CMS* Priorities and the Medicare Access and CHIP Reauthorization Act

CMS* Priorities and the Medicare Access and CHIP Reauthorization Act Howard Pitluk, MD, MPH, FACS Vice President Medical Affairs and Chief Medical Officer June 4, 2016 *Centers for Medicare & Medicaid Services = CMS Disclosure I have nothing to report, nor are there any real or perceived conflicts of interest, implied or expressed, in the following presentation. Howard Pitluk, MD, MPH, FACS 2 1

The Quality Improvement Organization Program 3 Source:????? HSAG: Your Partner in Healthcare Quality HSAG is Ohio s Medicare Quality Innovation Network Quality Improvement Organization (QIN QIO). Committed to improving healthcare quality for more than 35 years. QIN QIOs in every state/territory are united in a network under CMS. The Medicare QIO Program is the largest federal program dedicated to improving healthcare quality at the community level. 4 2

About HSAG (cont.) Nearly 25 percent of the nation s Medicare beneficiaries HSAG is the Medicare QIN QIO for Florida, California, Ohio, Arizona, and the U.S. Virgin Islands. 5 HSAG: QIN QIO Works on initiatives to improve patient safety, reduce harm, and improve clinical care Engages healthcare providers, stakeholders, and beneficiaries to improve health quality, efficiency, and value Drives quality by offering technical assistance, and collecting, analyzing, and providing data for improvement to providers Facilitates learning and action networks (LANs) Teaches, advises, and communicates 6 3

The National Quality Strategy Better Care for Individuals: Improve overall care by making healthcare more patient centered, reliable, accessible, and safe. Better Health for Communities: Improve the health of the U.S. population through proven interventions to address behavioral, social, and environmental determinants of health. Affordable Care through Quality Improvement: Reduce the cost of quality healthcare for individuals, families, employers, and government. 7 National Quality Strategy: Six Priorities 1. Promoting prevention and treatment for the leading causes of mortality, starting with cardiovascular disease 2. Working with communities to promote wide use of best practices to enable healthy living 3. Making quality care more affordable by developing and spreading new healthcare delivery models 8 4

National Quality Strategy Six Priorities (cont.) 4. Making care safer by reducing harm caused in the delivery of care 5. Ensuring that each person and family are engaged as partners in their care 6. Promoting effective communication and coordination of care 9 QIN QIO: Five Year Goals and Objectives Improve cardiac health and reduce cardiac healthcare disparities Reduce disparities in diabetes care: Everyone with Diabetes Counts (EDC) Improve prevention coordination through meaningful use (MU) of health information technology (HIT) Reduce healthcare associated infections (HAIs) in hospitals Reduce healthcare acquired conditions in nursing homes Coordination of care: Reduce hospital admission/readmissions by 20 percent by 2019 10 5

QIN QIO: Five Year Goals and Objectives (cont.) Make Care More Affordable Move from passive payer to active purchaser Transition from fee for volume to fee for value Increase transparency/pay for reporting Implement quality improvement through the Physician Value Based Payment Modifier (VBPM) and the Physician Feedback Reporting Program Undertake projects that advance efforts for better care at a lower cost (accountable care organizations, patient centered medical homes, independent physician associations) 11 What Does Value Based Payment Mean to CMS? Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient healthcare Tools and initiatives for promoting better quality, while avoiding unnecessary costs Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program Initiatives: pay for reporting, pay for performance, gain sharing, competitive bidding, bundled payment, coverage decisions, direct provider support (i.e., EHR incentive etc.) Five principles: Define the end goal, not just the process for achieving it. All providers incentives must be aligned (includes hospitals and physicians). Right measures must be developed and implemented in rapid cycle. CMS must actively support quality improvement. Clinical community and patients must be actively engaged. 12 VanLare JM, Conway PH. Value Based Purchasing National Programs to Move from Volume to Value. NEJM July 26, 2012 11 6

Medicare Payment Prior to MACRA: Volume, Not Value FFS payment system, where clinicians are paid based on volume of services, not value. The Sustainable Growth Rate (SGR) was established in 1997 to control the cost of Medicare payments to physicians. IF > Overall physician costs Target Medicare expenditures Physician payments cut across the board 13 Medicare Payment Prior to MACRA: The SGR The SGR Each year, Congress passed temporary doc fixes to avert cuts (no fix in 2015 would have meant a 21% cut in Medicare payments to clinicians). MACRA replaces the SGR with a more predictable payment method that incentivizes value. 14 7

What Is MACRA? MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015, bipartisan legislation signed into law on April 16, 2015. 15 What Does MACRA Do? Repeals the Sustainable Growth Rate (SGR) Formula Changes the way that Medicare pays clinicians and establishes a new framework to reward clinicians for value over volume Streamlines multiple quality reporting programs into one new system: the Merit Based Incentive Payment System (MIPS) Provides bonus payments for participation in eligible Alternative Payment Models (APMs) 16 8

MACRA Is Part of a Broader Push Towards Value and Quality In January 2015, the Department of Health and Human Services announced new goals for valuebased payments and Alternative Payment Models in Medicare. 17 Medicare Reporting Prior to MACRA Currently, there are multiple quality and value reporting programs for Medicare clinicians: Physician Quality Reporting Program (PQRS) VBPM Medicare EHR Incentive Program 18 9

Old Model 19 Medicare Reporting Under MACRA MACRA streamlines these programs into the Quality Payment Program. PQRS VBPM Medicare EHR Incentive Program Quality Payment Program MIPS or APMs 33 10

PQRS and the VBM What Is PQRS? A quality reporting program previously known as Physician Quality Reporting Initiative (PQRI) Created under the Tax Relief and Health Care Act of 2006 as voluntary The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 made the program permanent. Authorized incentive payments through 2010 Patient Protection and Affordable Care Act Extended incentive payments through 2014 Established mandatory reporting beginning in 2015 Applicable to those physicians providing care to Medicare beneficiaries under Part B covered professional services under the Medicare Physician Fee Schedule Beginning in 2014, professionals who reassign benefits to a Critical Access Hospital that bills at a facility level can now participate in PQRS (except for claims billing). 22 11

PQRS Basics Reporting on the quality of care to Medicare began in 2007. Feedback reports (ongoing) Lump sum incentive payments (2007 2014) Negative payment adjustments (beginning 2015) Eligible Providers (EPs) can participate: as individuals analyzed by their rendering/individual National Provider Identifier (NPI); OR register to report as a group under the group practice reporting option (GPRO), analyzed by their Tax Identification Number (TIN) 23 Reporting for PQRS Quality Domains Requirement is to report nine measures across three national Quality Strategy (NQS) domains Patient safety Person and caregiver centered experience and outcomes Communication and care coordination Effective clinical care Community/population health Efficiency and cost reduction Alignment same domains as the Clinical Quality Measures domains for meaningful use a.k.a. the EHR Incentive program Striving for alignment among the reporting programs 24 12

MACRA Changes How Medicare Pays Clinicians The current system: Services provided Medicare Fee Schedule Adjustments Final payment to clinician PQRS VBM Medicare EHR Incentive Program 25 2015 Incentive Payments and 2017 Payment Adjustments 26 Wolfe, Ashby. Understanding PQRS and the Value Based Modifier: CMS Plan to Achieve High Value Care Through Transforming Payment Systems. Centers for Medicare & Medicaid Services: June 2015. 13

Pay for Value: The Future Under MACRA MACRA signed on April 16 Permanently repealed the SGR Institutes a stable period of annual updates (0.5 percent through 2019) Establishes new payment models MACRA establishes MIPS, which combines PQRS, the VBM, and the EHR MU programs. APMs also established Individual payment adjustments for PQRS, VBM, and MU sunset in 2018. 27 MACRA Changes How Medicare Pays Clinicians MACRA streamlines these programs into the Quality Payment Program. PQRS VBM Medicare EHR Incentive Program MIPS 33 14

MACRA Changes How Medicare Pays Clinicians (cont.) The system after MACRA: Services provided Medicare Fee Schedule Adjustments Final payment to clinician MIPS *or special lump sum bonuses through participation in eligible APMs 29 How Much Can MIPS Adjust Payments? Based on a composite performance score, clinicians will receive +/ or neutral adjustments up to the percentages below. +/- Maximum Adjustments +4%+5% +7%+9% -4% -5%-7% -9% 2019 2020 2021 2022 onward MIPS Adjusted Medicare Part Bpaymentto clinician The potential maximum adjustment % will increase each year from 2019 to 2022 40 15

How Much Can MIPS Adjust Payments? (cont.) MIPS will be a budget neutral program. Total upward/downward adjustments will be balanced so the average change is 0 percent. +4%+5% +7%+9% *Potentialfor 3X adjustment +/- Maximum Adjustments -4% -5%-7% -9% 2019 2020 2021 2022 onward MIPS 41 What Will Determine My MIPS Score? The MIPS composite performance score will factor in four weighted categories: Quality Resource use Clinical practice improvement activities Use of certified EHR technology MIPS Composite Performance Score 42 16

What Will Determine My MIPS Score? Quality The MIPS composite performance score will factor in four weighted categories: Quality Resource use Clinical practice improvement activities Use of certified EHR technology MIPS Composite Performance Score Qualitymeasureswillbe publishedinanannuallist *Clinicianswillbeabletochoose the measuresonwhichthey ll beevaluated 43 What Will Determine My MIPS Score? Quality (cont.) Quality (Replaces PQRS) Worth 50 percent of composite score in year 1 Six ecqm* measures with one cross cutting and one outcome measure, reporting on 90 percent of eligible patients For individual clinicians and small groups (2 9), MIPS calculates two population measures based on claims data For groups with 10 or more clinicians, MIPS calculates three population measures Submission includes claims (80 percent of FFS eligible patients), QCDRs**, Qualified registry, EHR (90 percent of eligible patients) or Administrative claims (no submission required) Report data on all payers, unless using the CMS Web Interface or CAHPS*** for MIPS (CMS uses Part B sample) 34 *Electronic clinical quality measures (ecqms) **Qualified Clinical Data Registries (QCDRs) *** Consumer Assessment of Healthcare Providers & Systems (CAHPS) 17

What Will Determine My MIPS Score? Resource Use The MIPS composite performance score will factor in four weighted categories: Quality Resource use Clinical practice improvement activities Use of certified EHR technology MIPS Composite Performance Score Willcompareresourcesusedto treat similarcare episodesand clinical conditiongroupsacross practices *Canbe risk adjusted to reflectexternal factors 44 What Will Determine My MIPS Score? Resource Use (cont.) Resource Use Worth 10 percent of composite score in year 1 Continuation of two measures from VBM: Total per costs capita for all attributed beneficiaries Medicare spending per beneficiary (MSPB) with minor technical adjustments Also episode based measures, as applicable to the MIPS eligible clinician 36 18

What Will Determine My MIPS Score? Clinical Practice Improvement Activities The MIPS composite performance score will factor in four weighted categories: Quality Resource use Clinical practice improvement activities Use of certified EHR technology MIPS Composite Performance Score Examples includecarecoordination, shareddecision making,safety checklists, expandingpracticeaccess 45 What Will Determine My MIPS Score? Clinical Practice Improvement Activities (CPIA) Worth 15 percent of composite score in year 1 Activities include: Those focused on care coordination Beneficiary engagement Patient safety 90 options for these activities Credit given for this category for participating in APMs or PCMH Submission of measures include attestation, QCDR, Qualified Registry, and EHR 38 19

What Will Determine My MIPS Score? Certified Use of EHR Technology The MIPS composite performance score will factor in four weighted categories: Quality Resource use Clinical practice improvement activities Use of certified EHR technology MIPS Composite Performance Score Percentage weight of this may decrease as more users adopt EHR 46 What Will Determine My MIPS Score? Use of Certified EHR Technology (cont.) Advancing Care Information replaces MU Worth 25 percent of composite score Not an all or nothing anymore Focuses on Stage 3 like measures Interoperability Health information exchange Electronic care coordination Submission includes attestation, QCDR, qualified registry, and EHR 40 20

What Will Determine My MIPS Score? Four Weighted Categories The MIPS composite performance score will factor in performance in 4 weighted categories: Quality Resource use Clinical practice improvement activities Use of certified EHR technology MIPS Composite Performance Score 2019 2020 2021 50% 10% 15% 25% 45% 15% 15% 25% 30% 30% 15% 25% % weights for quality and resource use are scheduled to adjust each year until 2021 41 RECALL: Exception to Participation in MIPS There are three groups of clinicians who will NOT be subject to MIPS: FIRST year of Medicare Part B participation Below low patient volume threshold Certain participants in ELIGIBLE APMs Note: MIPS does not apply to hospitals or facilities 42 21

MU Changes EHR MU changes for eligible hospitals, critical access hospitals (CAHs), EPs, and eligible clinicians The Office of the National Coordinator (ONC) Authorized Certification Bodies (ACBs) given health oversight authority to conduct rigorous surveillance of certified technologies and capabilities in the field Three new attestations required 43 New MU Attestations Not limiting or restricting compatibility or interoperability of certified EHR technology The certified EHR technology was, at all relevant times: connected compliant with all exchange of information implemented in a manner to allow timely access by patients to their electronic health information implemented in a manner to allow for the timely, secure, and trusted bi directional exchange of electronic health information with other healthcare providers You responded in good faith and in a timely manner to EHR requests, including from patients, healthcare providers, and other persons impartially 44 22

Who Will Not Participate in MIPS? There are three groups of clinicians who will NOT be subject to MIPS: FIRST year of Medicare Part B participation Below low patient volume threshold Certain participants in ADVANCED APMs 45 Other Changes of Note in MIPS Removes Measure Groups as a data submission method Significant changes to many measures, i.e., breast cancer now ages 50 74 Some 2016 PQRS measures have been removed (see Table F in rule) for MIPS 2017, i.e., Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL C Control (<100 mg/dl) CPIA s encourage participation with your QIO, participation in TCPI or a HEN 46 23

2017 Pediatric PQRS Measures Carried Over From 2016 Data CMS E NQF/PQRS Submission Measure ID Method Measure Type National Quality Strategy Domain Measure Title and Description N/A/327 N/A Registry Process Effective Pediatric Kidney Disease: Adequacy of Volume Management: Clinical Care Percentage of calendar months within a 12 month period during which patients aged 17 years and younger with a diagnosis of End State Rental Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist. Measure Steward Renal Physicians Association 1667/328 N/A Registry Intermedia te Outcome Effective Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Clinical Care Hemoglobin Level <10 g/di: Percentage of calendar months within a 12 month period during which patients aged 17 years and younger with a diagnosis of ESRD receiving hemodialysis or peritoneal dialysis have a hemoglobin level <10 g/dl. N/A/398 N/A Registry Outcome Effective Optimal Asthma Control: Patients ages 5 50 (pediatrics ages 5 17) Clinical Care whose asthma is well controlled as demonstrated by one of three age appropriate patient reported outcome tools. 0733 Registry Outcome New Patient Operative Mortality Stratified by the Five STSEACTS Mortality Safety Categories: Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi institutional validated complexity stratification tool. Renal Physicians Association Minnesota Community Measurement The Society of Thoracic Surgeons 47 Pediatric Specialty Measure Set NQF/PQRS CMS E Measure ID Data Submission Method Measure Type National Quality Strategy Domain Measure Title and Description 0069/065 154v4 Registry EHR Process Appropriate Treatment for Children with Upper Respiratory Efficiency and Infection (URI): Percentage of children 3 months through 18 Cost Reduction years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode. Measure Steward National Committee for Quality Assurance N/A/066 146v4 Registry EHR Process Appropriate Testing for Children with Pharyngitis: Percentage National Efficiency and of children 3 18 years of age who were diagnosed with Cost Reduction pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode. Committee for Quality Assurance 0653/091 N/A Claims Registry Process Effective Acute Otitis External (AOE): Topical Therapy Percentage of Clinical Care patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations. American Academy of Otolaryngolo gy Head and Neck Surgery 48 24

Pediatric Specialty Measure Set (cont.) NQF/PQRS CMS E Measure ID Data Measure Submissio Type n Method National Quality Strategy Domain 0654/093 N/A Claims Registry Process Efficiency and Cost Reduction Measure Title and Description Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy Avoidance of Inappropriate Use Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy. Measure Steward American Academy of Otolaryngolo gy Head and Neck Surgery 0418/134 2v5 Claims Web, EHR Process Population Health Preventive Care and Screening: Screening for Centers for Interface, Community Depression and Follow Up Plan Percentage of patients aged 12 years and Medicare & Registry older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow up plan is documented on the date of the positive screen. Medicaid Services / Mathematica / Quality Insights of Pennsylvania 0405/160 52v4 EHR Process Effective HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of patients aged 6 weeks and older with a diagnosis of Clinical Care HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis. National Committee for Quality Assurance 49 What Is a Medicare APM? APMs are new approaches to paying for medical care through Medicare that incentivize quality and value. As defined by MACRA, APMs include: CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award). MSSP (Medicare Shared Savings Program). Demonstration under the Health Care Quality Demonstration Program. Demonstration required by federal law. 50 25

Eligible APMs Are the Most Advanced APMs As defined by MACRA, eligible APMs must meet the following criteria: Base payment on quality measures comparable to those in MIPS. Require use of certified EHR technology. The APM either: 1. Bears more nominal financial risk for monetary losses, OR 2. Is a Medical Home Model expanded under CMMI* authority. *Center for Medicare & Medicaid Innovation (CMMI) 51 How Do the APMs Fit Into MACRA? Note: MACRA does NOT change how any particular APM rewards value. Instead, it creates extra incentives for APM participation. 52 26

MACRA Provides Additional Rewards for Participating in APMs Potential financial rewards Not in APM In APM In Advanced APM MIPS adjustments MIPS adjustments + APM-specific rewards If you are a qualifying APM participant (QP) APM-specific rewards + 5% lump sum bonus 53 How Do I Become a Qualifying APM Participant (QP)? 25%in2019 and 2020 Eligible APM QP You must have a certain % of your patients or payments through an eligible APM. QPs will: Be excluded from MIPS. Receive a 5% lump sum bonus. Bonus appliesin 2019 2024; will then receive higher feescheduleupdate starting in 2026. 57 27

What About Private Payer or Medicare APMs? Can they help me qualify to be a QP? Yes, starting in 2021, participation in some of these APMs with other non Medicare payers can count toward criteria to be aqp. Combination all payerand Medicare threshold option If theapms meetcriteriasimilarto thosefor eligibleapms runby CMS: Certified EHR use Quality Measures Financial Risk 58 Most Practitioners Will Be Subject to MIPS Not in APM In non eligible APM QP in eligibleapm In eligible APM, but not a QP Some practitioners may be ineligible APMs, but they do not have enough payments or patients through the eligible APM to be a QP. 59 Note: Figure not to scale. 28

When Will These MACRA Provisions Take Effect? 57 MIPS Adjustments Will Begin in 2019 2017 2018 2019 2020 2021 2022 2023 2024 2025 MIPS +4% -4% +5% -5% +7% +9% -7% -9% Maximum MIPS Payment Adjustment +/ *NOTE: Similar to prior quality programs, adjustments for MIPS will be based on performance in a prior year. The exact time (e.g. 1 yr. prior) will be determined in upcoming rule making. 58 29

Qualifying Bonuses Also Begin in 2019 2017 2018 2019 2020 2021 2022 2023 2024 2025 MIPS Participation in Qualifying APM +4% -4% +5% -5% +7% +9% -7% -9% Maximum MIPS Payment Adjustment (+/ ) +5% bonus (excluded from MIPS) *NOTE: Bonus payment for APM will be based on estimated aggregate payment for the prior year. E.g. bonus in 2019 will be based on payment for services in 2018. 59 Fee Schedule Update Begins in 2016 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Fee Schedule +0.5% each year No change +0.25% or 0.75% QPs will also get a +0.75% update to the fee schedule conversion factor each year. Everyone else will get a +0.25% update. 60 30

Putting It All Together 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 & on Fee Schedule +0.5% each year No change +0.25% or 0.75% MIPS 4 5 7 9 9 Maximum MIPS Payment Adjustments +/ Participation in Qualifying APM +5% bonus (excluded from MIPS) 61 How Will MACRA Affect Me? MIPS and APM Flowchart Am I in an eligible APM? Yes No Am I in an APM? Yes No Is this my first year in Medicare OR am I below the low volume threshold? Do I have enough payments or patients through my eligible APM? Yes No Qualifying APM Participant Excluded from MIPS 5% lump sum bonus payment (2019 2024), higher fee schedule updates (2026+) APM specific rewards Favorable MIPS scoring & APMspecific rewards Yes Not subject to MIPS No Subject to MIPS Bottom line: There will be financial incentives for participating in an APM, even if you don t become a QP. Key: APM = Alternative Payment Model MIPS = Merit Based Incentive Payment System QP = Qualifying APM Participant 31

Take Away Points 1. MACRA changes the way Medicare pays clinicians and offers financial incentives for providing high value care. 2. Medicare Part B clinicians will participate in the MIPS program unless they are in their first year of Part B participation, have a low volume of patients, or participate in an Advanced APM. 3. Payment adjustments and bonuses will begin in 2019. 4. A proposed rule is targeted for spring 2016, with the final rule targeted for fall 2016. 65 What Should I Do to Prepare For MACRA? Look for future educational activities. Look for a proposed rule in spring 2016 and provide comments on the proposals. Final rule targeted for early fall 2016 Consider collaborating with your QIN QIO for MIPS or one of the TCPI* Practice Transformation Networks or Support and Alignment Networks for MACRA. *Transforming Clinical Practice Initiative (TCPI) 64 32

Transforming Clinical Practice Initiative Support more than 140,000 clinicians in their practice transformation work Improve health outcomes for millions of Medicare, Medicaid, and CHIP beneficiaries and other patients Reduce unnecessary hospitalizations for five million patients Generate $1 to $4 billion in savings to the federal government and commercial payers Sustain efficient care delivery by reducing unnecessary testing and procedures Build the evidence base on practice transformation so that effective solutions can be scaled 65 Practice Transformation Networks (PTNs) In Region 9 Arizona Health e Connection Southwest Pediatric Practice Transformation Network Local Initiative Health Authority of Los Angeles County National Rural Accountable Care Consortium Pacific Business Group on Health Vizient Great Lakes 66 33

Six Important Benefits to Participating Clinicians 1. Optimize health outcomes for your patients 2. Promote connectedness of care for your patients 3. Learn from high performers how to effectively engage patients and families in care planning 4. More time spent caring for your patients 5. Stronger alignment with new and emerging federal policies 6. Opportunity to be a part of the national leadership in practice transformation efforts http://www.healthcarecommunities.org/community News/TCPI.aspx 67 References and Further Reading Health Care Payment Learning and Action Network http://innovationgov.force.com/hcplan CMS Innovation Center https://innovation.cms.gov/ CMS Draft Quality Measures Development Plan https://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/Value Based Programs/MACRA MIPS and APMs/Draft CMS Quality Measure Development Plan MDP.pdf MACRA: Medicare Access and CHIP Reauthorization Act of 2015 https://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/Value Based Programs/MACRA MIPS and APMs/MACRA MIPS and APMs.html CMS Health Equity Plan https://www.cms.gov/about CMS/Agency Information/OMH/OMH_Dwnld CMS_EquityPlanforMedicare_090615.pdf Contact information for the Transforming Clinical Practice Initiative http://www.healthcarecommunities.org/communitynews/tcpi.aspx 68 34

Questions? 69 Thank You Howard Pitluk, MD, MPH, FACS Vice President Medical Affairs and Chief Medical Officer HSAG 602.801.6600 hpitluk@hsag.com Ashby Wolfe, MD, MPP, MPH Chief Medical Officer, Region IX CMS 415.744.3631 ashby.wolfe1@cms.hhs.gov 70 35

This material was prepared by, the Medicare Quality Improvement Organization for Arizona, 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. Publication No. AZ 11SOW D.1 06022016 01 71 36