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Oklahoma State Medical Association
Jack Beller, MD
2016
MACRA: Fundamentally Changing Physician Practices?
Rev. 10/17/16
© 2016 American Medical Association. All rights reserved.
MACRA
• Repeals the Sustainable Growth Rate (SGR) Formula and sets up 2 payment programs: MIPS and APMs
• Streamlines multiple quality programs (Meaningful Use, PQRS, Value-based Modifier) under MIPs
• APM: Bonus payments for participation in eligible models.
• MIPS: Additional payment for exceptional performance possible
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© 2016 American Medical Association. All rights reserved.
Some general observations
• MACRA is complex
– More than a “replacement for the SGR”
– Regulations can add complications and have
• Many of the new requirements are simply revisions of current requirements
• One goal of MACRA was to simplify administrative processes for physicians
– Compared to recent past/ current framework, the proposed regulations include some improvements but there is more to be done.
– More improvements are needed— to make this less of a burden on doctors’ offices.
• The proposed rule issued in April is a draft attempt to implement a complex law.
– Lengthy and detailed recommendations have been submitted for improvements.
• Final rules were released mid October and are being evaluated at this point.
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© 2016 American Medical Association. All rights reserved.
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MACRA establishes two Medicare paths for physicians
• MACRA was designed to offer physicians two payment model pathways:
• A modified fee-for-service model (MIPS)
• New payment models that reduce costs of care and/or support high-value services not typically covered under the Medicare fee schedule (APMs)
• In the beginning, most (estimated to be about 80%) are expected to participate in MIPS
• There is a third option – do nothing and be guaranteed the maximum penalty for the first year.
MIPS
APMs
Merit-based Incentive Payment System (MIPS)
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© 2016 American Medical Association. All rights reserved.
MIPS components
Quality Reporting (was
PQRS)
Resource Use or Cost (was Value-based Modifier)
Advancing Care Information (was
MU)
Clinical Practice Improvement
Activities
MIPS
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MIPS aims: • Retain a fee-for-service payment option • Align 3 current independent programs • Add 4th component to promote improvement and
innovation • Provide more flexibility and choice of measures Clinicians exempt from MIPS: • First year of Part B participation • Medicare claims < $30K OR < 100 patients • Advanced APM participants • Would exempt 29% of physicians (vs. 10%) while
covering 93% of Medicare spending • Mean Medicare revenue per physician is about
$109K
© 2016 American Medical Association. All rights reserved.
2019 (first year) penalty risks compared MIPS factors 2019 scoring
Quality measurement 50% of score
Advancing Care Info. 25% of score
Resource use 10% of score
Clinical improvement activities 15% of score
Total penalty risk Max of -4%
Bonus potential Max of 4%, plus potential 10% for high performers
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© 2016 American Medical Association. All rights reserved.
Timeline on payment adjustments
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2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 on
Fee Schedule Updates
MIPS
QPs in Adv. APMs
0.5% annual baseline updates No annual baseline updates
4% 5% 7% 9% Max Adjustment (additional bonuses possible)
0.25% or
0.75%
9% 9% 9%
5% bonus
© 2016 American Medical Association. All rights reserved.
Quality Reporting
Quality
6 measures
Partial credit allowed
Flexibility in choice of measures
AMA recommendations
Maintain scoring thresholds at 50% (vs. proposed 80-90%)
Further reduce the number of required quality measures to 4
Simplify the scoring methodology
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© 2016 American Medical Association. All rights reserved.
Resource Use
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Resource Use
Focuses solely on cost/ resource-use; no duplicative quality reporting
41 episode-based measures proposed
Plans to improve attribution methods in 2018 (for 2020 payments)
AMA recommendations
Cost measures flawed, episode groups need testing/ improvement
Improve attribution methods for episodes
Develop pilot rather than using flawed measures
Do not incorporate Part D or B drug costs
© 2016 American Medical Association. All rights reserved.
Advancing Care Information
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ACI
Pass-fail program replaced with base and performance scoring
Measures reduced
Performance score thresholds eliminated
Public health registry reporting reduced
AMA recommendations
50 point base score threshold still 100%; grant credit for measures reported
Maintain existing measure exclusions
Permit proposals for more relevant measures
Establish a 90-day reporting period
© 2016 American Medical Association. All rights reserved.
CPIA basics • 15% of total MIPS score • 90-day reporting period MIPS weight
• 8 activity categories • 90+ activities • Do not need activities in each category
CPIA categories
• 60 points = 100% CPIA score • 7 of 8 categories have both high (20 points) and medium (10 points) weighted
activities Scoring
• Certified PCMH (60 points); other APM (30 points) • Non-patient facing specialties & small rural practices need fewer points (one
activity for partial credit, 2 activities for full credit) Exceptions
• High weight activities should be expanded, required activities reduced • Credit for APM participation should be increased • Practices should be able to maintain CPIA activities over time
Concerns
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© 2016 American Medical Association. All rights reserved.
CPIA categories
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety & Practice
Assessment
Achieving Health Equity
Emergency Response and Preparedness
Integrated Behavioral & Mental Health
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© 2016 American Medical Association. All rights reserved.
MIPS component weights and scoring in 2019
50%
25%
15%
10%
Component Weights
Quality
ACI
CPIA
Resource Use
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© 2016 American Medical Association. All rights reserved.
Four Reporting Options for MIPS • Option One: Test the Program
– Physicians required to report some data from after Jan. 1 to the Quality Payment Program. No penalty – no bonus.
• Option Two: Partial-Year Reporting – Physicians can choose to report Quality Payment Program information for a
reduced number of days. No penalty – eligible for partial bonus.
• Option Three: Full-Year Reporting – If ready, physicians can go ahead and report for the full calendar year 2017.
– No penalty – eligible for full bonus.
• Option Four: Advanced Alternative Payment Model (APM) – No penalty – eligible for full bonus – eligible for exceptional bonus.
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© 2016 American Medical Association. All rights reserved.
Some observations about MIPS
Positives: • Overlapping quality measurement
across separate programs eliminated
• Overall reduction in measures, many thresholds eliminated
• More flexibility in measure choice
• Pass/ fail approach (largely) eliminated
• Financial risk from penalties significantly reduced
Issues to address: • Aggregate administrative burden
for practices is still too high
• MU measures largely retained in ACI
• Full-year reporting for most components
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© 2016 American Medical Association. All rights reserved.
Small practice accommodations
Provisions
• Low-volume MIPS exemption
• Fewer quality measures, CPIA reporting requirements
• Reporting category exemptions if insufficient measures applicable
• Cost score not calculated if volume insufficient for measures
AMA Recommendations
• Peer-to-peer comparisons on performance
• Further reduce reporting requirements
• Consistent definition of small practice
• Implement virtual group provision
• Maintain EHR exemption for lack of high speed Internet, physicians who do not refer patients
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© 2016 American Medical Association. All rights reserved.
MACRA
• CMS has estimated that up to 80% of physicians will take the MIPS option or do nothing for the first year. The reason for this is primarily because not enough APMs have been designed yet.
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Alternative Payment Models (APMs)
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© 2016 American Medical Association. All rights reserved.
APMs participation options as outlined by CMS
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Advanced APMs
Qualified Medical Homes
MIPS APMs
• “Advanced” APMs--term established by CMS; these have greatest risks and offer potential for greatest rewards
• Qualified Medical Homes have different risk structure but otherwise treated as Advanced APMs
• MIPS APMs receive favorable MIPS scoring
• Physician-focused APMs are under development
Physician-focused
APMs TBD
© 2016 American Medical Association. All rights reserved.
MACRA incentives for Advanced APM participation
Model design • APMs have shared savings, flexible payment bundles and other desirable features
Bonuses • In 2019-2024, 5% bonus payments made to physicians participating in Advanced APMs
Higher updates • Annual baseline payment updates will be higher (0.75%) for Advanced APM participants than
for MIPS participants (0.25%) starting 2026
MIPS exemption • Advanced APM participants do not have to participate in MIPS (models include their own
EHR use and quality reporting requirements)
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© 2016 American Medical Association. All rights reserved.
CMS criteria for Advanced APMs
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Advanced APMs
EHR use
Quality Reporting
Financial Risk
• Participants must use certified EHR technology
• Payment based on quality measures comparable to MIPS
• Bear “more than nominal risk” for monetary losses
© 2016 American Medical Association. All rights reserved.
Currently proposed Advanced APMs
Comprehensive ESRD Care Model
(currently 13)
Comprehensive Primary Care Plus (coming in Fall 2016 –
Oklahoma has one)
Medicare Shared Savings Track 2
(currently 6 ACOs, 1% of total)
Medicare Shared Savings Track 3 (currently 16 ACOs,
4% of total)
Next Generation ACO Model (currently 18)
Oncology Care Model, 2-Sided
Risk Arrangement (coming in 2018)
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© 2016 American Medical Association. All rights reserved.
MIPS APMs
Criteria • Do not meet qualifications for Advanced APM—most likely financial risk • Examples includes Track 1 ACOs, certified medical homes, bundled payment programs, any upside
risk-only models
Advanced APM benefits do not apply • Must participate in MIPS to receive any favorable payment adjustments • Do not qualify for 5% APM bonus payments 2019-2024 • Not eligible for higher baseline annual updates beginning 2026
Other benefits • Certified medical home participants get full CPIA score (60 points); others get half (30 points) • APM-specific rewards (e.g., shared savings) • Eligible for annual MIPS bonuses, which continue indefinitely (vs. 6 years for 5% APM bonuses)
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© 2016 American Medical Association. All rights reserved.
Requirements and payments for APM participants
Qualified Participant in Advanced APM
Partially Qualified Participant in Advanced APM
MIPS APM participant
Patient and revenue thresholds required
>25% revenues or >20% patients in 2019, rising to 75% or 50%, respectively by 2023
>20% revenues or >10% patients in 2019, rising to 50% and 35%, respectively, by 2023
None
Eligible for APM bonus, higher updates
Yes No No
Must participate in MIPS No Optional (but no performance adjustments without MIPS)
Yes
MIPS scoring and adjustments
N/A Favorable weighting and scoring
Favorable weighting and scoring
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© 2016 American Medical Association. All rights reserved.
APMs and MIPS reporting at a glance
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In an APM?
Yes No
In first year in Medicare or below the volume threshold?
Yes No
In an Advanced APM?
Yes No
Enough payments or patients to meet the threshold?
Yes No
Qualifying APM Participant. Eligible for: • 5% lump sum bonus payment 2019-2024 • Higher fee schedule updates 2026 and beyond • APM-specific rewards • Exclusion from MIPS reporting
Not subject to MIPS
Subject to MIPS
Partially qualified or MIPS APM participant: • Favorable CPIA scoring • APM-specific rewards
© 2016 American Medical Association. All rights reserved.
Some observations about APM pathway
• Performance judged on group basis
• Too few qualified APMs will be available in 2017
• Timeline for developing new models is long
• Risk requirements are unrealistic (e.g., risk for costs vs. revenues, no credit for investment)
• Risk requirements too complicated
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Moving Forward
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© 2016 American Medical Association. All rights reserved.
Timeline on payment adjustments
29
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 on
Fee Schedule Updates
MIPS
QPs in Adv. APMs
0.5% annual baseline updates No annual baseline updates
4% 5% 7% 9% Max Adjustment (additional bonuses possible)
0.25% or
0.75%
9% 9% 9%
5% bonus
© 2016 American Medical Association. All rights reserved.
Four Reporting Options for MIPS
• Option One: Test the Program – Physicians required to report some data from after Jan. 1 to the Quality Payment
Program. No penalty – no bonus.
• Option Two: Partial-Year Reporting – Physicians can choose to report Quality Payment Program information for a
reduced number of days. No penalty – eligible for partial bonus.
• Option Three: Full-Year Reporting – If ready, physicians can go ahead and report for the full calendar year 2017. – No penalty – eligible for full bonus.
• Option Four: Advanced Alternative Payment Model (APM) – No penalty – eligible for full bonus – eligible for exceptional bonus.
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© 2016 American Medical Association. All rights reserved.
Regulatory timeline
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NPRM comments deadline • June 27, 2016
Final MACRA rule issued • Fall 2016
(Nov. 1?)
MIPS measurement and APM participation begins • Jan 1, 2017
Second year of measurement • 2018
MIPS and APM pay adjustments for 2017 performance occur • Jan 1, 2019
• Implementation timeline concerns:
• Short lead-time for physicians to learn the rules
• Inadequate time to make practice adjustments
• Too few APMs are available
What Physicians Can Do to Prepare
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© 2016 American Medical Association. All rights reserved.
General Considerations
• Determine whether you have $30,000 or less in Medicare charges OR 100 or fewer Medicare patients annually. If so, you are exempt from MIPS participation.
• If you are not already participating in a patient clinical data registry, contact your specialty society about participating in theirs—data registries can streamline reporting and assist with MIPS performance scoring.
• Physicians in a practice of more than one eligible clinician should decide whether to report individually or as a group.
• Determine whether your practice meets the requirements for small, rural or non-patient- facing physician accommodations.
• Go to www.AMA-ASSN.org/go/Medicarepayment • Go to www.GPP.CMS.gov
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© 2016 American Medical Association. All rights reserved.
MIPS: Quality Measurement and Reporting • Check your Medicare Physician Quality Reporting System (PQRS) feedback
reports. Make sure that you understand your current quality metrics reporting requirements and how you are scoring across both PQRS and private payers. Determine which quality measures you plan to report on; there are individual measures and specialty-specific measure sets.
• Access and review the 2014 annual PQRS feedback reports to see where improvements can be made. Authorized representatives of group and solo practitioners can view the reports on the CMS Enterprise Portal using an Enterprise Identity Data Management account with the correct role.
• Consider whether 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.
• Seek out support from your EHR vendor.
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© 2016 American Medical Association. All rights reserved.
MIPS: Resource Use
• Check your Medicare quality and resource use reports (QRURs) to see where improvement can potentially be made.
• Review CMS’s proposed list of episode groups.
• Identify your most costly patient population conditions and diagnoses. Identify targeted care delivery plans for these conditions.
• Identify any internal workflow changes that can be made to support care delivery plans.
• Identify potential partners outside of your practice to advance a coordinated care plan (e.g., other specialists to whom you refer patients).
• Go to www.CMS.gov. Search Medicare, then search CPIA, MIPS, Advancing care information, etc.
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© 2016 American Medical Association. All rights reserved.
MIPS: Clinical Practice Improvement Activities
• Review the proposed rule's list of clinical practice improvement activities (CPIAs) to evaluate what activities your practice is already doing and what adjustments it should make to complete additional activities in 2017.
• The reporting period for CPIAs is 90 days. Consider which 90 days in 2017 would work best for your practice's selected CPIAs.
• If you participate in a nationally recognized, accredited patient-centered medical home (PCMH), a Medicaid medical home model, a medical home model, or are recognized by the National Committee for Quality Assurance as a patient-centered specialty model, ensure that your certifications and accreditations (as applicable) are current. Physicians participating in these medical homes earn full CPIA credit.
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© 2016 American Medical Association. All rights reserved.
MIPS: Advancing Care Information • If you have an EHR, make sure it is certified EHR technology. Determine whether it is 2014- or 2015-
edition certified health information technology; the version will determine the measures on which you report in 2017.
• Speak with your vendor about how their product supports new payment model adoption. For example: How does their product support Medicare quality reporting? Document these conversations.
• Consider how to ensure that you can report at least one unique patient (or answer "yes," as applicable) for each measure of the base score’s six objectives. Ideas include:
– Reach out to existing patients to encourage their use of patient portals to view, download and transmit their health information in 2017.
– Your EHR may allow you to send a secure message through the patient portal to all of your patients at once—if so, and doing so is appropriate for your practice, consider sending an appointment reminder to all of your patients in 2017.
• Conduct a careful security risk analysis in early 2017. Failure to properly do so will result in a score of zero for this category. Your risk analysis should comply with the HIPAA Security Rule requirements. The AMA website has resources to help with this step at ama-assn.org/go/hipaa.
• Determine whether there is an additional public health registry to which you can report to receive an additional point towards your total Advancing Care Information score.
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© 2016 American Medical Association. All rights reserved.
Alternative Payment Models
Confirm whether you are a participant in any of the advanced APMs. If not, contact your specialty society or state medical society to find out if there are APM opportunities for your practice.
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© 2016 American Medical Association. All rights reserved.
Actions to Take
• If you have an EHR, make sure it is certified EHR technology (CEHRT)
– Using a certified EHR is essential for both APM participation and MIPS reporting
• Speak with your EHR vendor about how their product supports the requirements of MACRA
• Join the OSMA in establishing a members only virtual ACO.
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© 2016 American Medical Association. All rights reserved.
AMA Tools to help prepare for MACRA
• AMA Payment Model Evaluator
– Provides guidance as to which payment model is best for your practice
• AMA STEPS Forward
– Provides educational modules on different topics
• Inside Medicare’s New Payment System
– Guidance on implementing MACRA and how to avoid pitfalls
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© 2016 American Medical Association. All rights reserved.
Take advantage of educational opportunities
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www.stepsforward.org
Completion of select STEPSForward™ modules meets eligibility criteria for CPIA credit
© 2016 American Medical Association. All rights reserved.
Stay informed
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www.ama-assn.org/go/medicarepayment
Leverage resources from the AMA and other Federation groups
• Contact your specialty or state medical societies to find out if there are APM opportunities for your practice
• Seek out local support for your quality improvement activities
• Many local organizations such as Practice Transformation Networks provide resources and technical support, often free of charge, to help small practices
New tools coming soon
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