Quality Payment Program and Alternative Payment Models Brian R. Bourbeau, MBA COA Administrators Network April 11, 2018
Speaker Background Associate Director, Business Metrics & Analysis Clinical Affairs Department, American Society of Clinical Oncology Academic, non-academic hospital, and independent practice. Experience with: Oncology Care Model Medicare Shared Savings Program Accountable Care Organization Ohio Medicaid Episodes of Care Aetna Oncology Medical Home UHC Episodes of Care Multiple Pathway Programs
Objectives Evolution of the CMS Quality Payment Program QPP 2018 Changes Inclusion / Exclusion Individual vs. Group Reporting MIPS Categories, Weights & Scoring Reporting Requirements QOPI Reporting Registry Alternative Payment Models Risk vs. Reward
EVOLUTION OF THE CMS QUALITY PAYMENT PROGRAM
Evolution of the CMS Quality Payment Program PQRS Value-Based Modifier Meaningful Use MIPS
Timeline for Payment Adjustments 0.25 BBA BBA on professional charges
Medicare Quality Payment Program (QPP) APMs MIPS Merit Based Incentive Program System Measures Quality, use of CEHRT, Improvement Activity and Cost. Peer Comparisons Incentives/Penalties Publicly Reported Alternative Payment Models New Payment Mechanisms New Delivery Systems Negotiated Incentives Automatic Bonus
QPP 2018 CHANGES
Pick-Your-Pace for 2017 Participation -% 0% +% +% 2017 Don t Participate Test the Program Partial MIPS Reporting Full MIPS Reporting Not participating in the Quality Payment Program: If you don t send in any 2017 data, then you receive a Report: 1 quality measure or 1 Improvement Activity or The required ACI measures Report for at least 90 days:* 1+ Quality measure or 1+ Improvement Activity or More than the required ACI Report for at least 90 days:* Required Quality measures and Required Improvement Activities and Required ACI *consecutive days *consecutive days Avoid penalties; eligible for partial positive payment adjustment Avoid penalties; eligible for full positive payment adjustment; exceptional performance bonus
Differences in 2018 MIPS Reporting 2017 3 point performance threshold (0%) 3 points for reporting a measure (at least 1 patient) 2018 15 point performance threshold (0%) 1 point for reporting a measure; 3+ points for 60% completeness BBA 90 days for all categories Minimum 1-year for quality Quality category at 60% weight Cost category at 0% Improvement activities at 15% Advancing care information at 25% 30,000 allowed charges or 100 beneficiary low volume threshold Quality category at 50% weight Cost category at 10% Improvement activities at 15% Advancing care information at 25% professional? BBA 90,000 allowed charges or 200 beneficiary low ^volume threshold
Other Differences in 2018 MIPS Additional bonuses available: 5% small practice bonus 5% complex patient bonus 10% bonus for achieving improvement activity with CEHRT 20 additional improvement activities Improvement scoring for quality and cost BBA Virtual groups Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the final score for clinicians impacted by hurricanes Irma, Harvey and Maria and other natural disasters
INCLUSION / EXCLUSION
Will It Affect Me? Physician Physician Assistant Medicare Part B (Physician Services) Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist
Will It Affect Me? 1 st time Part B Participant Medicare Part B (Physician Services) Low Volume( $90K ) or Low Patient Count (200 Patients) AAPM Qualified Participant
Special Status Small Practice: </=15 eligible clinicians Medicare Part B (Physician Services) Rural and HPSA : Billing TINs/NPIs in zip code designated as Rural or Health Professional Shortage Area MIPS APM Participants
INDIVIDUAL VS. GROUP REPORTING
Individual, Group and Virtual Group Reporting Available Individual Reporting NPI TIN Group Reporting 2+ individuals under a TIN TIN assessed as a group OR APN entity assessed as a group Virtual Group Reporting NEW Combinations of 2 or more individuals and/or groups of up to 10 Join virtually to report as a group
Virtual Group Eligibility Criteria Specialty and location do not matter Solo practitioners: must be MIPS eligible Groups: at least one clinician must be MIPS eligible Participation is at the TIN level Assessed and scored as a group in all 4 categories Submission mechanisms: same as groups Election process required Written formal agreement between members
Data Submission Mechanisms: Individual & Group Reporting Each performance category can utilize a separate and distinct reporting mechanism. Must report as a group or individual across all categories. Performance Category Individual Reporting Mechanisms Group Reporting Mechanisms Quality QCDR Qualified Registry EHR Administrative Claims Claims QCDR Qualified Registry EHR CMS Web Interface (>25 prov) CAHPS for MIPS (>25 providers) Administrative Claims Claims Cost Administrative Claims Administrative Claims Improvement Activities Advancing Care Information Attestation QCDR Qualified Registry EHR Attestation QCDR Qualified Registry EHR Attestation QCDR Qualified Registry CMS Web Interface EHR Attestation QCDR Qualified Registry EHR CMS Web Interface
MIPS CATEGORIES, WEIGHTS & SCORING
Categories and Weights 2018 Quality 50% Cost Improvement Activities Advancing Care Information 10% 15% 25%
10% 15% Quality 25% Cost 50% Improvement Activities Advancing Care Information 0 14 15 69 70 100 Low Performers -4% High Performers +4x Exceptional Performers
MIPS Payment Adjustments Timeline +/- 4% 2019 +/- 5% 2020 +/- 7% 2021 +/- 9% 2022+ 2018 2020 2017 2019 2021 Year 1 = Performance Year 2 = Analysis Year 3 = Adjustment
50% Quality Reporting Requirements
Oncology Quality Measures Reporting 50% of total score General Oncology Measures Set 19 reportable measures, both process and outcome Radiation Oncology Measure Set 4 reportable measures Reporting Requirements Report on 6 measures At least 1 measure must be an outcome/high priority measure Must report on at least 60% (2018) of patients eligible for each measure and have a 20 case minimum Can report >6 measures and will be judged on 6 highest scores Patient population: Some reporting methods are All Payer NOT Medicare only 50% Must report a minimum of 1 measure for 1 Medicare beneficiary
General Oncology Measure Set Measure Data Submission Method Claims Registry EHR Web Interface Measure Type High Priority Advance care plan X X Process Prostate bone scan (overuse) X X Process Yes Current meds X X X Process Pain intensity X X Process Yes Tobacco screening X X X X Process Prostatectomy path reports X X Process Hypertension screening & f/u X X X Process Receipt of specialist report X Process Adolescent tobacco use X Process Alcohol screening X Process HER2 negative X Process Yes HER2 positive X Process Yes KRAS testing/+egfr X Process KRAS testing/-egfr X Process Yes Chemo last 14 days X Process Yes Not admitted to hospice X Process Yes >1 ED visit last 30 days X Outcome Yes ICU last 30 days X Outcome Yes Hospice for less than 3 days X Outcome Yes
Who am I being compared to? Quality Measure Benchmarks Compared to all physicians and groups who reported that measure Established by CMS using largely earlier data Most benchmarks will be published prior to performance period
10% Cost Reporting Requirements
Cost 10% of total score (2018) Measures: Medicare Spending per Beneficiary (MSPB) Total Per Capita Cost Does not include episode-based measures Calculated using claims data Must meet case minimum for attributed patients Compared to other MIPS participant during the performance year Includes Part B drugs 10% 2017 0% 2019 30%? BBA 2018 10%
15% Improvement Activities Reporting Requirements
Improvement Activities 15% 15% of total score Choose from 112 activities in 9 subcategories Medium weight = 10 points High weight = 20 points Report on 1-4 activities, depending on practice size Small and rural practices: 1-2 activities Credit for using appropriate use criteria (AUC) Total category points: 40 Report by attestation to participation in the activities
Scoring Considerations Most participants Complete up to 4 improvement activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area Complete up to 2 activities for a minimum of 90 days Participants in certified patient-centered medical homes, comparable specialty practices, or Medical Home Model APM You will automatically earn full credit Participants in MIPS APMs such as the Oncology Care Model Automatically receive points based on the requirements of the APM Some activities qualify for ACI bonus Documentation Reporting via attestation Visit qpp.cms.gov for documentation guidance
2018 ASCO Improvement Activities CMS MIPS Improvement Activity: QOPI Certification Program (QCP) Activity ID Subcategory Activity Title Activity Description (New) Weighting ACI Bonus Eligible IA_PSPA_2 Patient Safety and Practice Assessment Participation in MOC Part IV Participation in Maintenance of Certification (MOC) Part IV, such as the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or ASA Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results. Medium No
2018 ASCO Improvement Activities CMS MIPS Improvement Activity: Quality Training Program (QTP) Activity ID Subcategory Activity Title Activity Description Weighting ACI Bonus Eligible IA_PSPA_28 Patient Safety and Practice Assessment Completion of an Accredited Safety or Quality Improvement Program Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement according to the following criteria: *The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity; *The activity must have specific, measurable aim(s) for improvement; *The activity must include interventions intended to result in improvement; *The activity must include data collection and analysis of performance data to assess the impact of the interventions; and The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information. Medium No
25% Advancing Care Information Reporting Requirements
Advancing Care Information 25% weight of total score 25% Scoring from three EHR categories: Base score (50%) is required from traditional EHR activities (Security, E-Prescribing, Patient Access, Health information Exchange) Performance measures (90%) based on adoption of workflows Bonus score for public health (5%), clinical data registry reporting (5%), use of CEHRT for Improvement Activities (10%) 2014 or 2015 Edition CEHRT allowed 10% bonus for using only 2015 Edition
Scoring Advancing Care Information 100 80 10 10 60 6 40 5 4 5 Yes 10 20 3 2 0 Provide Patient Access Patient Specific Information View, Download, Transmit Secure Messaging Patient- Generated Health Data Send a Summary of Care Request/Accept a Summary of Care Clinical Information Reconciliation Immunization Registry Reporting Security Risk Analysis E-Prescribing Base (50%) Perfor mance (90%) Bonus (25%) ACI Score
10% 15% 25% 50% Summary Reporting Requirements
MIPS Reporting Requirements Summary Quality Reporting Six applicable measures (including at least one outcome measure) 60% of eligible patients per measure (minimum of 20 patients) Full year reporting Some methods require all-payer reporting (at least one Medicare beneficiary) Cost MSPB and Total per Capita Cost data collected via claims Practice Improvement Improve clinical practice or care delivery 112 potential activities Perform 1 to 4 activities (dependent on size of practice and activity weight) Attest to completion Advancing Care Information (certified EHR capability) Security, Electronic Prescribing, Patient Electronic Access
MIPS Participation for an Oncologist Sample Quality Measures Sample Improvement Activities ACI (Base Score) Chemotherapy plan documented Documentation of current medications/medication reconciliation Advance care plan Pain intensity quantified Tobacco use - screening & cessation counseling HER2 negative no HER2 targeted therapies administered Metastatic CRC anti-egfr w/kras testing >1 ED visit last 30 days of life Participation in a QCDR (e.g. QOPI) Participation in MOC IV Registration/use of PDMP Engagement of patient/family/caregivers in developing care plan Implementation of medication management practice improvements Implementation of practices / processes for developing regular individual care plans Participation in private payer improvement activities Use of decision support and standard treatment protocols Telehealth services that expand access to care Protect PHI/security risk analysis E-prescribing Provide patient electronic access HIE send/receive summary of care
Bonus and other points MIPS Scoring improvement Quality: up to 10% increase available for improvement in category Cost: up to 1% increase for statistically significant changes Bonus Points BBA Complex patients: up to 5 bonus points; measured by Hierarchical Condition Category risk score and % of dual eligible beneficiaries Small practice: up to 5 bonus points for practices with 15 or fewer clinicians ACI bonuses: up to 25% for high priority measures and end-to-end reporting
Making Every Activity Count Improvement Activity: 10 20 pts Personalized plan for high risk patients; integrate patient goals, values, priorities Activity: Chemotherapy plan documented in EHR Advancing Care Information: Up to 10% + 10% Bonus: IA using CEHRT Patient specific education Quality Measurement: 3-10 points Personalized plan for high risk patients; integrate patient goals, values, priorities
Data Submission Mechanisms: Individual & Group Reporting Each performance category can utilize a separate and distinct reporting mechanism. Must report as a group or individual across all categories. Performance Category Individual Reporting Mechanisms Group Reporting Mechanisms Quality Quality Clinical Data Registry Qualified Registry EHR Administrative Claims Claims Quality Clinical Data Registry Qualified Registry EHR CMS Web Interface (>25 prov) CAHPS for MIPS (>25 providers) Administrative Claims Claims Cost Administrative Claims Administrative Claims Improvement Activities Advancing Care Information Attestation Quality Clinical Data Registry Qualified Registry EHR Attestation Quality Clinical Data Registry Qualified Registry EHR Attestation Quality Clinical Data Registry Qualified Registry CMS Web Interface EHR Attestation Quality Clinical Data Registry Qualified Registry EHR CMS Web Interface
QOPI REPORTING REGISTRY
Qualified Clinical Data Registry (QCDR) Collects medical and/or clinical data for patient and disease tracking to foster improvement of quality of care CMS Approved Quality Measures National Quality Foundation MIPS Measures ASCO measures approved by CMS New for 2017, can also report Practice Improvement and EHR Technology Quality Oncology Practice Improvement (QOPI) Reporting Registry is a CMS approved QCDR
QCDR 16 Quality Measures Practice Improvement Attestation Reporting Advancing Care information Reporting Electronic submission FIGmd redesign CancerLinQ (18 measures active, 11 QCDR overlap) Practice Improvement Library (QOPI, QTP, QCP, ASCO University) Strategies for Maximum MIPS Score
MEASURE NAME NQF QUALITY ID Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk 389 102 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer 390 104 Documentation of Current Medications in the Medical Record 419 130 Oncology: Medical and Radiation - Pain Intensity Quantified 384 143 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 28 226 Radical Prostatectomy Pathology Reporting 1853 250 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented N/A 317 HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment 1857 449 Trastuzumab Received By Patients With AJCC Stage I (T1c) - III HER2 Positive Breast Cancer 1858 450 KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies 1859 451 1860 452 Proportion Receiving Chemotherapy in the Last 14 Days of Life 210 453 Proportion Admitted to Hospice for less than 3 days 216 457 Chemotherapy treatment administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented. (Lower Score - Better) Combination chemotherapy treatment received within 4 months of diagnosis by women under 70 with AJCC stage IA (T1c) and IB - III ER/PR negative breast cancer N/A N/A 559 N/A GCSF administered to patients who received chemotherapy for metastatic cancer N/A N/A
Individual Systems Integrated Approach
Individual Systems Integrated Approach
ALTERNATIVE PAYMENT MODELS
A Framework for Value-Based Care A Foundation Payments for Infrastructure & Operations B Pay for Reporting C Rewards for Performance D Rewards & Penalties for Performance A APMs with Upside Gainsharing B APMs with Upside Gainsharing & Downside Risk Health Care Payment Learning & Action Network. Alternative Payment Model Framework Final White Paper. 2016. A Condition-Specific Population-Based Payment B Comprehensive Population-Based Payment
A Journey Towards Value-Based Care
Timeline for Payment Adjustments 0.25 BBA In the interest of broad-scale payment reform, it is imperative to exert downward pressure on FFS-based payment rates. BBA on professional charges - The Population-Based Payment Work Group, HCP LAN
What is an Advanced APM? CMS Recognized Alternative Payment Models (APM) Advanced APM Qualifying Participants Requires use of Certified EHR Ties payment to quality, similar to MIPS Meets Financial Standards At least 8% of revenues at risk; or Maximum loss of at least 3% of spending benchmark at risk
Who is a Qualifying Participant? CMS Recognized Alternative Payment Models (APM) APM entities must meet thresholds for percent of Medicare payments received through, or Medicare patients in Advanced APMs Advanced APM Partially Qualifying Participants 75% 50% 35% 25% 20% 50% Qualifying Participants 2019 2021* 2023 and beyond* Payments Patients *Beginning in 2021, other payer APMs may be considered
APM Impact on MACRA CMS Recognized Alternative Payment Models (APM) Advanced APM Qualifying Participants Exemption from MIPS 5% Lump Sum Bonus on Physician Fee Schedule Services APM Specific Rewards
Advanced APMS Comprehensive ESRD Care Two-Sided Next Generation ACO Model Bundled Payments for Care Improvement Advanced Comprehensive Primary Care Plus Comprehensive Care for Joint Replacement Track 1 (CEHRT) Shared Savings Program Track 2 Oncology Care Model Two-Sided Shared Savings Program Track 3 Shared Savings Program Track 1+
Advanced APM All-Payer Combinations Begins in 2019 performance period Participation in Advanced APMs operated by other payers may qualify participants Medicaid Medicare Advantage CMS Multi-payer models Other commercial/private payers Criteria must be similar to Advanced Medicare APMs Must participate in Advanced Medicare APMs and other payer Advanced APMs Clinicians may be assessed at the individual or group level
Patient Centered Oncology Payment Model (PCOP)
The Transformation of Oncology Payment www.asco.org/paymentreform
Savings Will More Than Offset New Payments $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 Current FFS Payment ER/Hospital Admissions Other Services Testing Avoidable $ Drugs ER/Hospital Admissions Other Services Testing Avoidable $ Drugs Patient- Centered Oncology Payment SAVINGS ER/Admissions Other Services Testing Drugs > 4% reduction in total spending 30% reduction in ER visits & hospital admits 5-7% reduction in spending on drugs & tests $10,000 $5,000 $0 E&M Infusions Non-E&M Care Mgt PCOP Pmts E&M Infusions PCOP Pmts E&M Infusions 50% increase in payments to oncology practices
PCOP Episode of Chemo/Immuno-Therapy Additional One-Time Payment for Each New Patient $1,200 $1,000 Care Mgt Care Mgt Care Mgt Monthly Care Management Payments During Treatment Months Care Mgt Care Mgt PATIENT- CENTERED ONCOLOGY PAYMENT (PCOP) $800 $600 $400 New Patient Infusion Infusion Infusion Infusion Infusion Care Management Payments During Active Monitoring Months Up to 6 Months After End of Treatment $200 E&M E&M E&M E&M E&M CM E&M E&M CM CM CM E&M $0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 CM EM CM EM CM EM EM TREATMENT MONTHS ACTIVE MONITORING
PCOP Characteristics Therapy Episode of Care (oral or parenteral therapy, immunotherapy) Pathway incorporation (diagnostic, therapeutic, triage) Pathway compliance and quality metrics (QOPI) adjust additional and shared savings payments Total cost of care less drug costs Individual patient risk adjustment Reduced administrative burden Four additional payments plus usual Part B payments Two sided risk with downside mitigated by reinsurance
PCOP Current Status Active Commercial Payer Pilots New Mexico Blues and Dr. McAneny completed 18 months. Data under evaluation. Potential pilots in Alabama and Vermont Physician focused payment model Technical Advisory Committee (PTAC) Evaluates physician developed APMs and if approved, recommends to CMS for activation PCOP model infrastructure completion underway PTAC submission target second quarter 2018