-patient facing if > 75% of NPIs billing under the group s TIN during a performance period are labeled as non-patient facing There are more flexible reporting requirements for non-patient facing clinicians 20

How do Eligible Clinicians Participate in the Merit-based Incentive Payment System? 21

Pick Your Pace for Participation for the Transition Year Participate in an Advanced Alternative Payment Model Test Pace MIPS Partial Year Full Year Some practices may choose to participate in an Advanced Alternative Payment Model in 2017 Submit some data after January 1, 2017 Neutral or small payment adjustment Report for 90-day period after January 1, 2017 Small positive payment adjustment Fully participate starting January 1, 2017 Modest positive payment adjustment Not participating in the Quality Payment Program for the Transition Year will result in a negative 4% payment adjustment. 22

MIPS: Choosing to Test for 2017 Submit minimum amount of 2017 data to Medicare Avoid a downward adjustment You Have Asked: What is a minimum amount of data? 1 Quality Measure OR 1 Improvement Activity OR 4 or 5 Required Advancing Care Information Measures 26

MIPS: Partial Participation for 2017 Submit 90 days of 2017 data to Medicare May earn a positive payment adjustment So what? - If you re not ready on January 1, you can start anytime between January 1 and October 2 Need to send performance data by March 31, 2018 27

MIPS: Full Participation for 2017 Submit a full year of 2017 data to Medicare May earn a positive payment adjustment Best way to earn largest payment adjustment is to submit data on all MIPS performance categories Key Takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted. 28

Individual vs. Group Reporting OPTIONS Individual 1. Individual under an NPI number and TIN where they reassign benefits Group 2. As a Group a) 2 or more clinicians (NPIs) who have reassigned their billing rights to a single TIN* b) As an APM Entity * If clinicians participate as a group, they are assessed as group across all 4 MIPS performance categories 26

Get your Data to CMS Individual Group Quality QCDR (Qualified Clinical Data Registry) Qualified Registry EHR Claims QCDR (Qualified Clinical Data Registry) Qualified Registry EHR Administrative Claims CMS Web Interface (groups of 25 or more) CAHPS for MIPS Survey Advancing Care Information Attestation QCDR Qualified Registry EHR Vendor Attestation QCDR Qualified Registry EHR Vendor CMS Web Interface (groups of 25 or more) Improvement Activities Attestation QCDR Qualified Registry EHR Vendor Attestation QCDR Qualified Registry EHR Vendor 27

Group Registration Registration is required for eligible clinicians participating as a group that wish to report via: Web Interface CAHPS for MIPS survey Group registration closes on June 30, 2017. 28

Submission Methods: Helpful Information Submission Mechanism Qualified Clinical Data Registry (QCDR) Qualified Registry Electronic Health Record (EHR) Attestation CMS Web Interface Claims How does it work? A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. Each QCDR typically provides tailored instructions on data submission for eligible clinicians. A Qualified Registry collects clinical data from an eligible clinician or group of eligible clinicians and submits it to CMS on their behalf. Eligible clinicians submit data directly through the use of an EHR system that is considered certified EHR technology (CEHRT). Alternatively, clinicians may work with a qualified EHR data submission vendor (DSV) who submits on behalf of the clinician or group. Eligible clinicians prove (attest) that they have completed measures or activities. A secure internet-based application available to pre-registered groups of clinicians. CMS loads the Web Interface with the group s patients. The group then completes data for the pre-populated patients. Clinicians select measures and begin reporting through the routine billing processes. 29

MIPS Vendor Reporting Health information technology (HIT) vendors submit data on behalf of clinicians for: Quality Improvement Activities Advancing Care Information Quality Improvement Activities Advancing Care If data for activities is derived from CEHRT, vendors must indicate data source and transmit data in a CMS-specified form and manner 30

The Merit-based Incentive Payment System Performance Categories 31

What are the Performance Category Weights? Weights assigned to each category based on a 1 to 100 point scale Transition Year Weights 25% Quality Cost Improvement Activities Advancing Care Information 60% 0% 15% 25% Note: These are defaults weights; the weights can be adjusted in certain circumstances 32

MIPS Scoring for Quality (60% of Final Score in Transition Year) Select 6 of the approximately 300 available quality measures (minimum of 90 days) Or a specialty set Or CMS Web Interface measures Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks Quick Tip: Easier for a clinician that participates longer to meet case volume criteria needed to receive more than 3 points Bonus points are available Failure to submit performance data for a measure = 0 points 33

MIPS Scoring for Cost (0% of Final Score in Transition Year) No submission requirements Clinicians assessed through claims data Clinicians earn a maximum of 10 points per episode cost measure 34

MIPS Performance Category: Improvement Activities Attest to participation in activities that improve clinical practice - Examples: Shared decision making, patient safety, coordinating care, increasing access Clinicians choose from 90+ activities under 9 subcategories: 1. Expanded Practice Access 2. Population Management 3. Care Coordination 4. Beneficiary Engagement 5. Patient Safety and Practice Assessment 6. Participation in an APM 7. Achieving Health Equity 8. Integrating Behavioral and Mental Health 9. Emergency Preparedness and Response 35

MIPS Performance Category: Improvement Activities No clinician or group has to attest to more than 4 activities Special consideration for: Practices with 15 or fewer clinicians Rural or geographic HPSA Non-patient facing APM Certified Medical Home Keep in mind: This is a new category 36

MIPS Scoring for Improvement Activities (15% of Final Score in Transition Year) Total points = 40 Activity Weights - Medium = 10 points - High = 20 points Alternate Activity Weights* - Medium = 20 points - High = 40 points *For clinicians in small, rural, and underserved practices or with nonpatient facing clinicians or groups Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice 37

MIPS Performance Category: Advancing Care Information Promotes patient engagement and the electronic exchange of information using certified EHR technology Ends and replaces the Medicare EHR Incentive Program (also known as Medicare Meaningful Use) Greater flexibility in choosing measures In 2017, there are 2 measure sets for reporting based on EHR edition: Advancing Care Information Objectives and Measures 2017 Advancing Care Information Transition Objectives and Measures 38

MIPS Performance Category: Advancing Care Information Clinicians must use certified EHR technology to report For those using EHR Certified to the 2015 Edition: For those using 2014 Certified EHR Technology: Option 1 Option 2 Option 1 Option 2 Advancing Care Information Objectives and Measures Combination of the two measure sets 2017 Advancing Care Information Transition Objectives and Measures Combination of the two measure sets 39

MIPS Performance Category: Advancing Care Information Advancing Care Information Objectives and Measures: Base Score Required Measures 2017 Advancing Care Information Transition Objectives and Measures: Base Score Required Measures Objective Measure Objective Measure Protect Patient Health Information Electronic Prescribing Patient Electronic Access Security Risk Analysis e-prescribing Provide Patient Access Protect Patient Health Information Electronic Prescribing Security Risk Analysis e-prescribing Health Information Exchange Send a Summary of Care Patient Electronic Access Provide Patient Access Health Information Exchange Request/Accept a Summary of Care Health Information Exchange Health Information Exchange 40

MIPS Performance Category: Advancing Care Information Advancing Care Information Objectives and Measures 2017 Advancing Care Information Transition Objectives and Measures Objective Measure Objective Measure Patient Electronic Access Patient Electronic Access Coordination of Care through Patient Engagement Coordination of Care through Patient Engagement Coordination of Care through Patient Engagement Provide Patient Access* Patient-Specific Education View, Download and Transmit (VDT) Secure Messaging Patient-Generated Health Data Patient Electronic Access Patient Electronic Access Patient-Specific Education Secure Messaging Provide Patient Access* View, Download and Transmit (VDT) Patient-Specific Education Secure Messaging Health Information Exchange Health Information Exchange Health Information Exchange Public Health and Clinical Data Registry Reporting Send a Summary of Care* Request/Accept a Summary of Care* Clinical Information Reconciliation Immunization Registry Reporting Health Information Exchange Medication Reconciliation Public Health Reporting Health Information Exchange* Medication Reconciliation Immunization Registry Reporting 41

Advancing Care Information: Requirements for the Transition Year Test means: Submitting 4 or 5 base score measures o Depends on use of 2014 or 2015 Edition Reporting all required measures in the base score to earn any credit in the Advancing Care Information performance category Partial and Full means: Submitting more than the base score in the Transition Year For a full list of measures, please visit QPP.CMS.GOV 42

Advancing Care Information: Flexibility CMS will automatically reweight the Advancing Care Information performance category to zero for Hospitalbased MIPS clinicians, clinicians who lack of Faceto-Face Patient Interaction, NP, PA, CRNAs and CNS Reporting is optional although if clinicians choose to report, they will be scored. A clinician can apply to have their performance category score weighted to zero and the 25% will be assigned to the Quality category for the following reasons: 1. Insufficient internet connectivity 2. Extreme and uncontrollable circumstances 3. Lack of control over the availability of CEHRT 43

Transition Year 2017 Final Score >70 points Positive adjustment Payment Adjustment Eligible for exceptional performance bonus minimum of additional 0.5% 4-69 points Positive adjustment Not eligible for exceptional performance bonus 3 points Neutral payment adjustment 0 points Negative payment adjustment of -4% 0 points = does not participate 44

Getting Started 45

Getting Started Start by: Determining if you are included in MIPS and need to actively participate. How: Review the Clinician Participation Letter provided by CMS. - This letter will tell you who is included in MIPS and who is exempt. - The letters were sent at the TIN level rather than to individual clinicians, so check-in with the representative of your practice group for details. - This letter was mailed beginning on April 27, 2017. 46

Getting Started: Clinician Participation Letter 47

Getting Started: Clinician Participation Letter 48

Getting Started: Clinician Participation Letter Attachment A: What is this? Explains who is included in MIPS and should actively participate. o Identifies included vs. exempt status. Lists the NPIs associated with the TIN. Provides contact information for the Quality Payment Program for direct support. 49

Getting Started: MIPS Participation Look-Up Tool You could also check your participation status by: Using the MIPS Participation Look-up Tool on qpp.cms.gov. 50

Getting Started: MIPS Participation Look-Up Tool Enter your NPI into the search field and select Check Now. 51

Getting Started: MIPS Participation Look-Up Tool - Included XXXXXXXXXX Jane Sample, MD Jane Sample, MD XXXXXXXXXX Medical Group A 1234 MAIN STREET SUITE 100 BALTIMORE, MD 212447631 52

Getting Started: MIPS Participation Look-up Tool - Exempt XXXXXXXXXX Jen Doe, CNM Jen Doe, CNM XXXXXXXXXX Medical Group B 1234 NEW STREET BALTIMORE, MD 212447631 53

Prepare to Participate 54

Preparing and Participating in MIPS: A Checklist Determine your eligibility and understand the requirements. Choose whether you want to submit data as an individual or as a part of a group. Choose your submission method and verify its capabilities. Verify your EHR vendor or registry s capabilities before your chosen reporting period. Prepare to participate by reviewing practice readiness, ability to report, and the Pick Your Pace options. Choose your measures. Visit qpp.cms.gov for valuable resources on measure selection and remember to review your current billing codes and Quality Resource Use Report to help identify measures that best suit your practice. Verify the information you need to report successfully. Care for your patients and record the data. Submit your data by March 2018. 55

Prepare to Participate How Do I Do This? 1. Consider your practice readiness. Have you previously participated in a quality reporting program? 2. Evaluate your ability to report. What is your data submission method? Are you prepared to begin reporting data between January 1, 2018 and March 31, 2018? 3. Review the Pick Your Pace options for Transition Year 2017. Test Partial Year Full Year 56

Choose to Submit Data as an Individual or as a Part of a Group How Do I Do This? 1. Individual: Submit your data under your unique TIN/NPI combination using your chosen submission method(s). 2. Group: You and the other eligible clinicians in the group collectively submit performance data under a single TIN. 57

Choose Your Measures/Activities 58

Choose Your Measures/Activities How Do I Do This? 1. Go to qpp.cms.gov. 2. Click on the tab at the top of the page. 3. Select the performance category of interest. 4. Review the individual Quality and Advancing Care Information measures as well as Improvement Activities. 59

Choose Your Measures/Activities Tips for Reviewing and Selecting Measures/Activities Consider the following: Your patient population and the clinical conditions that you treat Your practice location Your practice improvement goals Quality data that you may submit to other payers If you re currently participating in one the legacy quality programs, consider your current billing codes and Quality Resource Use Report (QRUR) to help identify suitable measures 60

https://qpp.cms.gov 61

Submit Your Data Early 62

Submit Your Data Early How Do I Do This? 1. Care for your patients and record the data. 2. Submit your data to CMS prior to the March, 2018 deadline using your chosen submission method. - CMS anticipates the data submission window to open January 1, 2018. - You are encouraged to submit as early as possible following this date to ensure the timely receipt and accuracy of your data. 63

MIPS Summary The Merit-based Incentive Payment System: - Streamlines the Legacy Programs - Moves Medicare Part B clinicians to a performance-based system - Measures clinicians on four Performance Categories: Quality, Cost, Improvement Activities, and Advancing Care Information - Calculates a Final Score for clinicians based on their performance in the four Performance Categories and adjusts payments based on the Final Score 64

Introduction to Advanced Alternative Payment Models (APMs) 65

Alternative Payment Models (APMs) A payment approach that provides added incentives to clinicians to provide high-quality and costefficient care. Advanced APMs are a Subset of APMs APMs Can apply to a specific condition, care episode or population. May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs. Advanced APMs 66

Advanced APMs Must Meet Certain Criteria To be an Advanced APM, the following three requirements must be met. The APM: Requires participants to use certified EHR technology; Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk. 67

Advanced APMs in 2017 For the 2017 performance year, the following models are Advanced APMs: Comprehensive End Stage Renal Disease Care Model (Two-Sided Risk Arrangements) Comprehensive Primary Care Plus (CPC+) Shared Savings Program Track 2 Shared Savings Program Track 3 Next Generation ACO Model Oncology Care Model (Two-Sided Risk Arrangement) The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements as needed. 68

What is the benefit of participating in an Advanced APM? 69

Qualifying APM Participant (QP) Qualifying APM Participants (QPs) are clinicians who have a certain % of Part B payments for professional services or patients furnished Part B professional services through an Advanced APM Entity. Beginning in 2021, this threshold % may be reached through a combination of Medicare and other non- Medicare payer arrangements, such as private payers and Medicaid. 70

What are the Benefits of Participating in an Advanced APM as a Qualifying APM Participant (QP)? Are excluded from MIPS QPs: Receive a 5% lump sum bonus Receive a higher Physician Fee Schedule update starting in 2026 71

How do Eligible Clinicians become Qualifying APM Participants? The Threshold Score is compared to the corresponding QP threshold table and CMS takes the better result. Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements) Performance Year 2017 2018 2019 2020 2021 2022 and later Percentage of Payments through an Advanced APM Percentage of Patients through an Advanced APM 72

What if Clinicians do not meet the QP Payment or Patient Thresholds? Clinicians who participate in Advanced APMs, but do not meet the QP threshold, may become Partial Qualifying APM Participants (Partial QPs). Partial QPs choose whether to participate in MIPS. Payment Year Percentage of Payments Medicare-Only Partial QP Thresholds in Advanced APMs 2019 2020 2021 2022 2023 2024 and later Percentage of Patients 73

When Will Clinicians Learn their QP Status? Reaching the Qualifying APM Participant threshold at any one of the three QP determinations will result in QP status for the eligible clinicians in the Advanced APM Entity Eligible clinicians will be notified of their QP status after each QP snapshot. 74

What if my APM is does not meet the Advanced Criteria? 75

What are MIPS APMs? APMs MIPS APMs are a Subset of APMs MIPS APMs 76

To which APMs does the APM Scoring Standard apply in 2017? For the 2017 performance year, the following models are considered MIPS APMs: Comprehensive ESRD Care (CEC) Model (All Arrangements) Comprehensive Primary Care Plus (CPC+) Model Shared Savings Program Tracks 1, 2, and 3 Next Generation ACO Model Oncology Care Model (OCM) (All Arrangements) The list of MIPS APMs is posted at QPP.CMS.GOV and will be updated on an ad hoc basis. 77

Participation in MIPS APMs How does it work? Not evaluated 2017 Full Credit Streamlined MIPS reporting and scoring for eligible clinicians in certain APMs. All eligible clinicians in an APM Entity receive the same MIPS final score. Uses APM-related performance to the extent practicable. 78

Where can I go to learn more? 79

Technical Assistance for Clinicians CMS has free resources and organizations on the ground to provide help to clinicians who are participating in the Quality Payment Program: 61

Quality Payment Program: How to get help https://qpp.cms.gov Ashby Wolfe, MD, MPP, MPH Chief Medical Officer, Region IX Centers for Medicare and Medicaid Services ashby.wolfe1@cms.hhs.gov 81

Quality Payment Program: Year 2 Comments on Notice of Proposed Rule for Quality Payment Program Year 2 were due on August 21, 2017 82

Quality Payment Program Year 2 83

Questions?