PYA Principal Martie Ross and Senior Manager Graham Fox presented, “Mastering MIPS" at the American College of Healthcare Executives’ Congress on Healthcare Leadership. Learning objectives included: Gaining an understanding of MIPS—why it was implemented and how it will impact reimbursement, governance, and strategic planning for healthcare organizations. Identifying questions organizations must consider during MIPS implementation that will lead to financial and operational success.

1. Martie Ross, JD
Graham Fox, FACHE
Presentation prepared for
ACHE Congress on Healthcare Leadership
Mar. 27-30, 2017
Mastering MIPS

2. Page 1
Learning Objectives
 Gain an understanding of MACRA, why it was
implemented, and how it will impact
reimbursement, governance, and strategic
planning for healthcare organizations
 Identify questions organizations must consider
during MIPS implementation that will lead to
financial and operational success

3. Page 2
Agenda
 MACRA and the QPP
 Advanced Alternative Payment
Models
 Merit-Based Incentive Payment
System
 Game Plan

4. MACRA and the QPP

5. Page 4
VBR Framework
FEE-FOR-SERVICE
(FFS) PAYMENTS
POPULATION-BASED
APMs
ADJUSTED FFS
PAYMENTS
APMs INCORPORATING
FFS PAYMENTS
$
$
Bank
A Pay For
Reporting
B Pay For
Performance
C Pay/Penalty
For
Performance
A Total Cost of
Care Shared
Savings
B Total Cost of
Care Shared
Risk
C Retrospective
Episodic
Payment
A Prospective
Episodic Payment
B Primary Care
Population-
Based
Payments
C Comprehensive
Population-
Based
Payments
A Traditional FFS
B Infrastructure
Incentives
C Care
Management
Payments

6. Page 5
Has VBR Been Trumped?
 ObamaCare Repeal
 Front half vs. back half of the ACA
 Episodic Payment Model (AMI & CABG)
 3/20 Federal Register Notice extending start date to
10/1/17
 MSSP
 3/22 announcement of 2018 application cycle

7. Page 6
Medicare Access and CHIP
Reauthorization Act of 2015
Advanced Alternative
Payment Model
Merit-Based Incentive
Payment System
Quality
Payment
Program

8. Page 7
Transition Period
Through
December 31,
2018
Starting
January 1, 2019
 0.5% annual MPFS update (2016-
2019)
 Payment adjustments
 Potential 2% PQRS reporting penalty
 Potential 3% EHR meaningful use
penalty
 Up to +/- 4% Value-Based Modifier
bonus/penalty
 Annual MPFS update:
 0% in 2020 through 2025
 0.25% thereafter (0.75% for Advanced
APM participants)
 Payment Adjustments
 5% bonus for participation in
advanced APMs thru 2024
 Up to +/- 9% MIPS bonus/penalty

9. Page 8
Years 1 and 2 Years 3+
Physicians (MD/DO, DPM, OD, DC,
DMD/DDS)
PAs, APRNs, CNSs, CRNA
Physical or occupational therapists,
speech-language pathologists,
audiologists, nurse midwives, clinical
social workers, clinical psychologists,
dieticians/nutritional professionals
Eligible Clinicians

10. Advanced APMs

11. Page 10
Advanced APMs (Traditional Medicare)
Definite
Medicare Shared Savings Program
(Tracks 2 & 3 Only)
Next Generation ACO Model
Comprehensive ESRD Care
(LDO arrangement and Two-Sided Risk)
Comprehensive Primary Care Plus
(re-open applications)
Oncology Care Model
(Two-Sided Risk)
In Development
Medicare Shared Savings Program
Track 1+
Comprehensive Care for Joint
Replacement
(CEHRT Track)
Episodic Payment Model
(CEHRT and non-CEHRT Tracks)
Cardiac Rehabilitation
Incentive Payment Model
Medicare Diabetes
Prevention Program
New Voluntary Bundled Payment
Program
Vermont Medicare ACO Initiative

12. Page 11
Qualifying Participant
Qualifying Participant
 Higher % of patients or payments
 Bonus = 5% of MPFS payments
Partial Qualifying Participant
 Lower % of patients or payments
 No bonus, no MIPS
Non-Qualifying Participant
 Subject to MIPS
Payment Year 2019 2020 2021 2022 2023 2024
QP Threshold 25% 25% 50% 50% 75% 75%
Partial QP Threshold 20% 20% 40% 40% 50% 50%
Payment Year 2019 2020 2021 2022 2023 2024
QP Threshold 25% 25% 50% 50% 75% 75%
Partial QP Threshold 20% 20% 40% 40% 50% 50%
Medicare Option – Payment Amount Threshold
Medicare Option – Patient Count Threshold

13. Page 12
12
Other Payer Advanced APMs
 Credit for participation in Other Payer Advanced APMs starting in 2019
 Three criteria: (1) Use of CEHRT; (2) Quality measures; and (3) More than nominal
financial risk or medical home model
 Submission and approval process
 Still requires some level of participation in Advanced APMs
Payment Year 2019 2020 2021 2022 2023 2024
MCR MCR Total MCR Total MCR Total MCR Total MCR
QP Threshold - - 50% 25% 50% 25% 75% 25% 75% 25%
Partial QP Threshold - - 40% 20% 40% 20% 50% 20% 50% 20%
Payment Year 2019 2020 2021 2022 2023 2024
MCR MCR Total MCR Total MCR Total MCR Total MCR
QP Threshold - - 35% 20% 35% 20% 50% 20% 50% 20%
Partial QP Threshold 25% 10% 25% 10% 35% 10% 35% 10%
All Payer Combination Option – Payment Amount Threshold
All Payer Combination Option – Patient Count Threshold

14. MIPS

15. Page 14
MIPS Final Score Components
Quality Cost Performance
Improvement
Activities
Advancing Care
Information
60%
0%
15%
25%
50%
10%
15%
25%
30%
30%
15%
25%
2017 Performance Year 2018 Performance Year 2019 Performance Year
Impacts 2019 Payments Impacts 2020 Payments Impacts 2021 Payments

16. Page 15
2017 Final Score Calculation
Quality
Component Score
Cost Performance
Component Score
Improvement
Activities
Component Score
Advancing Care
Information
Component Score
Multiply Each By
Component Weight
Final
Score

17. Page 16
MIPS Payment Adjustments
2019 2022+2020 2021
+4%
-4%
+5%
-5%
+7%
-7%
+9%
-9%
Up to 12% Scaling Factor*
Up to 15% Scaling Factor
Up to 21% Scaling Factor
Up to 27% Scaling Factor
Performance
Threshold**
* Due to budget neutrality, higher bonuses will be paid if total penalties exceed projections, not to exceed 3 times the base bonus percentage.
** Performance Threshold will be adjusted each year based on historical performance.

18. Page 17
March 31, 2018
Deadline for
individual/group to
report on required
measures
Performance-To-Adjustment Cycle
Perform Submit AdjustFeedback
CY 2017
Period of time for
which performance
will be evaluated
2017 only: may elect
90-day continuous
performance period
Q3 2018
CMS reports on prior
year performance,
including calculation
of Final Score and
payment adjustment
for upcoming year
CY 2019
Positive or negative
MPFS payment
adjustments based on
2017 Final Score

19. Page 18
MIPS Participation Election
 Final Score assigned to each NPI/TIN
 Group reporting must include all NPIs who reassign to
TIN; cannot pick and choose
 NPI who reassigns to TIN reporting as a group may
also report individually

20. Page 19
Low-Volume Threshold
 For 2017, individual or group exempt from MIPS if:
 $30,000 or less in allowable Part B charges; or
 See 100 or fewer traditional Medicare beneficiaries
 If elect group reporting, NPIs who would be exempt if
reporting individually are NOT exempt
 Two determination periods (both with 60-day claims run-out)
 September 1, 2015, to August 31, 2016
 September 1, 2016, to August 31, 2017

21. Page 20
2017: Pick Your Pace
2017 Reporting Option 2019 Payment Impact
No reporting
4% penalty on all MPFS payments
Report performance for minimum of 90-day continuous
period
 One quality measure OR
 One clinical practice improvement activity OR
 All required measures for advancing care information
No penalty, no bonus
Report performance for minimum of 90-day continuous period
 More than one quality measure OR
 More than one clinical practice improvement activity OR
 More than the required measures for advancing care
information
Eligible for up to 12% bonus on all MPFS payments (amount
varies based on Final Score and budget-neutral scaling factor)
Report performance on all required measures for minimum of 90-
day continuous period.
Eligible for up to 12% bonus on all MPFS payments
(amount varies based on Final Score and budget-
neutral scaling factor)
If Final Score ≥ 70, eligible for additional Exceptional
Performance Bonus (amount varies based on Final Score and
distribution of $500 million annual fund; cannot exceed 10% of
Part B allowed charges)

22. MIPS Components
Reporting Requirements and Scoring Methodology

23. Page 22
Quality Reporting
Manner of
Participation
Reporting Mechanism
Measure
Requirements
Data Completeness
Individual Part B Claims
6 measures (at least 1
outcome measure) OR
specialty-specific
measure set (including
oncology)
50% of Part B patients
(60% in 2018)
Individual or Group
QCDR
Qualified Registry
EHR
6 measures (at least 1
outcome measure) OR
specialty-specific
measure set (including
oncology)
50% of individual’s or
group’s patients who
meet measure
denominator (60% in
2018)
Group CMS Web Interface
(register by 06/30/17)
All measures included
CMS-selected sample
of Part B patients

24. Page 23
Quality Scoring Methodology
 Measure No. 7: All-Cause Readmissions
 CMS calculates using claims data; minimum 200 cases
 Group or NPI/TIN based on participation election
 Point conversion – examples to follow
 CMS calculates deciles for each measure based on national performance in baseline
period
 Compare score to decile breaks and assign corresponding points
 Assign zero points for unreported measures
 If report more than required number of measures, CMS uses top points to calculate
quality component score
 Bonus points
 1 extra point for each measure reported using CEHRT for end-to-end electronic
reporting up to 10% of total possible points
 2 points for additional outcome/patient experience measure; 1 point for other high
priority measures up to 10% of total possible points
 Quality component score
 Total points on 7 measures + bonus points
 Adjusted based on measures with insufficient # of cases

25. Page 24
Point Assignment Based on Deciles
Measure Name
Submission
Method
Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10
Topped
Out
Preventive Care
and Screening:
Influenza
Immunization
(#110)
Claims
22.64 -
31.75
31.76 -
43.13
43.14 -
54.68
54.69 -
66.38
66.39 -
77.47
77.48 -
92.03
92.04 -
99.99
100 No
EHR
11.22 -
18.57
18.58 -
24.99
25.00 -
31.84
31.85 -
38.92
38.93 -
47.86
47.87 -
59.99
60.00 -
79.01
>= 79.02 No
Registry/ QCDR
11.57 -
21.39
21.40 -
31.39
31.40 -
41.31
41.32 -
51.13
51.14 -
62.04
62.05 -
74.27
74.28 -
91.83
>= 91.84 No
Sample Benchmarks for 2017 MIPS Quality Reporting and
Measurement
Source: 2017 MIPS benchmarks as provided by CMS through qpp.cms.gov
Example:
Provider A
Provider B
Claims
EHR
61%
61%
6 points
9 points
Submission
Method
Performance Points Earned

26. Page 25
Point Assignment Based on Deciles
Sample Benchmarks for 2017 MIPS Quality Reporting and
Measurement
Source: 2017 MIPS benchmarks as provided by CMS through qpp.cms.gov
Example:
Provider A
Provider B
Claims
EHR
98.6%
98.6%
4 points
10 points
Submission
Method
Performance Points Earned
Measure Name
Submission
Method
Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10
Topped
Out
Preventive Care
and Screening:
Tobacco Use:
Screening and
Cessation
Intervention
(#226)
Claims
95.60 -
97.85
97.86 -
99.25
99.26 -
99.99
-- -- -- -- 100 Yes
EHR
72.59 -
81.59
81.60 -
86.68
86.69 -
90.15
90.16 -
92.64
92.65 -
94.67
94.68 -
96.58
96.59 -
98.51
>= 98.52 No
Registry/ QCDR
76.67 -
85.53
85.54 -
89.87
89.88 -
92.85
92.86 -
95.14
95.15 -
97.21
97.22 -
99.10
99.11 -
99.99
100 No

27. Page 26
Improvement Activities Reporting
90+ Improvement Activities Across 9 Subcategories
Each Graded Medium (10 pts) or High (20 pts)
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety and Practice Assessment
Participation in an APM
Achieving Health Equity
Integrated Behavioral and Mental Health
Emergency Preparedness and Response

28. Page 27
Improvement Activities Scoring
Improvement Activities Component Score (capped at 100) =
(# of Medium Activities * 10) + (# of High Activities * 20) / 40 possible points
Most Participants
Attest to completion of 4 activities for
minimum of 90 days
Groups (a) with fewer than 15
participants, (b) located in rural area or
HPSA
Attest to completion of 2 activities for
minimum of 90 days
Participants in certified PCMH or
comparable specialty practice
designation
Full credit
Participants in MIPS APM Full credit
Participants in other APMs Half credit
*

29. Page 28
Advancing Care Information Reporting
Base Score (Required) Measures
(10 points each; Y/N or report numerator/
denominator)
Performance Score Measures
(0 to 10 points each based on level of
performance)
Security Risk Analysis Patient-Specific Education
E-Prescribing View, Download, or Transmit
Provide Patient Electronic Access Provide Patient Electronic Access*
Health Information Exchange Health Information Exchange*
Medication Reconciliation
Secure Messaging
Immunization Registry Reporting (Y/N)
Option 1: Clinicians with CEHRT 2014 or CEHRT 2015 (2017 Only)
*Select measures worth up to 20 points toward performance score

30. Page 29
Advancing Care Information Reporting
Base Score (Required) Measures
(10 points each; Y/N or report numerator/
denominator)
Performance Score Measures
(0 to 10 points each based on level of
performance)
Security Risk Analysis Patient-Specific Education
E-Prescribing View, Download, or Transmit
Provide Patient Electronic Access Provide Patient Electronic Access
Send a Summary of Care Send a Summary of Care
Request and Accept Summary of Care Request and Accept Summary of Care
Secure Messaging
Patient-Generated Health Data
Clinical Information Reconciliation
Immunization Registry Reporting (Y/N)
Option 2: Clinicians with CEHRT 2015* (Mandatory in 2018)
*CEHRT 2015 is required for MIPS-Eligible Clinicians to successfully meet ACI requirements in 2018 and beyond

31. Page 30
Advancing Care Information Scoring
50-point Base Score +
0- to 90-point Performance Score +
Up to 15 Bonus Points =
(syndromic surveillance, electronic case, public health registry, and clinical data
registry reporting; reporting improvement activities using CEHRT)
Up to 100 points

32. Page 31
Cost Performance Component
 Not included in 2017 Final Score calculation, but feedback
provided
 No additional reporting; CMS calculate from claims data
 Two categories of measures (attribution)
 Two total cost of care measures
 Total per capita costs
 Medicare Spending Per Beneficiary
 Ten episode-based efficiency measures
 Reported in 2014 supplemental QRUR
 Scored on deciles (like quality component)

33. Page 32
Patient Relationship Categories
 MACRA-mandated tools to compare relative cost
performance among eligible clinicians/groups
 Begin including codes on claims no later than 01/01/2018
 CMS to publish codes in April 2017
 Continuing care relationship
 Acute care relationship
 Care furnished pursuant to order from other practitioner

34. Page 33
Final Score Calculation
 Sum of each of the products of each component score and
each component’s assigned weight, multiplied by 100.
 Example:
 Quality = (55 points / 70 possible points) x 60%
 Advancing Care Information = (84 points / 100 possible points) x
25%
 Improvement Activities = (40 points / 40 possible points) x 15%
 FINAL SCORE = 83.14

35. Page 34
APM Scoring Standard
 Applies to those eligible clinicians identified on MIPS APM
participant list
 MIPS APM
 Advanced APMs
 Track 1 MSSP ACO
 Oncology Care Model (one-sided model)
 Included on participant list as of March 31, June 30, or August 31
of performance year

36. Page 35
Applying the APM Scoring Standard
 50% Quality
 Based on APM performance measures
 20% Improvement Activities
 Full Credit
 30% Advancing Care Information
 Weighted mean average of APM participants’ reported scores
1)

37. Game Plan

38. Page 37
Public Reporting
 Individual profile pages
 Participation in APM
 Final Score
 Component scores
 Aggregate data
 Range of Final Scores and component scores

39. Page 38
Reputational Impact
Individual patients
Employment/acquisitions
Provider networks
Medical staff credentialing
Professional liability insurance

40. Page 39
Action Items
 Education
 Group vs. individual reporting
 Pick-Your-Pace
 Quality measure selection and corresponding performance
improvement
 Improvement activities selection and execution
 “Meaningful Use”
 Reporting mechanism(s)
 Preparation for cost performance measures
 Future APM participation

41. Page 40
Faculty Biography & Contact Info
Following a successful two-decade career as a healthcare transactional and regulatory attorney,
Martie Ross now serves as a trusted advisor to providers navigating the ever-expanding maze of
healthcare regulations. Her profound understanding of new payment and delivery systems and
public payer initiatives is an invaluable resource for providers seeking to strategically position
their organizations for the future. Martie identifies opportunities and develops realistic plans of
action where others only see obstacles.
Martie has an uncanny ability to synthesize complex regulatory schemes and explain in
straightforward and practical terms their impact on providers. She has made hundreds of
presentations to professional and community organizations on a broad range of industry topics.
Martie provides dynamic, customized educational and planning sessions for directors, executives,
and managers, as well as employee compliance training programs.
Martie Ross
Principal, PYA
mross@pyapc.com
(913) 748-4604

42. Page 41
Faculty Biography & Contact Info
Graham M. Fox has over 15 years’ experience overseeing the strategic, operational, and
financial growth of physician practices. He specializes in physician practice/health
system integration and has held multiple senior leadership roles in both nonprofit systems
and academic medical centers where he led numerous physician acquisitions and
integrations, as well as practice startups, turnarounds and employment agreement
negotiations. He returned to consulting in 2015 and has since led numerous projects in
revenue cycle efficiency, organizational development, and provider compensation
redesign. Graham is a Fellow of the American College of Healthcare Executives and
currently resides in Dalton, GA with his wife and two daughters.
Graham M. Fox
Consulting Senior Manager, PYA
gfox@pyapc.com
(404) 266-9876 x2156

43. Page 42
Bibliography/References
 Medicare Program; Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule,
and Criteria for Physician-Focused Payment Models (Final Rule)
 https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-
merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm
 CMS/Medicare – Physician Compare
 https://www.medicare.gov/physiciancompare
 PYA White Paper
 http://www.pyapc.com/pya-white-paper-helps-providers-master-mips/