Kelly Court Chief Quality Officer Wisconsin Hospital Association Brian Vamstad Government Relations Consultant Gundersen Health System
Overview and Key Takeaways of the Medicare Quality Payment Program Merit-based Incentive Payment System Overview Participation MIPS Measure Categories/Domains Quality Resource Use Advancing Care Information Clinical Quality Improvement Activities Strategic Implications & Conclusion
Quality Payment Program Re-brand of separate initiatives in Part B Much is continuing existing programs, re-packaged Medicare Part B focused, but implications for hospitals Strategically important to engage with physician partners, IT and Quality departments MIPS Dominant/default payment track for 90%+ providers Attempt increase flexibility and reduce admin burden Risk gradually increases Advantages & preferential scoring for enrolling in MIPS Alternative Payment Models
Track 1 (mandatory) Track 1 (optional) Track 2 MIPS Eligible Clinicians MIPS Eligible Clinicians participating in MIPS APM Partial Qualifying APM Participants Qualifying APM Participants ( QPs ) Not considered APM participants Participants not in an Advanced APM or Participants in an Advanced APM but fall short of participation thresholds Participants in an Advanced APM; fall short of participation thresholds but meet partial thresholds Participants in an Advanced APM that meet participation thresholds 5
Overview
Meaningful use of EHR PQRS Physician Value Modifier Merit-Based Incentive Payment System (MIPS)
Traditional fee-for-service Advanced APMs MIPS APMs Qualifying APM participants ( QPs ) in Advanced APMs
CMS evaluation and determination of MIPS adjustment or eligibility for QP bonus 2017 2018 2019 Performance Year 1 Payment Year 1
PARTICIPANTS & PROGRAM STRUCTURE
OR Individual National Provider Identifier (NPI) Taxpayer Identification Number (TIN) Group 2 or more clinicians billing under taxpayer identification number (TIN), would be assessed across all four domains NOTE: CMS not proposing virtual groups for year 1
Physicians Years 1 and 2 Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse Anesthetists Years 3 and Beyond Secretary has authority to expand list of eligible clinicians Physical or Occupational Therapists Speech-language Pathologists Audiologists Nurse Midwives Clinical Social Workers Clinical Psychologists Dieticians/Nutrition Professionals Hospital Implications Applies to Critical Access Hospitals billing under Method II Hospital/Health System employed providers
First Year Medicare Part B Participation Low Volume Advanced APM Others Below low patient volume threshold $10,000 Medicare Part B billing claims and 100 Medicare patients per calendar year Qualified participants in an Advanced Alternative Payment Model Hospitals or facilities
Agreements with CMS Favorable scoring under MIPS Do not qualify for advanced APM status Non-two-sided risk based models Advanced APMs that do not meet thresholds can also fall into MIPS status MSSP ACO Track 1 Bundled Payment for Care Initiative Medicare Part B Drug Payment Model Oncology Care Model 1-sided risk
15% 25% 50% 30% 50% 10% 20% MIPS Quality Resource Use Clinical Practice Improvement Activities Advancing Care Information MSSP ACO s (subject to MIPS)
Performance Category Quality Resource Use CPIA Advancing Care Information Performance Standard Measure against benchmarks to assign 1-10 points Bonus points for: outcomes, patient experience, appropriate use, patient safety Zero points for measures not reported Measures averaged for a score Measure against benchmarks to assign 1-10 points Max points depends on number of applicable measures Completion of CPIA activity for at least 90 days 20 points for high weighted activity 10 points for medium weighted activity Max. 60 points for full credit Combination of: base score (meeting minimum reporting obligations on each of 6 objectives and corresponding measures) and performance score of 1-10 based on achievement Max. 100 points Scores based on peer performance benchmarks Scores based on own performance
Qualified Clinical Data Registry (QCDR)* Meets specific CMS qualifications but scope of registry is to limited to PQRS measures EHR* Office of the National Coordinator-certified EHR submits data directly to CMSR Qualified Registry* Meets specific CMS qualifications and scope of registry is limited to PQRS measures CMS Web Interface* Group Practice Reporting Option via CMS QualityNet Attestation or Claims Attestation: TBD, CMS may utilize existing MU attestation portal Claims: Coded data inputted through claims CAHPS Vendor CMS certified vendor used for combined CAHPS and PQRS reporting *Reporting methods that cut across all MIPS performance categories
QUALITY PERFORMANCE CATEGORY
CMS scores each measure from 1-10 based on performance compared to historical benchmark 6 reported measures: 1 cross-cutting and 1 outcome or other high priority 3 automatically calculated population-based measures High priority measures / CEHRT Up to 60 points Up to 30 points Bonus points Quality score 90 Total Possible Points
MIPS MEASURES Established via Rulemaking Pre-rulemaking processes > 200 proposed measures 80% specialty services Claims-based population measures Acute Condition Composite Bacterial Pneumonia, UTI, Dehydration Chronic Condition Composite Diabetes, COPD, Asthma, Heart Failure All cause hospital readmission for groups 10 only NON-MIPS (QCDR) MEASURES Exempt from formal rulemaking rigorous approval process during nomination period Measures posted spring 2017, no later than January 1 for future performance periods
EHR, QCDR, Registries Any 6 measures, or specialty set Selection must include: outcome measure (or other high priority measure if no outcome measure is applicable) and one cross-cutting measure Web Interface Report all measures populate data first 248 consec. ranked and assigned beneficiaries Data completeness: Medicare Part B Sampling High priority measures Outcome Appropriate use Patient experience Safety Care coordination Efficiency CMS may increase outcome/high priority measures in future years
Benchmarks established for each reporting option Each must have 20 MIPS EPs with data Benchmarks from baseline period used to assign points Baseline period- two years prior to performance period Top decile awarded 10 points 0% performance rate not included in benchmarks
RESOURCE USE CATEGORY
Claims-based; no additional reporting required CMS scores each measure from 1-10 based on performance compared to a benchmark set using actual performance year data Medicare Spending per Beneficiary Total Per Capita Costs Average of scores for all attributed measures Proposed episodebased measures New
Measure Medicare Spending per Beneficiary Total per Capita Cost Episode-based measures New Attribution TIN providing plurality of Medicare Part B claims (20 minimum cases) Two-step process: (20 minimum cases) 1. TIN of PCP providing plurality of primary care services 2. TIN of specialist providing plurality of primary care services 41 measures proposed; Parts A & B costs Not currently in Physician Value Modifier, but data available via Supplemental QRURs For acute condition episodes, attributed to all clinicians that bill at least 30% of E&M visits during the trigger event; more than one clinician can be attributed For procedural episodes, attributed to all clinicians billing a part B claim with a trigger code during the trigger event
ADVANCING CARE INFORMATION CATEGORY
Protecting Patient Health Information *mandatory for credit eprescribing Public Health and Clinical Data Registry Reporting Patient Engagement Health Information Exchange Patient Electronic Access Performance Score Categories
25 possible weighted points redistributed to other categories for those participating in MIPS but not eligible for Advancing Care Information category
CMS allows partial credit for meeting minimum reporting standards, and additional points (1-10) based on performance Base score Performance score Numerator/Denominator or Yes/No 50 points Up to 80 points Bonus point Score of up to 100 points Reporting on each required measure
CLINICAL PRACTICE IMPROVEMENT CATEGORY
Inventory 90+ activities weighted high (20 points) or medium (10 points) 60 points max. Points earned for participation, not performance (no baseline) Clinicians must participate via attestation for at least 90 days during performance period Patient-centered medical homes earn full credit APMs earn half credit several for using QCDRs Small groups and rural/shortage areas report any 2 activities
Expanded Practice Access Beneficiary Engagement Population Management Patient Safety and Practice Assessment Care Coordination Achieving Health Equity Emergency Response and Preparedness Integrated Behavioral and Mental Health
PERFORMANCE SCORING
Provider A Quality Advancing Care Information Resource Use Max Points Possible 90 100 40* 60 Points Earned 72 80 30 40 Weight 50% 25% 10% 15% Weighted Score 40 20 7.5 10 Clinical Practice Improvement Total for Provider A : 77.5 points * Resource Use Max points depends on how many resource use measures a clinician/group
Composite performance score of 0-100 is sum of all performance categories Linear-based scoring Compared to MIPS median performance (½ positive, ½ negative)
CONCLUSION AND NEXT STEPS
Industry reaction Complex Rapid Timeline Challenge for small/rural practices Limited risk adjustment (socioeconomic) EHR still challenging Disappointment MSSP Track 1 not eligible for advanced APM CMS could change Performance period timing Scoring methodology Some reporting flexibility for certain clinicians Criteria for APM nominal risk Entity level for scoring Only Congress can change Timing of payment adjustments MIPS category weights broadly Types of clinicians Nominal risk criterion Range of penalties/bonuses
Impacts nearly all providers Should plan for MIPS, even if striving towards advanced APM status (most deadlines passed for enrolling in new APMs) APM (not QP advanced) do have advantages in MIPS Assess current state PQRS status Meaningful Use performance Resource Use measures Population/Community Health Activities (CPIA) Partnerships Quality Assurance and Information Technology Maximize performance & analytics Align reporting methods
All MIPS Measures Excel List of All Proposed MIPS Measures CMS Website and slide decks Quality Payment Program MIPS Quality Category MIPS Advancing Care Information Category MIPS Resource Use Category MIPS CPIA Category Advisory Board Presentations MACRA Proposed Rule Operational action items Strategic Implications
Questions? Kelly Court Chief Quality Officer Wisconsin Hospital Association kcourt@wha.com Brian Vamstad Government Relations Consultant Gundersen Health System bsvamsta@gundersenhealth.org