Macra 2017

1. MACRA DR. JOSE DELGADO

2. Points to Consider CMS Programs MACRA

3. Qualified Providers • MD/DO •Physician Assistants •Nurse Practitioners •CRNAs •Clinical Nurse specialists •Groups of previous blocks Qualified (Year 1 & 2) • Physical Therapists • Speech Pathologists • Audiologists • Nurse midwives • Clinical psychologists • Dietitians / Nutritionist •Speech Pathologists •Audiologists •Nurse Midwives •Clinical Psychologists •Dietitians / Nutritionists Future Consideration (Year 3+)

4. Basic Options APM MIPS MACRA

5. MACRA Models Advanced Alternative Payment Models (APMs) Higher risk model Risk is shared throughout APM Limited number of acceptable models Rules to being considered a qualified provider (QP) Merit Based Incentive Program (MIPS) Designed for individuals and small group practices Not all or nothing. Can receive partial credit. Incentive based on sliding scale. Replaces all current incentive programs Fee for service with adjustments based on performance Note: APM = Risk Most Providers are expected to choose MIPS

6. MACRA – MIPS Components Quality Reporting /PQRS Resource Use or Cost (Value-based Modifier) Advancing Care Information (MU) Clinical practice improvement activities MIPS

7. 45% 15% 15% 25% 2020 MIPS PAYMENT YEAR 30% 30% 15% 25% 2021+ MIPS PAYMENT YEAR *The weight for advancing care information could decrease (not below 15 percent) if the Secretary estimates that the proportion of physicians who are meaningful EHR users is 75 percent or greater. The remaining weight would then be reallocated to one or more of the other performance categories. How is Performance Categorized in MIPS? 60% 15% 25% 2019 MIPS PAYMENT YEAR Quality Resource UseAdvancing Care Information* CPIA Weighting

8. How is Performance Determined in MIPS? Quality performance category score x Quality performance category weight Resource Use performance category score x Resource Use performance category weight CPIA performance category score x CPIA performance category weight Advancing Care Information performance category score x Advancing Care Information performance category weight 100 Composite Performance Score (CPS) 0-100 point scale

9. 2019 2020 2021 2022 + 4% 5% 7% 9% 4% 5% 7% 9% Financial Incentives and Adjustments Through MIPS  Lowest 25% = maximum reduction  Exceptional performance bonuses can be up to another 10% up to $500M available each year from 2019 to 2024  MIPS will be a budget-neutral program. Total upward and downward adjustments will be balanced so that the average change is 0%. Performance Threshold Mean/Median CPS

10. Penalties Comparison < 2017 2019 Adjustments PQRS - 2 % MU - 5 % Value Based Modifier - 4 % or more Total Penalty Risk - 11 % or more Bonus Potential Value Based Modifier Unknown MIPS Factors 2019 Scoring Quality (PQRS) 60 % Advancing Care Information (MU) 25 % Clinical Improvement Activities 15 % Total Penalty Risk - 4 % Bonus Potential 4 % Max Bonus Potential for High Performers 10 % Prior to MACRA MACRA

11. Quality Reporting Basics - PQRS •60% in 2019 •45% in 2020 •30% in 2022 MIPS weight •6 measures instead of 9 (200 measures available), reported by physicians •One cross-cutting measure, one outcome measure •2 population health measures calculated by CMS administratively via claims (Groups of 2 or more) Measures •Each measure worth up to 10 points •80 total points for small groups 90 total points for groups >10 •Distribution of points for each measure based on performance benchmarks (80% for claims reporting, 90% for registry reporting) Scoring •Up to 4 bonus points may be added for reporting on outcome and high priority measures •1 bonus point possible for each measure captured and reported through CEHRT •Total bonus points capped at 5% of those used to calculate the quality score Bonus points

12.  Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.  Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.  Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.  Controlling High Blood Pressure: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.  Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. MIPS Proposed Cross-Cutting Measures

13.  Closing the Referral Loop: Receipt of Specialist Report: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.  Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.  Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user  Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. MIPS Proposed Cross-Cutting Measures

14. Advancing Care Information - MU •25% in 2019 •25% in 2020 •25% in 2022 • May be reduced if >75% of clinicians are successful MIPS weight •Protect Patient Information (Security Risk Analysis) – Yes/No •e-Prescribing - Numerator/Denominator •Provide Patient Access - Numerator/Denominator •Send Summary of Care - Numerator/Denominator •Request/Accept Summary of Care - Numerator/Denominator • Public Health and clinical data registry reporting – Yes/No Measures •50 points for achieving 6 objectives (pass/fail) •Immunization registry reporting required; •Provide numerator/denominator or yes/no attestation for each Scoring •Reporting to more than one public health registry earns bonus pointBonus points

15. Advancing Care Information ▪ To receive the base score, physicians must simply provide the numerator/denominator or yes/no for each objective and measure ▪ The overall Advancing Care Information score would be made up of a base score and a performance score for a maximum score of 100 points ▪ Protect Patient Information (Security Risk Analysis) yes required or no points allotted

16. Advancing Care Information Performance Category Score capped at 100 points with greater than 100 points available to allow more flexibility to achieve the maximum score. 100 points or more translates into 25 points in final score Base Score Performance Score Bonus Point Composite Score 50 Points 80 Points 1 Point Maximum 100 points

17. Advancing Care Information – Base score ▪ Protect Patient Information (Security Risk Analysis) – Yes/No ▪ e-Prescribing - Numerator/Denominator ▪ Provide Patient Access - Numerator/Denominator ▪ Send Summary of Care - Numerator/Denominator ▪ Request/Accept Summary of Care - Numerator/Denominator • Public Health and clinical data registry reporting – Yes/No

18. Advancing Care Information – Performance Score Performance Score (80 Points) ▪ Patient Electronic Access ▪ Coordination of Care through patient engagement ▪ Health Information Exchange Bonus Point (1 Point) ▪ Immunization registry is required, but reporting to another surveillance registry will award 1 bonus point to over all ACI score.

19. Clinical Practice Improvement Activities - New •15% in 2019 •15% in 2020 •15% in 2022 MIPS weight •9 activity categories •90+ activities •Do not need activities in each category •Attest to four medium-weighted or two high-weighted activities Measures •60 points = 100% CPIA score •7 of 8 categories have both high (20 points) and medium (10 points) weighted activities Scoring

20. Subcategories 1.Expanded Practice Access Beneficiary Engagement Achieving Health Equity Population Management Patient Safety and Practice Assessment Emergency Preparedness and Response Care Coordination Participations in APM including Medical Home Model Integrated Behavioral and Mental Health

21. CPIA categories and examples Expanded Practice Access 24/7 access to clinicians/care teams Use of telehealth Patient experience data used to improve practice Population Management Participation in systematic anticoagulation program Participation in CMMI models such as Million Hearts Campaign QCDR participation that includes use of data for QI Care Coordination Participate in Transforming Clinical Practice Initiative Closing the referral loop Develop and update individual care plans Beneficiary Engagement Collect / follow up on patient experience & satisfaction data Use QCDR for shared clinical decision making Provide access to enhanced patient portal 20 point activities All others are 10 point activities

22. CPIA categories and examples--continued Patient Safety & Practice Assessment Consult PDMP for Schedule- II opioid prescriptions of >3 days Participate in MOC part IV Complete AMA STEPS Forward program Achieving Health Equity Timely care for Medicaid patients (including duals) Participate in State Innovation Model activities Use QCDR to screen for social determinants of health Emergency Response & Preparedness Participate in Disaster Medical Assistance teams Participate in domestic or international humanitarian volunteer work Integrated Behavioral & Mental Health Colocation of mental health services in clinical care settings Depression screening and follow-up planning Prevention & treatment for unhealthy alcohol or tobacco use 20 point activities All others are 10 point activities

23. Resource Use – Value Modifier •0% in 2019 •15% in 2020 •30% in 2022 MIPS weight •CMS will calculate administratively via claims over full year •40+ episode specific measures •No data submission required Measures •10 points, calculated average of all attributable cost measures (worth 10 points each) •20 patient sample required for measure attribution •If patient volume insufficient for all measures, score is zero and other MIPS categories will be reweighted Scoring

24. Submission of Data – Individual Quality (PQRS) • CAHPS for MIPS • Administrative Claims • EHR Vendors • Qualified Registry • Qualified Clinical Data Registry Advancing Care (MU) • Attestation • EHR Vendors • Qualified Registry • Qualified Clinical Data Registry Clinical Practice Improvement Activities • Attestation • Administrative Claims • EHR Vendors • Qualified Registry • Qualified Clinical Data Registry CAHPS = Consumer Assessment of Healthcare Providers and Systems

25. Submission of Data – Groups Quality (PQRS) • CMS Web Interface (Groups of 25 or more) • Administrative Claims • EHR Vendors • Qualified Registry • Qualified Clinical Data Registry Advancing Care (MU) • Attestation • CMS Web Interface (Groups of 25 or more) • EHR Vendors • Qualified Registry • Qualified Clinical Data Registry Clinical Practice Improvement Activities • Attestation • CMS Web Interface (Groups of 25 or more) • EHR Vendors • Qualified Registry • Qualified Clinical Data Registry

26. Program Cycle 2017 Performance Year Data Submission Mar 31, 2018 Payment Adjustment Jan 1, 2019

27. Options - % + % + %0 Don’t Participate • No data Submitted • Receive a negative 4% payment adjustment Submit Something • Submit minimum amount of data • Avoid downward adjustment Partial Year • Submit 90 days • May earn a neutral or small positive adjustment Full Year • Submit a full year • May earn a moderate positive payment adjustment Current Payment Don’t Participate Submit Something Partial Year Full Year

28. Considerations and Recommendations Considerations Bipartisan Support – not going anywhere Budget Neutral Measurements started 1 Jan 2017 Payment adjustments begin 1 Jan 2019 Recommendations Submit Meaningful Use Attestation Analyze current data collection and select measures Aim to submit data for full year Review measures monthly

29. Questions Taino Consultants Inc. Dr. Jose Delgado www.TainoConsultants.com DrDelgado@TainoConsultants.com

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