MACRA and the New Quality Payment Program

MACRA and the New
Quality Payment Program:
Most Frequently Asked
Questions

© 2016 Health Catalyst
Proprietary and Confidential
Responses from webinar in May 2016 after release of
proposed regulations
Are we ready?
2
12%
23%
56%
8%
1%
0%
10%
20%
30%
40%
50%
60%
Not at all Somewhat Unsure Ready Very Ready
How ready are you to participate in MACRA?

• New rule on how Medicare pays doctors
• Broader push to overhaul Federal health spending
• New bonus and penalties tied to performance
• Anne Phelps, U. S. healthcare regulatory director, Deloitte
“It’s a disruptive law.”
October 14- Wall Street Journal Article
3
Source: U.S. Officials Finalize Rule for Medicare Payment to Doctors
Melanie Evans, Oct 14, 2016

(1)Support care improvement by focusing on better
outcomes for patients, decreased provider burden,
and preservation of independent clinical practice;
(2) Promote adoption of alternative payment models that
align incentives across healthcare stakeholders;
(3) Advance existing efforts of Delivery System Reform,
including ensuring a smooth transition to a new
system that promotes high-quality, efficient care
through unification of CMS legacy programs.
Aims of Quality Payment Program
4

What is a good source? Qpp.cms.gov
5

Disruption signs
New future
New language
New economics
Source: Healthcare Disrupted, Jeff Elton and Anne
O’Riordan
Are we at a tipping point?
6

Two Tracks
7
2017 2019
2020
2018
.5% annual update
thru 2019
Combine
MU,
PQRS,
VBM
2018
MIPS
APM QP
2019
Performance year
+/- 5%
2021 2022
+/-4% +/- 7% +/- 9%
2017
Performance year
2023
20242020
2021 2022
2023
2024

Why is 2017 so important?
Transition Year
8

CMS Expenditures
9
30%
28%
19%
11%
4% 4%
2% 2%
0%
5%
10%
15%
20%
25%
30%
35%
Inpatient OP PAC Physician E&M Hospice Part B DME Ambulance
2014 Breakout of CMS Expenditures
Source: Geographic variation file from CMS
89% of beneficiaries used
E&M code
13,058 encounters per
1,000 beneficiaries

Potential for Bonus Points
10

• Removed for first year, weighted at 10% for 2020
• Based on per capita and 10 episodes
Examples: Lens and cataract procedures
Hip repair or replacements
Knee arthroplasty
• CMS will calculate from claims
Cost Performance – Weighted 0%
11

Did you know this data is available?
State with high spending
12

Reporting period will be annual - only see your results
once a year
First report due March 2018
First feedback report – August 2017
When do I need to report for 2017?
13

MIPS
Merit-based
Incentive Payment
System

Status quo
15

Interesting Fact #1:
A survey conducted in March, 2016 by Weill
Cornell Medical College and the Medical Group
Management Association (MGMA) found that
physicians spend an average of ??? hours
every week processing quality metrics.

Interesting Fact #2:
The time physicians spend processing quality
metrics translates to an average cost of
$40,069 per physician, per year

MIPS combines 3 existing programs:
EHR (MU) Incentive Program
VBPM (Value Based Payment Modifier)
PQRS (Physician Quality Reporting Program)
And ADDS Clinical Practice Improvement Activities
Between approximately 592,000 and 642,000 eligible clinicians will be required to
participate in MIPS in its transition year.
Practices with fewer than 15 providers and in rural areas may be qualified for technical
assistance. Estimate of 14% providers will be low volume and excluded.
CMS expects MIPS to evolve and change
18

Proprietary and Confidential19
The rule defines a group as a
single Taxpayer Identification
Number (TIN) with two or
more MIPS eligible clinicians,
as identified by their
individual National Provider
Identifier (NPI), who have
reassigned their Medicare
billing rights to the TIN.

Are you in the low volume threshold that
is excluded? This is $30,000 in Part B
charges OR less than or equal to 100
Medicare patients.
Newly Medicare-enrolled EP’s are also
excluded from reporting the first year.
Or you are a QP (Qualified Provider) as
part of an APM
For MIPS do I need to report individually or as a
group?
20
Are you part of the Exclusion Criteria?

Additional considerations for reporting as an
individual or a group:
21
1. Do you report to other external agencies today with your TIN or NPI
number? Do you participate in MU, PQRS or other reporting today? If
so, review the performance and how successful you are.
2. The submission requirements for Groups and Individuals are different.
You must participate in MIPS as a whole, either as a group or an
individual; not mixed. Group reporting performance will be assessed
and scored across the TIN and MIPS payment adjustments applied to
the group level of the eligible clinicians in the group.
3. You can join virtual groups in the future years once CMS has
determined that definition.

Composite Performance Score (CPS)
22
Area Weight in 2019
(Changes by year)
Quality 60%
Cost 0%
Improvement activities 15%
Advancing care information (Meaningful use of
certified EHR technology)
25%

• Stay in the pit and get penalty
• Try one lap
• Try one lap for 90 days
• Go for the entire race
Pick your pace in 2017
23

Full vs Minimal Participation
24
Report on 6 quality measures OR 1 specialty-
specific or subspecialty specific measure set
one of those should be an outcome measure if
available, if no outcome measure available then
report on a high priority measure
Report on 4 medium weighted activities OR 2
high weighted activities in the Improvement
Activities performance category
Report on 5 Advancing Care measures;
additional measures for potential bonus3.
Report on 1 quality measures if not a group
submission; if a group submission via CMS
Web Interface, more measures are required
Report on 1 high weighted measure in the
Improvement Activities performance category
3.
Report on the 5 required Advancing Care
measures
2.
1.
2.
1.
90 Days Minimal-Full Year
And/Or
And/Or

Neutral MIPS adjustment because the performance threshold is
set at 3 points
Scoring Minimal Participation for the first year
25
Individual A:
Submits 1 Quality Measure, No Improvement activity or ACI data
Quality
3 pts
out of
60
((5% * 60%) + (0%* 15%) + (0%* 25%) * 100)
Improvement
0 pts out of
40
ACI
0 pts
out of
100%
CPS
3 Points

Neutral MIPS adjustment because the performance threshold is
set at 3 points
Scoring Minimal Participation for the first year
26
Group A:
Submits 0 Quality Measure, 1 Improvement Activity and no ACI
Quality
0 pts
out of
60
((0% * 60%) + (.25%*15%) + (0%*25%) *100)
Improvement
10 pts out of
40
ACI
0 pts
out of
100%
CPS
3.75 Points

Clinicians who achieve a final score of 70 or higher will
be eligible for the exceptional performance adjustment,
funded from a pool of $500 million.
Scoring Full Participation for the first year
27
Individual or Group A:
Submits 6 Quality Measures, 4 Improvement activities and 5 required ACI measures
Quality
50 pts
out of
60
((83% * 60%) + (75%*15%) + (60%*25%) *100)
Improvement
30 pts out of
40
ACI
60 pts
out of
100%
CPS
76 Points

1. What is your organization currently doing?
2. Alignment efforts with Medicaid measure sets and
Core Quality Measure Collaborative is under way:
“Our strategic interest is a future state where measurement in multi-payer
systems, Medicaid, and Medicare can be seamlessly integrated into CMS
programs.” page 424 CMS-5517FC.pdf
3. This is 60% of your composite score the first year.
Existing measures finalized in CMS-1631-FC
What Quality Measures should you report?
28

1. There are 13 High Quality Measures and at least one must be selected from these 8
subcategories:
2. Are you participating in other activities such as a registry, Million Hearts, CMS
Transforming Clinical Practice Initiative, Health Information Exchange, Patient Experience and
Satisfaction Survey, Consumer Assessment of Healthcare Providers and Systems Survey,
Domestic or International volunteer work for 60 or more days as an example as these are
included in the Improvement activity measures.
3. Review what activities you are currently doing and align these Improvement Activities to
what is important to your practice.
4. This is 15% of your composite score the first year.
Improvement Activities
29
Expanded Practice
Access
Population
Management
Care Coordination Beneficiary
Engagement
Patient Safety and
Practice Assessment
Achieving Health
Equity
Emergency Response
and Preparedness
Integrated Behavioral
and Mental Health

*Refer to Section II.E.5.g(7)(a) of final rule for final changes
30
Advancing Care Information
Objective
Advancing Care Information
Measure*
Required/ Not Required for Base
Score (50%)
Performance Score (up
to 90%)
Reporting Requirement
Protect Patient Health Information Security Risk Analysis Required 0 Yes/No Statement
Electronic Prescribing e-Prescribing Required 0 Numerator/ Denominator
Patient Electronic Access
Provide Patient Access Required Up to 10% Numerator/ Denominator
Patient-Specific Education Not Required Up to 10% Numerator/ Denominator
Health Information Exchange
Send a Summary of Care Required Up to 10% Numerator/ Denominator
Request/Accept Summary of Care Required Up to 10% Numerator/ Denominator
Clinical Information Reconciliation Not Required Up to 10% Numerator/ Denominator
Coordination of Care Through
Patient Engagement
View, Download, or Transmit (VDT) Not Required Up to 10% Numerator/ Denominator
Secure Messaging Not Required Up to 10% Numerator/ Denominator
Patient-Generated Health Data Not Required Up to 10% Numerator/ Denominator
Public Health and Clinical Data
Registry Reporting
Immunization Registry Reporting Not Required 0 or 10% Yes/No Statement
Syndromic Surveillance Reporting Not Required Bonus Yes/No Statement
Electronic Case Reporting Not Required Bonus Yes/No Statement
Public Health Registry Reporting Not Required Bonus Yes/No Statement
Clinical Data Registry Reporting Not Required Bonus Yes/No Statement
Bonus (up to 15%)
Report to one or more additional public health and clinical data
registries beyond the Immunization Registry Reporting measure
5% bonus Yes/No Statement
Report improvement activities using CEHRT 10% bonus Yes/No Statement
Advancing Care Information Performance Category

Proprietary and Confidential31
Webinar in February 2017
We are working to help organizations
and providers align their efforts,
measure their performance and help
gather the necessary data for reporting.

Work towards
32
Alignment
of Effort

Advanced APM
Advanced
Alternative Payment
Model

Goals of CMS
• Overall goal – 90% of
Medicare payments shifted to
quality or value by 2018
• Encourage participation in
APMs
• Expand to other payers
• Goals:
• Better care
• Smarter spending
• Healthier people
34

• Participants use CEHRT
• Payment received on quality measures comparable to
quality measures under MIPS
• Bear risk for monetary loss or be “MACRA” Medical
Home Model
Advanced APM requirements
35

• Comprehensive ESRD Care Model (Two sided risk)-
12 participants
• Medicare Shared Savings Program—Track 2 and
Track 3 – 24 participants
• Next Generation ACO Model -21 participants
• Comprehensive Primary Care Plus (CPC+)
• Oncology Care Model Two-Sided Risk Arrangement
FINAL LIST to be published by January 2017
Models that Qualify for Advanced APM
36

During a specific period comparing actual to expected
expenditures:
• Withhold payments to AMP entity
• Reduce payments to AMP entity
• Require APM entity to owe payment to CMS
Separate Medical Home Model Financial Risk Standard
Standard Provisions for Financial Risk
37

• New Medicare ACO Track 1+ Model for 2018
• New voluntary bundled payment model
• Comprehensive Care for Joint (CEHRT)
• Advancing Care Coordination thru Episode (CEHRT)
• Medical Home Model
List will grow, forecast 25% of clinicians by 2018
Pathways to performance-based risk
38

Alternative
Payment
Model
Advanced
APM
Advanced
APM
Entity
Qualifying
Participant
Process
39

First qualify as advanced APM, then go to next step
QP Qualified Participants
Estimate 70,000 to 120,000 providers in
2017
Advanced APM Entity
40

Quality Participants (QP) Thresholds
Payment amount formula Patient Count formula-more flexible
** Partial QP could select MIPS
Professional services at CAH, FQHC ACO,
RHC ACO
41
2019 QP 25%
2019 Partial QP 20%
2019 QP 20%
2019 Partial QP 10%
OR
Snapshots- Three times in 2017
March, June, Aug

Now QP in advanced APM
• Do not participate in MIPS
• Get 5% increase in fee schedule
Met all criteria
42

Physicians, Physician Assistants, Nurse Practitioners,
Clinical Nurse Specialists, Certified Registered Nurse
Anesthetists, groups that include clinicians who bill under
Part B.
However, any practitioner that does not exceed the low
volume threshold of $30,000 in Part B allowed charges;
that has 100 or fewer Medicare patients; is newly
enrolled in Medicare; or is a Qualified Participant in an
Advanced APM.
Who are eligible clinicians subject to MIPS?
44

Final Rule The Changes
Hospital-Based MIPS eligible clinician who furnishes 75 percent or
more of covered professional services in an inpatient
hospital, on-campus outpatient hospital or
emergency room setting in the year preceding the
performance period.
Change from Proposed Rule: The
threshold to determine hospital-based
MIPS eligible clinicians lowered from
90 percent to 75 percent. On-campus
outpatient hospital was added as a
site of service.
Non-Patient Facing • Individual MIPS eligible clinician who bills 100 or
fewer patient-facing encounters (including
Medicare telehealth services) during the non-
patient facing determination period.
• A group where more than 75% of the NPIs billing
under the group’s TIN meet the definition of a
non-patient facing individual MIPS eligible
clinician during the non-patient facing
determination period.
Change from Proposed Rule: The
threshold to determine non-patient
facing status increased from 25 to
100 encounters. Revision to the
methodology of identifying a non-
patient facing group finalized.
Defining Providers in Unique Situations
45

CMS estimates that between 592,000 and 642,000
Eligible clinicians will be required to participate in MIPS in
2017.
How many clinicians will be eligible for MIPS?
46

Physicians “who are practicing in big, well-organized organizations . . . we’re not
worrying about MACRA”…if he were in a small practice, “there would be no way I
could deal with this . . . . It requires scale and leadership and management to
respond.”
Thomas H. Lee, M.D. CMO for the Press Ganey patient experience consulting firm
“MIPS and APM are very bad for the solo practitioner. They likely signify the
destruction and death of the one- and two-doctor practices, particularly primary
care physicians.”
A family practitioner in Georgia
“I’m frankly not going to report and take the penalty. It’s not worth it to report”.
Family physician in Southern California
What doctors are saying about MACRA
47

How did MACRA benefit practitioners?
48
Without the passage of MACRA, physicians could have been
subject to negative payment adjustments of 11% or more in 2019
as a result of the MU, PQRS and VBM programs, with even
greater penalties in future years. In contrast, under MACRA, the
largest penalty a physician can experience in 2019 is 4%. MACRA
also provides incentives for physicians to develop and
participate in different models of health care delivery and
payment known as alternative payment models (APMs).

Another reason to report: it’s all reported
publicly! Physician Compare

Doctors have urged CMS to "Make the transition to
MACRA as simple and as flexible as possible."
Andy Slavitt, Acting CMS Director
Is CMS Listening?
50

“The AMA believes the actions that the administration
announced today will help give physicians a fair shot in
the first year of MACRA implementation. This is the
flexibility that physicians were seeking all along.”
Andrew Gurman, M.D., President, AMA
AMA commends CMS
51

• New opportunities to earn incentive payments for above average performance. MIPS presents the 1st real
opportunity for physicians to earn substantial bonuses for providing a higher quality of care. Additional funding is
provided for separate bonuses of up to 10% for exceptional performance, up to $500 million per year, from 2019
through 2024.
• A streamlined performance reporting system, which should be more easily managed than the multiple
existing reporting systems. The CMS currently allows group practices to report via QCDRs starting in 2017,
and MACRA encourages eligible professionals to use these registries for MIPS reporting.
• Improvements in performance scoring over current quality programs:
• Sliding scale assessment.
• Flexible selection of measures. Flexible weighting. The law has guidelines for the weighting of the 4 performance categories, yet
specifically allows administrative flexibility for those in practices or specialties that are at a disadvantage in meeting quality or Advancing
Care Information measure requirements.
• Credit for Improvement Activities.
• New measurement components. Small practices will receive $100 million in technical assistance.
• From fiscal years 2016 through 2020, $20 million per year will assist practices of up to 15 professionals to
participate in the MIPS program or transition to new payment models.
What are the Main Benefits Of Participation In MIPS?
52

Fifty percent say they have never heard of the law and 32 percent recognize it by name but are not
familiar with its requirements.
Twenty-one percent of self-employed or independent physicians say they are somewhat familiar with
the law, compared to nine percent of physicians employed by hospitals, health systems, or medical
groups owned by them.
Eight-in-ten say they prefer traditional fee-for-service (FFS) or salary-based compensation as
opposed to value-based payment models, some of which qualify under MACRA's alternative payment
model (APM) track.
Seventy-four percent of surveyed physicians believe that performance reporting is burdensome and
79 percent do not support tying compensation to quality, both requirements under MACRA.
Fifty-eight percent of physicians say they would opt to be part of a larger organization to reduce
individual increased financial risk and have access to supporting resources and capabilities.
How Ready are Physicians for MACRA?
53
The Deloitte Center for Health Solutions 2016 Survey of US Physicians

Beginning December of 2016 MACRA will provide $100 million to fund training and
education ($20 million each year for 5 years).
Medicare clinicians in individual or small group practices of 15 clinicians or fewer and those
working in underserved areas are eligible to receive this training.
The training will be conducted through local, experienced organizations using this funding
to help small practices select appropriate quality measures and health IT to support their
unique needs, train clinicians about the new improvement activities and assist practices in
evaluating their options for joining an Advanced APM.
Watch websites for additional details.
Assistance Needed!
54

1. Evaluate where you fall under MACRA (MIPS, APM or exempt?)
1. AMA payment model evaluator
2. Are you participating in a qualified clinical data registry, if
not, contact your specialty society about participating in
theirs (data registries can streamline reporting and assist with MIPS
performance scoring)
3. If you practice with >1 eligible clinician decide whether to
report individually or as a group.
4. Determine whether you meet the requirements for small,
rural or non-patient- facing physician accommodations.
What are steps can we take to prepare?
55

5. Access and review the 2014 annual PQRS feedback
reports to see where improvements can be made.
6. Review cost data from CMS in summer of 2017 for 2020
ramifications (attribution).
7. Consider how you plan to report through claims, electronic
health record (EHR), clinical registry, qualified clinical data
registry (QCDR) or group practice reporting option (GPRO)
Web-interface. The GPRO Web-interface is only available
for physicians in practices of 25 or more eligible clinicians.
Steps to take-continued
56

Connect locally with organizations and use their websites
AMA https://www.ama-assn.org/practice-management/medicare-payment-
delivery-changes
AHA http://www.aha.org/advocacy-issues/physician/index.shtml
AAFP http://www.aafp.org/practicemanagement/payment/macraready.html
ONC https://chpl.healthit.gov/#/search list of certified vendors
CMS Quality Payment Program qpp.cms.gov
Resources
MACRA READY programs

Questions
58
Bobbi Brown
Bobbi.brown@healthcatalyst.com
Bryan T. Oshiro, M.D.
Chief Medical Officer
Bryan.oshiro@healthcatalyst.com
Dorian DiNardo
Dorian.dinardo@healthcatalyst.com

Appendix

• MACRA – Medicare Access and CHIP Reauthorization Act of 2015
• SGR – Sustainable Growth Rate (replaced by MACRA)
• MIPS – Merit-based Incentive Payment System
• APM – Alternative Payment Models (Advanced)
• EP – Eligible professional becomes EC Eligible clinician
• ACI- Advancing Care Information (replaces Meaningful Use)
• CPIA –Clinical Practice Improvement Activity
• CPS – Composite Performance Score
Acronyms
60

Proposed Rule Final Rule
Quality • 6 individual measures or 1
measure set with at least one
cross-cutting measure and
outcome measure (if no outcome
measure, one other high priority
measure)
• Required reporting on 80% of
patients(claims method ) or 90%
(other submission methods)
6 quality measures (including
outcome measure) or 1 measure set
(if no outcome measures are
available in the measure set, report
another high priority measure )
Requires reporting on 50% of patients
(all submission methods)
Advancing Care Information (ACI) 11 required measures 5 required measures
Clinical Practice Improvement
Activities (CPIA)
• 6 medium-weighted activities or
• 3 high- weighted activities
• 4 medium-weighted activities OR
• 2 high-weighted activities
Cost (previously called Resource
Use)
Continues measures from the Value
Modifier program and episode-based
measures, as applicable to MIPS
eligible clinicians
Not measured in 2017 performance
year
What do we have to report?
61

Maximum negative adjustment of 4% in MIPS
Reporting Option 1: No Reporting
62

Report some data in 2017 to the Quality Payments
Program (QPP).
Protected from negative payment adjustment in MIPS,
but no positive payment adjustment available either.
Not exactly defined as to what “some data” actually
means.
CMS considers this a test of how doctors will be ready for
more intense reporting requirements in the following
years.
Reporting Option 2: Minimal Reporting
63

Participate for part of 2017.
Eligible for positive payment adjustment
Protected from negative payment adjustment
Participants will be testing their systems for future
MACRA compliance and may end up with a small
Medicare pay increase.
Reporting Option 3: Partial reporting
64

Participate for all of 2017.
Doctors who begin reporting data on January 1st 2017
will be eligible for a “modest” pay increase in 2019
Data on quality measures, use of technology and practice
improvement must be reported
Reporting Option 4: full reporting
65

Participate in an Advanced Alternative Payment Model
Doctors who begin reporting data on January 1st 2017
will be eligible for a “modest” pay increase in 2019
Data on quality measures, use of technology and practice
improvement must be reported
Reporting Option 5: Advanced APM
66

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