mips apm for acos: a hybrid reimbursement model
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15th November, 2017 | Author: Sonu Abraham, Healthcare Business Analyst,
Vinod Chavan, Healthcare Consultant
CitiusTech Thought
Leadership
MIPS APM for ACOs:
A Hybrid Reimbursement Model
2
Objective
CMS announced the Quality Payment Program (QPP) final rule in October 2017, stating how itplans to implement the clinician payment changes to QPP, mandated under the Medicare Accessand CHIP Reauthorization (MACRA) act
The implementation of the MACRA act impacts different type of organizations, one such beingthe Accountable Care Organizations (ACOs). ACOs are evaluated for payments on the basis ofquality care and the cost factors associated in achieving their quality goals
Post-MACRA implementation, all clinicians will receive payments as per the MIPS (Merit basedincentive payments) and Advanced APMs (Advanced alternative payment models). ACO’s canregister as APM entities and are eligible to receive payments under Advanced APMs
There is a third category of APM entities which participate in Advanced APMs models but do notmeet the threshold of payments and patients set by CMS. Such entities fall into a category that isstraddling the line between APM and the MIPS track, called MIPS APM (partially qualifying APMparticipants). This document discusses about the reporting, scoring and payments for the MIPSAPM entities
Who would benefit?
Providers willing to learn about changes post the final rule for 2nd year of MACRA - 2018
Providers reporting as ACOs and looking for payment adjustments for 2019 onwards
Providers who have decided to take the ACO path
Providers still deciding or considering to take a suitable path post MACRA reform
3
Overview & Threshold Criteria for Advanced APMs
Steps to Register as an ACO
Scoring Criteria for MIPS APM Entities
Reporting Timelines and Requirements for MIPS APM Entities
Payment Adjustments for MIPS APM Entities
Key Takeaways
References
Agenda
4
ACO Tracks Eligible for MIPS APMs
Medicare Shared Savings Program (MSSP)
• MSSP Track 1 (One sided risk) *
• MSSP Track 2 (Two-sided risk) **
• MSSP Track 3 (Two-sided risk) **
Next Generation Accountable Care Organization (NGACO) **
Comprehensive Primary Care Plus (CPC+) initiative **
Oncology Care Model (OCM- one and two sided risk arrangement) **
Comprehensive ESRD Care (CEC) Model (LDO arrangement) **
Comprehensive ESRD Care (CEC) Model (non LDO one and two-sided risk arrangement) **
MIPS APM Overview
Eligible Clinicians (ECs) in APMs not meeting patient and payment thresholds become a part of MIPS APM subset
ECs in MIPS APMs are scored using the APM Scoring Standard
Under the APM scoring standard, ECs are subject to the MIPS reporting requirements and payment adjustments
Using the APM Scoring Standard, one final score for the APM entity is calculated and applied to all ECs within the APM entity
ECs in MIPS APMs are not eligible for the annual AAPM 5% lump-sum bonus payment
One-sided risk model (Track 1) is subject to MIPS reporting requirements while two-sided risk model (Track 2 & 3) and other AAPMs will be subject to Advanced APM reporting requirement (if threshold is met)
* Alternative Payment Models (APMs)
** Advanced Alternative Payment Models (AAPMs)
5
Threshold Criteria for Advanced APMs
ACOs have to meet the following thresholds to be eligible for payments under Advanced APMs, those which do not fulfill this criteria become a part of MIPS APM
Payment Threshold Patient Threshold
The collective Part B payment for services provided to attributed beneficiaries should be at least 25% of all the services provided to attribute-eligible beneficiary.
The collective number of patients who receive services delivered should be at least 20% of all the patients who are attribute-eligible and received services.
Payment Year 2019 2020 2021 2022 2023 2024+
QP Payment Threshold 25% 25% 50% 50% 75% 75%
QP Patient Count Threshold 20% 20% 35% 35% 50% 50%
Threshold increases every two years until 2023 and remains flat afterwards. ACOs not qualifying these thresholds will become a part of MIPS APM entities.
6
Steps to Register as an ACO
Register as MSSP Track 1 ACO
For 3 years report on 31 ACO Measures
Apply for 3 years extension
Continue as MSSP Track 1 for 3 more years
Face applicable penalty as per
MIPS
Unable to successfully submit 31 ACO Measures
3 Years2018 2024
Upgrade ACO Track (APM’s/AAPM’s)
Can move to advance ACO track after 1 year of successful reporting or can be in one track for maximum period of 3 years.
3 Years
2021
Registering as an ACO
7
In 2018 CMS aligned weighting of scores across all MIPS APMs
MSSP tracks and Next Gen ACO can report the same quality measures that is part of PQRS quality measure set
A cumulative score will be calculated for all providers reporting as a group under these tracks which will help all physicians to receive equal reimbursement
Category.
Year 2017 Year 2018
MSSP Tracks & Next Gen ACO
Other MIPS APMs All MIPS APMs
Quality 50% 0% 50%
Cost 0% 0% 0%
Advancing Care Information
30% 25% 30%
ImprovementActivities
20% 75% 20%
MIPS APM Scoring: Transition Year 1 (2017) & Year 2 (2018)
8
Performance Category
MIPS MIPS – APM
Year 2017 2018 2019 2017 2018 2019
Quality 60% 50% 30% 50 50Not
defined
Cost 0 10% 30% 0 0 0
Advancing Care Information
15% 25% 25% 30 30Not
defined
Improvements Activities
25% 15% 15% 20 20Not
defined
Benefit to MIPS APM over MIPS Scoring Standard
CMS scores clinicians and groups on four categories: Quality, Cost, Advancing Care Information (ACI) and Improvement Activities (IA). Each performance category is assigned a weightage which cumulatively comes to 100%.
*
* As per CMS MIPS APM entities will not be scored on cost measures for 2018 and future years hence reduced burden of reporting these measures.
Payment for performance years 2017,2018 and 2019 will be done in the year 2019,2020,2021 respectively.
9
Data Gathering& Integration
Measure Computation
Measure Validation
Measure Submission
Final date forApplication
1st Jan 2018 Mid 2018 31st Dec 2018
Mid Jan 2019
Mid Feb 2019
31st Mar 2019
Reporting EndsPerformance Period31st July2017
31st May2017
Final date forNOIA
MIPS APM Reporting timelines
ACOs following MIPS APM Reporting Standard must report for full year: 1st Jan to 31st Dec 2018
The reporting for 2018 ends by 31st March 2019
CMS is yet to publish the dates for those providers who want to register as ACOs for 2019
10
ACO NQF Domain Measure Title Reporting Method
ACO-1 NQF 005Patient / Care Giver Experience
CAHPS: Getting Timely Care, Appointments, and Information
Survey
ACO-2 NQF 005Patient / Care Giver Experience
CAHPS: How Well your Providers Communicate
Survey
ACO-3 NQF 005Patient / Care Giver Experience
CAHPS: Patients’ Rating of Provider Survey
ACO-4 N/APatient / Care Giver Experience
CAHPS: Access to Specialists Survey
ACO-5 N/APatient / Care Giver Experience
CAHPS: Health Promotion and Education
Survey
ACO-6 N/APatient / Care Giver Experience
CAHPS: Shared Decision Making Survey
ACO-7 N/APatient / Care Giver Experience
CAHPS: Health Status/Functional status
Survey
ACO-34 N/APatient / Care Giver Experience
CAHPS: Stewardship of Patient Resources
Survey
Reporting MIPS APM Survey Measures
Providers reporting PQRS CAHPS measures can report the same measures for MSSP Tracks and Next Gen ACOs MIPS APM reporting.
11
ACO PQRS NQF Domain Measure TitleData Submission Method
ACO-12 PQRS 46 NQF 009CC / PatientSafety
Medication Reconciliation Post Discharge
Web Interface
ACO-13 PQRS 154 NQF 0101CC / PatientSafety
Falls: Screening for Future fall Risk Web Interface
ACO-14 PQRS 110 NQF 0041Preventive Health
Preventive Care and Screening: Influenza Immunization
Web Interface
ACO-15 PQRS 111 NQF 0043Preventive Health
Pneumonia Vaccination Status for Older Adults
Web Interface
ACO-16 PQRS 128 NQF 0421Preventive Health
Preventive Care and Screening: Body Mass Index Screening and Follow-Up
Web Interface
ACO-17 PQRS 226 NQF 0028Preventive Health
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Web Interface
ACO-18 PQRS 134 NQF 0418Preventive Health
Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan
Web Interface
Reporting MIPS APM Web Interface Measures (1/2)
Providers reporting PQRS measures can report the same web interface measures under MSSP Tracks and Next Gen ACOs reporting.
12
ACO PQRS NQF Domain Measure TitleData Submission Method
ACO-19 PQRS 113 NQF 0034Preventive Health
Colorectal Cancer Screening Web Interface
ACO-20 PQRS 112 NQF 2372Preventive Health
Breast Cancer Screening Web Interface
ACO-42 PQRS 438 N/APreventive Health
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Web Interface
ACO-40 PQRS 411 NQF 0710At Risk Population
Depression Remission at 12 Months
Web Interface
ACO-27 PQRS 1 NQF 0059At Risk Population
Diabetes: Hemoglobin A1c Poor Control
Web Interface
ACO-41 PQRS 117 NQF 0055At Risk Population
Diabetes Eye Exam Web Interface
ACO-28 PQRS 236 NQF 0018At Risk Population
Controlling High Blood Pressure Web Interface
ACO-30 PQRS 204 NQF 0068At Risk Population
Ischemic Vascular Disease: Use of Aspirin of another Antithrombotic
Web Interface
Reporting MIPS APM Web Interface Measures (2/2)
Providers reporting PQRS measures can report the same web interface measures under MSSP Tracks and Next Gen ACOs reporting.
13
Reporting MIPS APM Meaningful Use & Claim Measures
ACO Domain Measure Title Method of data Submission
ACO-8 CC / Patient Safety Risk-Standardized, All Condition Readmission Claims
ACO-35 CC / Patient SafetySkilled Nursing Facility 30-Day All-Cause Readmission Measures (SNFRM)
Claims
ACO-36 CC / Patient SafetyAll-Cause Unplanned Admissions for Patients with Diabetes
Claims
ACO-37 CC / Patient SafetyAll-Cause Unplanned Admissions for Patients with Heart Failure
Claims
ACO-38 CC / Patient SafetyAll-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions
Claims
ACO-43 CC / Patient SafetyAcute Composite (AHRQ Prevention Quality Indicator [PQI] #91)
Claims
ACO-44 CC / Patient Safety Use of Imaging Studies for Low Back Pain Claims
ACO- 11 CC / Patient Safety Use of Certified EHR TechnologyMeaningful Use Certified EHR(QPP)
ACOs do not need to collect or submit additional data aside from normal billing activities. The CMS ACO Program Analysis Contractor (ACO PAC) will coordinate with CMS to obtain the necessary Medicare claims files and calculate the rates for these measures for each ACO.
14
Exceptional performers receive additional positive adjustment factor up to $500M available each year from 2019 to 2024
For instance, a Provider is reporting as MSSP track 1 ACO with a revenue of approximately 100 million. For the consecutive years 2019 to 2022 payments will be calculated at 4%, 5%,7%,9% respectively as per the Composite Performance Score (CPS) received by the ACOs
The CPS is the weighted sum of the points in four performance categories that determine the payment adjustments ranging from 0-100 points. 3 points being the minimum to avoid any penalties and up to 100 points to receive the maximum payment adjustment.
Payment Adjustments for MIPS APM Entities
*
15
Key Takeaways
A path towards ACOs is beneficial as it is a move providers towards greater accountability and improved quality of care. MIPS APM scoring has clear benefits. It’s a win-win situation for both patients and providers
ACOs have additional benefits in MIPS scoring category with zero weightage on resource use measures (i.e. costs). There is greater overall weight to the quality category in which ACOs are expected to perform very well
No additional reporting requirements for claim measures. CMS will collect the information from ACOs and report these measures
ACOs that are MIPS APM entities will directly receive half of the total points for Clinical Practice Improvement Activities and also have the benefit to gain rest of the points by additional reporting
Advantages for specialists practices is that ACOs refer patients to specialists they know to support high quality and coordinated care so specialists participating in an ACO may increase their referral base
Two-sided ACOs that meet the QP thresholds (who are not MIPS APM) would earn a 5 percent bonus annually from 2019 through 2024. This bonus is in addition to the shared savings ACOs can earn through MSSP or the Next Generation ACO model, and the shared savings rate for these ACOs is greater than that available to track 1 ACOs
ACOs with IT infrastructure have a huge benefit over others who don’t, as they are able to manage, track and have easy access to quality data to support their findings. ACOs can leverage IT capabilities to identify gaps , fix the areas causing revenue loss and improve quality of patient care
Participating in an advanced track will be an opportunity for providers to be a part of innovative ways of healthcare delivery
16
References
http://www.aafp.org/practice-management/payment/medicare-payment/mips-apms.html
http://healthcareblog.pyapc.com/2017/05/articles/accountable-care-organizations/the-intersection-of-mips-and-mssp-how-the-apm-scoring-standard-works/
https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf
https://naacos.memberclicks.net/naacos-comments-letter-on-macra-final-rule
17
Thank You
Authors:
Sonu Abraham
Healthcare Business Analyst
Vinod Chavan
Healthcare Consultant
thoughtleaders@citiustech.com
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