dan mingle - determinants for successful transition from

9/20/2016

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9/20/2016 ©2016 Mingle Analytics 1

Agenda

• The Last Mile

– The Physician Quality Reporting System (PQRS) 2016

– Value Based Modifier (VBM)

– Quality Tiering

• The First Glimpse

– Quality Payment Program (QPP)

– Merit-Based Incentive Payment System (MIPS)


2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q2

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2015

Submissions

Jan Feb Mar Apr May Jun

Full Year Data

Set

2016

Submissions

Providers: Provide Care | Document Care | Accumulate Data

Monitor Extractions, Data Exchange, and

Performance. Remediate Problems

PQRS EndsQPP Begins

Submission Portal

Opens

EHR & QCDR

QRDA Due

Registry & QCDR

XML Due

GPRO Web

Interface Due

GPRO 2016 Self

Nomination Due

2015

Feedback

Reports

and

QRUR

Available

Submission Portal

Opens

EHR & QCDR

QRDA Due

Registry & QCDR

XML Due

GPRO Web

Interface Due

2017 Penalty

Notices

2017 Q1

PQRS - QPP Timeline

Apply for

Informal

ReviewPQRS

Adjustments

Pay Out Thru

2018


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2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q2

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2015

Submissions

Jan Feb Mar Apr May Jun

Full Year Data

Set

2016

Submissions

Providers: Provide Care | Document Care | Accumulate Data

Monitor Extractions, Data Exchange, and

Performance. Remediate Problems

PQRS EndsQPP Begins

Submission Portal

Opens

EHR & QCDR

QRDA Due

Registry & QCDR

XML Due

GPRO Web

Interface Due

GPRO 2016 Self

Nomination Due

2015

Feedback

Reports

and

QRUR

Available

Submission Portal

Opens

EHR & QCDR

QRDA Due

Registry & QCDR

XML Due

GPRO Web

Interface Due

2017 Penalty

Notices

2017 Q1

PQRS - QPP Timeline

Apply for

Informal

ReviewPQRS

Adjustments

Pay Out Thru

2018


Healthcare System in Transition

Triple Aims related “chaos”• Patient Centeredness

• Accountable Care – Shared Savings Program

• Electronic Health Record Incentive Program

• Physician Quality Reporting System � Quality Payment Program

• Value-Based Modifier

• Physician Feedback Program

• Physician Compare Website

Fee For

Service


Value Compass of Dartmouth’s Clinical Microsystem Group

Mingle’s Adaptation

9/20/2016Copyright 2012 Dan Mingle, MD

Cost

AccessQuality

&Safety

Practice

Vitality


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Triple AIMS of the Institute for Healthcare Improvement

Decrease the Cost of Care

Improve the

Experience of Care for Individuals

Improve the Health

of our Communities

Practice

Vitality

Accountable Care Patient Centered Care

New Payment Model

AccessQuality & Safety

Cost

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Revenue Cycle Opportunity


Money i$ on the Line&

Performance Counts

The Healthcare Visit Value Stream


Front

Office

Schedule

Appointment

Check

In

Check

Out

Patient

Care

Rooming Patient

Visit

Back

Office

Coding Billing Collection

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Errors Epidemic in the Value Stream

• Appointment Rules are Too Complex

• Unnecessary Waits and Delays

• Inadequate Capacity to Meet the Need

• Archaic Venues for Care Delivery

• Too Little Discipline to Track and Deliver Desirable

Interventions

• Too Much Attention to Opportunity for Profitable Procedures


Avoid The dreaded Notice from CMS

in Late 2017

“You will be subject to a 2.0% downward payment adjustment

against all of your Medicare payments for 2018 services due to

failure to make a qualifying 2016 PQRS submission”


“You will be subject to a 4.0% downward payment adjustment

against all of your Medicare payments for 2018 services due to

your Quality Tiering Adjustment for 2016”

Money to be Made – 2016 Reporting

• Quality Tiering under the Value Based Modifier

– 1-2% throughout 2018 for High Quality Care

– 1-2% throughout 2018 for Low Cost Care

• Maintenance of Certification (MOC)

– 0.5% Lump Sum Incentive in 2017

– When each are independently successful

• PQRS Submission

• Specialty Specific Maintenance of Certification Requirements

• 9% by 2022 MIPS Program Year


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Money to be Lost – 2016 Reporting

• 2% PQRS Adjustment throughout 2018 for failure to Submit

PQRS

• 2-4% Value Based Modifier Adjustment throughout 2018 for

failure to Submit PQRS

• Quality Tiering under the Value Based Modifier

– 1-2% throughout 2018 for Low Quality Care

– 1-2% throughout 2018 for High Cost Care

• 9% by 2022 MIPS Program Year


At Risk 2016PQRS

Adjustment

(-2%)

VBM

Adjustment

(-2%)

VBM

Adjustment

(-4%)

Based On

Failure to make a

Qualifying PQRS Submission

Non-Physician Groups

and

Physician Groups < 10

Providers

Where ≥ half did not

submit PQRS

Physician Groups ≥ 10

Providers

Where ≥ half did not

submit PQRS

Average Range Average Average

MD/DO $2,000 $0 - $335,000 $2,000 / Provider $4,000 / Provider

Other

Provider$650 $0 - $40,000 $650 / Provider $1,300 / Provider


Based on CMS 2013 PQRS Experience Report

3 Checkpoints

Checkpoints Judged as Submit as Adjustment

PQRS Practice-

Provider

Individual

or Group (GPRO)

0 or -2%

VBM Practice

Group

Group

or ≥ 50% Individuals

0 or -2% or -4%

Quality Tiering Practice

Group

Group -2% to +2% on Cost

-2% to +2% on Quality


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PQRS 2016


Submit 9

Measures

3 Domains

1CC

No PQRS Adjustment

2%

PQRS

Adjustment

YES

NO FailMAV

Pass

You Pass or Fail in PQRS Individually

Unless you deliberately choose

Group Practice Reporting Option (GPRO)

Measure Applicability Validation Test

VBM 2016


2%

VBM

Adjustment

4%

VBM

Adjustment

Group

Size

< 10

≥ 10

≥ 50% of

Group EPs

submitted

PQRS?

No VBM AdjustmentNOYES

Physician

in

Group?

NO

YES

You Pass or Fail in VBM as a Group

Then There’s Quality Tiering


2%

VBM

Adjustment

4%

VBM

Adjustment

Group

Size

< 10

≥ 10

≥ 50% of

Group EPs

submitted

PQRS?

No VBM AdjustmentNOYES

Physician

in

Group?

NO

YES

VBM Quality Tiering

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Performance Countsin Quality Tiering under the Value Based Modifier

• If you have at least one Physician

– Physician = doctors of medicine, osteopathy, dental surgery, dental

medicine, podiatric medicine, optometry, and chiropracty

• And your total Medicare Provider Count is 1 - 9

» Low Composite Quality Performance Score � -1% Quality Tiering

Adjustment (Penalty)

» Low Composite Cost Performance Score � -1% Quality Tiering

Adjustment (Penalty)

• And your total Medicare Provider Count is ≥ 10

» Adjustments Double


The Progressive Implementation of Quality Tiering


Reporting

Year

First

Program

Year

First

Negative

QT Year

Who Size

2013 2015 2015 Physician Groups 100 or more

2014 2016 2017 Physician Groups 10 or more

2015 2017 2018 Physicians Solo and All Groups

2016 2018 MIPS Select Non-Physicians Solo and All Groups

2017 2019 2019 All of the above

Physicians = Doctors of Medicine, Osteopathy, Dental surgery, Dental

medicine, Podiatric medicine, Optometry, Chiropracty

Select Non-Physicians = Nurse Practitioner, Physician Assistant,

Certified Registered Nurse Anesthetist, Clinical Nurse Specialist

VBM 2016 (2018 Program Year)

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PQRS

Successful

for ≥ 50%

EP

YES

NO

-4% VBM

Adjustment

Group

Size

< 10 or

Non-Physician≥ 10

GPRO or

Individual

Submissions

-2% VBM

Adjustment

Mandatory Quality Tiering

Non-Physicians Group or Solo

Low

Quality

Avg

Quality

High

Quality

0 +1x% +2x%Low

Cost

0 0 +1x%Avg

Cost

0 0 0High

Cost

Physician Groups of 1 - 9

Low

Quality

Avg

Quality

High

Quality

0 +1x% +2x%Low

Cost

-1% 0 +1x%Avg

Cost

-2% -1% 0High

Cost

Physician Groups of 10 or More

Low

Quality

Avg

Quality

High

Quality

0 +2x% +4x%Low

Cost

-2% 0 +2x%Avg

Cost

-4% -2% 0High

Cost

10%

10%

Neg

80%

©2016 Mingle Analytics

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VBM 2016 (2018 Program Year)

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PQRS

Successful

for ≥ 50%

EP

YES

NO

-4% VBM

Adjustment

Group

Size

< 10 or

Non-Physician≥ 10

GPRO or

Individual

Submissions

-2% VBM

Adjustment

Mandatory Quality Tiering

Non-Physicians Group or Solo

Low

Quality

Avg

Quality

High

Quality

0 +1x% +2x%Low

Cost

0 0 +1x%Avg

Cost

0 0 0High

Cost

Physician Groups of 1 - 9

Low

Quality

Avg

Quality

High

Quality

0 +1x% +2x%Low

Cost

-1% 0 +1x%Avg

Cost

-2% -1% 0High

Cost

Physician Groups of 10 or More

Low

Quality

Avg

Quality

High

Quality

0 +2x% +4x%Low

Cost

-2% 0 +2x%Avg

Cost

-4% -2% 0High

Cost

10%

10%

Neg

80%


For Payment Year 2016

X = 15.92

Who is Subject to PQRS?

• Essentially: Any Provider who Generates a Bill to Medicare Part B Covered by the Physician Fee Schedule

• Providers Employed by Critical Access Hospitals– NPI is now required in Type II billing

– Can submit PQRS if NPI is on the bill

– Will there be a penalty?

• Not Subject to PQRS:– FQHC

– Independent Diagnostic Testing Facilities

– Independent Laboratories


Reporting Basics

• 9 Measures

• 3 Domains

• ≥ 50 % of Eligible Medicare Patients

• Any Measure with 0% Performance will not be Counted

• Submit 1 Cross-Cutting Measure

– If there is at least 1 face-to-face visit

– AND 15 Eligible instances for any Cross-Cutting Measure


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Individual Group

Claims

Registry

2016 Reporting Options

Qualified Clinical Data Registry

EHR

Measure Groups

Web Interface Tool

GPRO Registry

GPRO EHR

Certified Survey Vendor

Qualified Clinical Data Registry

New in the 2016 Reporting Year

MIPS?

2016 Supported Method-Measures

2014 2015 2016

Claims Measures 110 72 79

EHR (CQM) Measures 64 62 63

Registry Measures 201 175 198

Web Interface Measures 22 17 18

Measures Groups 24 22 25


Beware: Inverse Measures, Stratified Measures, Annual re-

assignment of methods and domains

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Still the Best Mechanism

Cost-Effective and

Reliable

20162016

20162016

2016

We are adding

these

mechanisms in

2016

This is queued for

expansion. Complex

rules suggest value of

strategic partnerships

First mechanisms offered

after claims. Great

backup to GPRO Registry.

Highly Effective in our

hands


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To Use the Group Practice Reporting Option

(GPRO)

• You must declare on the PQRS portal by June 30

– Your Intention to make a GPRO Submission

– Your Intended Method:

• Registry, Qualified Clinical Data Registry, EHR Direct, Data Submission Vendor, Web Interface Tool

– Intent to Use CAHPS for PQRS Survey

• Groups ≥ 100 must use the CAHPS Survey

• As of November 2015 You are no longer Trapped in your choices

– Change Method

– Make Individual Submissions


Consumer Assessment of Healthcare Providers and Systems

CAHPS for PQRS

• Required for all Practices ≥ 100 Submitting GPRO

• Optional for all Group Practices ≥ 2

• Practice Bears the Expense

• Counts for 3 Measures, 1 Non-Specific Domain

• CAHPS is Based on 6 Months of Data, July 1 – December 31


Not Enough Measures?

• Claims and Registry Reporting

– Measure Applicability Validation (MAV)

• EHR Reporting:

– Submit what you’ve got

• Web Interface

– Submit what you’ve got

• Qualified Clinical Data Registry

– No excuses


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To MAV or not to MAV(Measure Applicability Validation Test)


PQRS 2016 (2018 Program Year)and the Measure Applicability Validation Test (MAV)

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Submit 9

Measures

3 Domains

1CC

No

Adjustment

-2%

PQRS

Adjustment

YES

NO

Other applicable Measures

not submitted

MAVCMS test for other

applicable measures

No other

Applicable measures

≥1 Measure Submitted

No Face to Face Visits

<15 Elig Instances for all

Cross Cutting Measures

≥1 CC Meas Submitted

≥50% Reporting Rate

Non-Zero Performance

YES

NO


Don’t be Intimidated by Medicare“CMS fully expects individual eligible professionals

to report a full complement of 9 measures covering 3 domains”

(CMS 1/14/2016)


CMS Qualifies that with:

“only use the MAV processes when reporting 9 measures covering 3 domains is

Simply not Appropriate or Possible” (CMS 1/14/2016)

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Physician Feedback Reports from the PQRS Portal

Report About Available

Feedback Report PQRS ± Third Quarter

Quality Resource and

Utilization Report

(QRUR)

Value Based Modifier and Quality

Tiering

± Third Quarter

QRUR Supplemental Episode of Care Cost Performance ± Fourth Quarter

QRUR Mid Year Split Year Last July – June Cost and

Administrative Claims Performance

± Second Quarter

QRUR Interim Report YTD Claims Performance Scattered sightings


Informal Review

Program Timeframe

PQRS Must be Requested Within 60

Days Following Publication of the

PQRS Feedback Report

VBM Requests due 60 days after

Publication of QRUR


About Claims Reporting

• High Failure Rate

• First Clue of Failure is Usually a

Penalty Notice

• Queued for Discontinuation

• Remains the Best way to Grade

and Communicate Performance

– For Some Measures

– For Some Practices

• Enduring Value to Claims

Performance Codes

– aka Quality Data Codes

– or QDC

• Usable to build a Registry

Submission

– Correct missing or mistaken data

– Pass/Fail is known at the time of

submission


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Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Quality Payment Program (QPP)

Merit-Based Incentive Payment Program (MIPS)

Reporting Dynamics unchanged from PQRS to QPP

QPP is entirely Pay-For-Performance

Measure Performance will need Continuous Attention


View our series of Webinars reviewing the MIPS/MACRA Proposed Rule

http://mingleanalytics.com/webinars

The Final Rule will be released November 2016

Redesign / Remix / Rebranding

2016 (2018) is the Final Year

in their current form:

– Physician Quality Reporting

System (PQRS)

– Value Based Modifier (VBM)

– Quality Tiering

– Meaningful Use

Merit-Based Incentive Payment System (MIPS)

– [(Quality Tiering + PQRS + VBM + EHR) + a – b] x N

• Competition on a 100 point scale

– 30 Quality Points

– 30 Resource Use Points

– 25 Advancing Care Information Points

– 15 Practice Improvement Points

• Increasing Adjustments

– ±4% 2017 (2019)

– ±9% 2020 (2022)



Quality Payment Program(QPP)

Merit-Based

Incentive Payment

System (MIPS)

Alternate Payment

Mechanisms (APM)

Eligible Clinicians

Qualified Providers (QP)

APM Type

APM Entity

Advanced APM

Partial QP

Split TIN

Virtual Groups

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Performance Matters

Strategies for Excellence in the Quality Tiering

Become

Strategies to Improve Quality Payment Program

(QPP) Performance


Estimated Impact

Program Applies to Negative

Adjustments

Positive

Adjustments

MIPS Adjustments 687k to 747k providers $833m $833m

Exceptional Performance Payments $500m

Advanced APM Incentives 30,658 – 90k Providers $146m - $429m


Quality Tiering

5% 90% 5%

Low

Qualit

y

Avg

Qualit

y

High

Qualit

y

0 +2x% +4x%

Low

Cost

5%

-2% 0 +2x%

Avg

Cost

90%

-4% -2% 0

High

Cost

5%


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The QPP Composite Performance Score

50 QualityPoints

10 CostPoints

15 CPIAPoints25 ACI

Points

PY 2019± 4%




50 QualityPoints

10 CostPoints

15 CPIAPoints25 ACI

Points

45 QualityPoints

15 CostPoints

15 CPIAPoints

25 ACIPoints

PY 2019PY 2020± 4%± 5%

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50 QualityPoints

10 CostPoints

15 CPIAPoints25 ACI

Points

45 QualityPoints

15 CostPoints

15 CPIAPoints

25 ACIPoints

30

QualityPoints

15 CPIAPoints

25 ACIPoints

PY 2019PY 2020PY 2021

30 CostPoints

± 4%± 5%± 7%



50 QualityPoints

10 CostPoints

15 CPIAPoints25 ACI

Points

45 QualityPoints

15 CostPoints

15 CPIAPoints

25 ACIPoints

30

QualityPoints

15 CPIAPoints

25 ACIPoints

PY 2019PY 2020PY 2021

30 CostPoints

± 4%± 5%± 7%± 9%

PY 2022

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Quality Payment Program(QPP)

Merit-Based

Incentive Payment

System (MIPS)

Alternate Payment

Mechanisms (APM)

Eligible Clinicians

Qualified Providers (QP)

APM Type

APM Entity

Advanced APM

Partial QP

Split TIN

Virtual Groups

50 QualityPoints

10 CostPoints

15 CPIAPoints25 ACI

Points

PY 2019± 4%

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9/20/2016 ©Copyright 2016 Mingle Analytics 49

Final Questions & How to Obtain More Information

Dr. Dan Mingle, MD

[email protected]

(866) 359-4458

www.mingleanalytics.com

Mingle Analytics: Proudly Partnering with HBMA

• HBMA members receive 25% discount on

PQRS/MIPS Solutions™ Products and Services

• Visit HBMA.org/member_value_program to learn more

dan mingle - determinants for successful transition from

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