Under the MACRAscope:

Under the MACRAscope: G08: Under the MACRAscope: MIPS and EHRs Robert Tennant, MA Director, HIT Policy, MGMA Government Affairs rtennant@mgma.org

Learning Objectives This session will provide you with the knowledge to: Distinguish the requirements related to the ACI component of MIPS Understand how ACI is expected to impact your medical group Recognize the challenges associated with ACI and tactics to help overcome them

Abstract The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) permanently eliminated the SGR s annual threat of physician payment cuts and enacted significant reforms to Medicare EHR requirements. MACRA requires that a Merit-Based Incentive Payment System (MIPS) include an EHR usage component known as Advancing Care Information (ACI) to replace Meaningful Use. This session will outline ACI, worth 25% of the MIPS calculation, which is a complex set of requirements that involve eligible clinicians achieving both a base score and a performance score in order to achieve success. Session participants will receive an overview of the key regulatory provisions of ACI, an analysis of the challenges associated with this MIPS component, and a discussion of potential ACI implementation strategies.

Agenda Changes to 2016 Meaningful Use MACRA Overview: Legislation / Final Regulation (MIPS/APMs) ACI Specifics Base Score / Performance Score / Bonus Points EHR Certification Exceptions Practice Action Steps Appendix Q/A #UndertheMACRAscope

Key regulatory proposals impacting EP participation in 2016 Meaningful Use Shorter Reporting Period. Any continuous 90- day reporting period for 2016. Clinical Quality Measurement. Any continuous 90 days for any EP who reports via attestation for 2016. Does not need to be same 90 days as the EHR reporting for measure and objectives. New Hardship Category for EPs Transitioning to MIPS. For EPs who are new to the MU program and plan on transitioning to MIPS in 2017.

MACRA (Medicare Access and CHIP Reauthorization Act)

MACRA: How we got here Historic, bipartisan legislation 484 members of Congress or 91% voted for MACRA Supported by MGMA, AMA, AHA, and many more physician stakeholders Signed into law April 2015

MACRA payment reform Pre- MACRA Annual update uncertainty resulting from SGR Largely fee-for-service payment Three fragmented quality reporting programs Limited bonuses and up to 9% reporting penalties Post- MACRA Permanent repeal of SGR, stable payment updates Incentivizes the transition to value-based payment Combines quality reporting programs into one Increased bonuses and decreased risk at outset

Andy Slavitt on The Death of Meaningful Use We are now in the process of ending Meaningful Use and moving to a new regime culminating with the MACRA implementation.the Meaningful Use program as it has existed, will now be effectively over and replaced with something better. - CMS Acting Administrator Andy Slavitt, Jan. 11, 2016

Advancing Care Information Final Rule

MIPS performance category weights ACI 25% 2017 2018 2019 IA 15% Quality 60% Advancing ACI Care Info 25% (EHR Use) 25% IA 15% Quality 50% Quality 30% ACI 25% IA 15% Cost 30% Cost 30% Over time, the cost category will gradually become larger and the quality category will become smaller Quality 30%

BASE SCORE + PERFORMANCE SCORE + BONUS POINTS = TOTAL ACI POINTS Earning 100 (or more) ACI points will award you the full 25 MIPS composite score points* f BASE SCORE PERFORMANCE SCORE BONUS POINTS (VIA PUBLIC HEALTH OR CLINICAL REGISTRY) BONUS POINTS (VIA CPIA) 50 POINTS 90 POINTS 5 POINTS 10 POINTS *90-day reporting in 2017-2018

Base Score 2017 (50 %) Base score comprised of 4 required objectives (down from 11 in the proposed rule): 1. Performing a Security Risk Analysis 2. E-Prescribing 3. Providing Patient Access to their Data 4. Health Information Exchange

Base Score 2018+ (50 %) Base score comprised of 5 required objectives: Performing a Security Risk Analysis E-Prescribing Providing Patient Access to their Data Sending Summary of Care via HIE Requesting/Accepting Summary of Care

Base Score Base Score numerators will be either one patient (e-prescribing, providing patient access, HIE) or a yes/no (conducted a Security Risk Analysis) answer during attestation Failure by an EC to meet any of the base score requirements will result in a 0 for the Base Score and a 0 for the entire ACI category

1. Protect Patient Health Information Objective: Protect ephi created or maintained by the CEHRT through the implementation of appropriate technical, administrative, and physical safeguards Measure: Conduct or review a security risk analysis in accordance with the requirements, including addressing the security (to include encryption) of ephi data created or maintained by CEHRT in accordance with requirements, implement security updates as necessary, and correct identified security deficiencies as part of the ECs risk management process. Note: RA-leading cause of failing MU audit!

Risk Analysis Tips Don t assume your RA will be conducted by your t EHR vendor (without additional cost) Talk to colleagues-how did they conduct their RA? Do assume that you will be audited Review the available resources (i.e., MGMA, HHS) Focus on highly vulnerable areas and consider outside help (i.e., mobile tech, security for remote access to EHR) Document everything RA-related

2. Electronic Prescribing Objective: Generate and transmit permissible prescriptions electronically Measure: At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using CEHRT Note: ERX not in performance category (topped out)

3. Patient Electronic Access (2017) Objective: The EC provides patients (or patientauthorized rep) with timely electronic access to their health information and patient-specific education Measure: At least one patient seen by the EC during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the EC s discretion to withhold certain information Note: HIPAA gives the EC the right to redact info that could be harmful to patient or someone else

4. Health Information Exchange Objective: the EC provides a summary of care record when transitioning or referring their patient to another setting of care, receives or retrieves a SOC record upon the receipt of a transition or referral or upon the first patient encounter with a new patient, and incorporates SOC information from other clinicians into their EHR using the functions of CEHRT Measure: the EC transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a SOC record; and (2) electronically transmits such summary to a receiving clinician for at least one transition of care or referral

Performance Score-2017 7 performance options in 2017 (2 from base) 10% each for 5 measures 20% for base score patient access / HIE measures 90 total points possible Achieving 90% in a given measure will earn 9 points (18 points if measure worth 20%). If you are between (such as an 85%), you would round to the nearest whole number 9 points.

2014 Edition Objectives (only available for use in 2017)

2014 Edition Objectives (only available for use in 2017)

Bonus Scoring Up to 5% for reporting to one or more additional public health or CDRs beyond Immunization registry reporting (active engagement) ECs can earn up to 10% in the performance score for reporting a designated improvement activity using CEHRT. Table 8 in final rule lists 18 IAs, Table H lists 19 Extra one is Provide self-management materials at an appropriate literacy level and in an appropriate language and CMS now tells us it doesn t count

ACI Improvement Activity Examples Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the CEHRT. Use decision support and protocols to manage workflow in the team to meet patient needs. Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: participate in a Health Information Exchange if available; and/or use structured referral notes Complete list at mgma.org/macta

Sample 2017 EC ACI Score Measure Action and Score 1 Base Score (50%) 50 ACI % 2 (Performance) Patient Electronic Access (20%) 3 (Performance) Health Information Exchange (20%) 4 (Performance) Secure Messaging (10%) 5 (Bonus) Public Health and CDR Reporting (5%) 6 (Bonus) Improvement Activity (10%) You provided 45% of your patients access to their medical record (VDT) on your portal within 48 hrs of the visit = 10 ACI %. You provided a summary of care via your EHR to 34% your patients during their transition/referral to other clinical sites = 6 ACI %. You had 37% of your patients send the practice a secure message = 4 ACI %. You were able to report to a state public health registry = 5 ACI % Used CEHRT decision support and protocols to manage workflow = 10 ACI % 7 Total ACI Percent (out of 100) 85 8 Total MIPS Composite Score Points 21.25 points (Out of a possible 25)

Data Blocking Attestation ECs must attest to 3 statements: 1. EC did not limit or restrict the compatibility or interoperability of certified EHR technology. 2. EC implemented technologies, standards, policies, practices, and agreements 3. EC responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information EC expected to take reasonable steps but EC will not be held accountable for factors that it cannot reasonably influence or control

Hardship Exceptions Exceptions same as existing 2016 Meaningful Use program: Insufficient Internet Connectivity Extreme and Uncontrollable Circumstances Lack of Control over the Availability of CEHRT Hospital-based (reduced from 90% to 75%, POS 21, 22, or 23 ) If granted, ACI weighted to zero % for MIPS final score

Rural Health Clinics/FQHCs Items and services furnished by an EC that are payable under the RHC or FQHC methodology 158 are not be subject to the MIPS payments adjustment These ECs have the option to voluntarily report on applicable measures and activities for MIPS

Level of EHR Certification Required 2014 CEHRT or a combination of 2014 and 2015 CEHRT is acceptable for 2017 For 2018, only 2015 CEHRT will be permitted While we understand the commenters concerns (We) encourage MIPS eligible clinicians to work with their EHR vendors in the coming months to prepare for the transition to 2015 Edition in for the performance period in CY 2018.

Have no EHR or Plan to Skip ACI in 2017? Can you avoid the penalty and potential get a bonus in 2019? YES! 2017-Quality component of MIPS is worth 60 points, IA 15 points Max these out (i.e., report 6 quality measures, and implement sufficient IAs) and you could see a small bonus OR report at least one quality measure or one IA to avoid the 2019 penalty

ACI issues and challenges Base Score (4-5 objectives make it easier, but still all or nothing ) Performance Score Many necessitate 3 rd party actions No thresholds = uncertainty regarding practice resource deployment 2015 CEHRT optional in 2017, required in 2018 2014 edition products certified = 4,225 2015 edition products certified = 19 (12 EPICs)

Action steps for your practice

Steps to Prepare Understand that specifications could change Specifications (2018+) subject to change CMS expected to release additional information/guidance Stay informed on all program updates via Washington Connection Assess your practice s performance under current the Meaningful Use program Are you/did you participate in MU? Build on your existing templates/dashboards Reporting quality data via EHR an option?

Steps to Prepare Explore technology-based clinical practice improvement opportunities Bonus points in the ACI category Look to also meet your 15% IA category Review IA alternatives and discuss internally the best options (clinical relevance, technology capability, staff availability, cost) Are you doing one or more IAs already? Leverage IAs in your marketing

Steps to Prepare Review your workflow processes related to patient engagement Determine the percentage of your patients who engaged your clinicians through secure messaging or viewed, downloaded or transmitted their record via your web portal More challenging for certain specialties What would you have to do to increase numbers? Assign FTEs, patient engagement campaigns, waiting room patient education, kiosks/ipads, include in pre-registration process

Steps to Prepare Review your workflow processes related to data exchange Determine what percentage of your external transitions of care involved data exchange via your EHR? Identify the care settings you interact with that can exchange summary of care documents Build those relationships for both sending and receiving SOC documents Evaluate your vendor and staff training needs in this area

Steps to Prepare Evaluate EHR and other tech vendor readiness Determine if your vendors are able to support the transition to MIPS/APMs Ask your vendor what IAs they can support When does your EHR expect to recertify to ONC 2015 requirements? If not Review your vendor contracts Identify potential new vendors Combine with PM review Network with your MGMA colleagues to help select Determine and budget for anticipated upgrade or replacement costs

Steps to Prepare Visit MGMA.org/MACRA for an member-benefit summary of the final rule, a guide for small practices, and all the latest news about MIPS and APMs. Join MGMA s new interactive e-group, MIPS/APMs Medicare Value-Based Payment Reform, to interact with your peers and ask MGMA Government Affairs staff questions as the MIPS and APM programs unfold. Read your Washington Connection enewsletter-we will communicate to members all policy changes from the government and announce any new CMS or MGMA member-benefit resources.

Summary ACI 25% of the total MIPS composite score 155 available ACI points / 100 ACI points gets you your full 25% Base Score is 50 points toward the ACI score and is all or nothing For 2017, Performance Score is worth up to 90 points with 7 options Bonus point opportunities (up to 15 points) by (i) PH/CDR reporting or (ii) reporting an improvement activity 2014 CEHRT in 2017, 2015 CEHRT starting in 2018 90-day reporting (2017-2018) ECs can skip ACI in 2017 and potentially STILL get small bonus and/or avoid 2019 penalty Look to MGMA for updates and resources!

Don t miss out on the other timely Government Affairs sessions at AC16! Today, don t miss the continuation of our Under the MACRAscope session series: 2:45-3:35 p.m. Group Practice Perspectives on APMs And on Wednesday, join GA for the culminating main stage session of AC16! 8:30-9:30 a.m. MGMA's View from Washington

Let Robert know what you thought! Fill out the speaker evaluation emailed to you at the end of each day or immediately through the MGMA16 mobile app. For Continuing Education (ACMPE 1 credit, CPE 1.2 credits, CEU 1 credit) CPE credit requires a code to claim credit use the code: AC16CPE1 Remember to get scanned into every session throughout the conference to qualify for CPE and CEU credit

Visit: mgma.org MACRA Resource Center Resources to assist members navigate each of the MIPS components and APMs Meaningful Use Resource Center Assistance in meeting the 2016 requirements HIPAA Resource Center Assistance in conducting a risk analysis

Thank You! Robert Tennant rtennant@mgma.org 202.293.3450

Let MGMA guide you to success. Benefits of MGMA Government Affairs MGMA s Washington Connection provides the latest in regulatory and legislative news straight from the nation s capital and helps you stay one step ahead of evolving federal requirements and deadlines. A variety of member-benefit webinars, articles, online tools and downloadable resources help you navigate complex federal programs and decipher need-to-know information. Expert MGMA Government Affairs staff are available to answer questions and offer guidance on healthcare policy issues.

Appendix

MIPS category weights for MIPS APMs MSSP Track 1 and Next Gen ACOs Other MIPS APMs IA 20% ACI 30% Quality Advancing 50% Care Info (EHR Use) 25% IA Quality 25% 30% ACI 75% Cost * Does NOT include cost * 30% Does NOT include cost or quality

Patient-Facing Encounters CMS will publish the list of patientfacing encounters on the CMS Web site located at www.qualitypaymentprogram.cms. gov

Summary of Care Requirements Summary of care must include the following information, if the provider knows it: Patient name / Demographic information (preferred language, sex, race, ethnicity, date of birth) / Vital signs (height, weight, blood pressure, BMI) / Smoking status Referring or transitioning provider s name and office contact information Encounter diagnosis / Procedures Laboratory test results / Immunizations Functional status, including activities of daily living, cognitive and disability status Care plan field, including goals and instructions Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider Reason for referral

2015 Edition Objectives (for use in 2018)

2015 Edition Objectives (for use in 2018)