january 2020 – reimbursement...• analyze the various approaches to reporting ed quality measures...

JANUARY 2020 – REIMBURSEMENT MACRA and MIPs Reporting Complexities for 2020: Strategies for Success DESCRIPTION PQRS has been retired, but we may long for the devil we know. Are you prepared for the next round of quality programs influencing up to 18 percent of physician reimbursement? OBJECTIVES

• Identify the barriers to successfully meeting the MIPS reporting requirements • Develop strategies to ensure your group’s financial success under MIPS • Analyze the various approaches to reporting ED Quality measures • Review reporting startagies for MIPS Improvement Activities

1/28/2020, 3:00 PM - 4:00 PM, MACRA and MIPs Reporting Complexities for 2020: Strategies for Success FACULTY Pawan Goyal, MD, MHA, CBA, PMP, FHIMSS, FAHIMA; Bill Malcom, MS, MBA, PMP; Aisha Terry, MD, MPH, FACEP DISCLOSURE (+) No significant financial relationships to disclose

MACRA and MIPs Reporting Complexities for 2020: Strategies for SuccessPawan Goyal , MD, MHA, FHIMSS, FAHIMAA s s o c i a t e E x e c u t i v e D i r e c t o r, Q u a l i t y, A C E P

B i l l Malcom, MBA, PMPPro g ram D i re cto r, C l in i ca l E m e rge ncy D ata Re g i st r y (C E D R ) , AC E P

Aisha Terry, MD, MPH, FACEP

AC E P B o ard M e m be r, C E D R L ia i so n , A sso c . Pro fe sso r o f E M & H e a l th Po l i cy

First: Key MIPS & Quality Measure Reporting Concepts §MIPS includes four performance categories:§Quality§Cost§Improvement Activities§Promoting Interoperability ( formally known as Meaningful Use)

§Quality Performance Category

What is the Quality Performance Category?

•What reporting mechanisms for Quality Payment Program (QPP) are used?: • Electronic health records (EHRs), claims, registries, Qualified Clinical Data Registries

(QCDRs), CMS Web Interface (for groups of over 25), and the CAHPS for MIPS survey

•To receive full credit in the Quality reporting category, clinicians must:• Collect measure data for 12-month performance period. The amount of data that must

be submitted depends on the collection (measure) type.• Submit data for at least 6 measures, or a complete specialty measure set (1 must be an

outcome measure)• For groups of 16 or more clinicians who meet case minimum of 200, admin. claims-based

all-cause readmission measure automatically scored as a seventh measure.

•Can submit any combination of measures using any reporting mechanism

What is Benchmarking?§Measures are assessed against its benchmark to determine how many points earned

§3 to 10 points for each MIPS measure that meets data completeness standards and case minimum requirements through benchmarks

§Benchmarks are specific to the type of submission mechanism

§Established using historical data, if available (i.e. performance data submitted two years prior the start of the applicable performance year)

§MIPS attempts to calculate a “performance year” benchmark if no historical benchmark exists

§ If no benchmark can be calculated, measure receives 3 points as long as data complete

§Presented in deciles; points awarded within each decile.

How are Measures Scored?

§Measure achievement points are determined by comparing performance on a measure to a measure benchmark.§If a measure can be reliably scored against a benchmark, it means:§A benchmark is available; and§Has at least 20 cases; and§Meets the data completeness requirement standard, (increasing to 70% in 2020)

What is Data Completeness?

§ Claims (only available for small practices): 70% of Medicare Part B patients for the performance period.§QCDR/Registry/EHR: 70% of clinician's or group's patients across all payers for the performance period.§CMS Web Interface: Sampling requirements for Medicare Part B patients.§Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey: Sampling requirements for Medicare part B patients.

Next: MIPS Results and Lessons Learned

MIPS 2018 Results§ 97% of MIPS eligible clinicians received positive payment adjustment for 2018 performance (affecting payments in 2020)

§ Largest possible bonus (for receiving a score of 100 percent) for 2020 was just 1.68%. While the MACRA statute allowed for a bonus of up to 5%, but it was adjusted down to preserve budget neutrality.

§CMS estimates a maximum positive adjustment for 2021 at 4.69%, and 2022 at 6.25%, per the 2019 Final Rule.

§Given historic patterns of estimate to actual, 3.52% and 4.69% are likely more realistic, respectively.

Sample 2018 MIPS Scores

2018 MIPS Final Score 2020 Payment Adjustment

27.53 0.05%35.00 0.07%39.11 0.09%63.25 0.18%83.20 0.89%100 1.68%

Lessons from 2018 Results: What to expect for penalties/bonuses going forward§ Performance threshold for MIPS in 2018 was established at relatively low level of 15 points, making it extremely easy for clinicians to avoid a penalty in 2020.

§ Overall, the performance threshold is increasing significantly over time § expect more clinicians to receive a negative payment adjustment, increasing the pool of bonuses

that are potentially available for clinicians who successfully report data.

§ Emergency physicians have an additional scoring option called the facility-based scoring option.§ clinicians who deliver 75% or more of their services in an inpatient hospital, on-campus outpatient

hospital, or emergency room setting will automatically receive the quality and cost performance score for their hospital.

§ Can still report quality measures through another submission mechanism and receive a “traditional” MIPS score for quality. § CMS will take highest of the hospital’s score and the traditional MIPS score.

Health Policy Brief: Medicare’s New Physician Payment System, Health Affairs, April 21. 2016

MIPS 2020 Highlights§Raising performance threshold to 45 points (from 30 points in 2019) and exceptional performance threshold to 85 points (from 75 points in 2019)

§ Introducing the MIPS Value Pathways (MVP) framework (2021 launch)

§ Ramping up requirements for qualified clinical data registries

§ Increasing data completeness threshold for the Quality category to 70%

§ Modifying definition of “hospital-based” for groups >> exempt from Promoting Interoperability category if 75% meet definition

§ Requiring groups to attest to an improvement activity only if at least 50% of clinicians in group participate in the activity

§ Maintaining same performance category weighting for all four performance categories◦ Quality: 45% ◦ Cost: 15% ◦ Promoting Interoperability (EHR): 25% ◦ Improvement Activities: 15%

Total Impact of Participation

QPP/MIPS Incentive &

Penalties

2020 Performance Year (2022 Payment Adjustment)

+/- 9.0%

For positive adjustments, the Secretary may increase/decrease the adjustment factor by a scaling factor of up to 3.0 in order to ensure budget neutrality.

Additional Exceptional Performance Bonus: 0.5% - 10%

Total amount allocated for exceptional bonus in a given year shall not exceed $500,000,000

2019(2021 payment yr)

2020(2022 payment yr) Total

Promoting Interoperability (formally known as Advancing Care Information)

25% 25% (NO CHANGE)

PI for EM Exemption (25% to Quality category) = 0%

0% (NO CHANGE) 0%

Quality 60% 50% (¯)Quality for EM 60% + 25% = 85% 50% + 25% = 75% (¯) 75%Cost 0% 10% () 10%

Promoting Interoperability Exceptions§ Certain clinicians automatically exempt from the Promoting Interoperability category§ Most emergency physicians meet this exception.

§ Before 2020, if individual clinicians decide to report as a group, would lose exemption status if even one did not meet definition of “hospital-based.”

§ ACEP has repeatedly argued that this “all or nothing rule” is unfair and penalizes hospital-based clinicians who work in multi-specialty groups.

§ CMS now modifying this policy by exempting groups from the Promoting Interoperability category if 75% of the individuals in the group meet the definition of hospital-based.



Promoting Interoperability

25% 25% (NO CHANGE)


0% (NO CHANGE) 0%

Quality 45% 45% (NO CHANGE)Quality for EM 45% + 25% = 70% 45% + 25% = 70% 70%Cost 0% 10% () 10%Improvement Activities

15 15% (NO CHANGE) 15%

Complex patients bonus

NA 5 points prn

Small practice bonus NA 5 points prnTOTAL 100%




25% 25% (NO CHANGE)


0% (NO CHANGE) 0%

Quality 45% 45% (NO CHANGE)Quality for EM 45% + 25% = 70% 45% + 25% = 70% 70%Cost 15% 15% (NO CHANGE) 15%Improvement Activities

15 15% (NO CHANGE) 15%


NA 5 points prn





25% 25% (NO CHANGE)


0% (NO CHANGE) 0%

Quality 45% 45% (NO CHANGE)Quality for EM 45% + 25% = 70% 45% + 25% = 70% 70%Cost 15% 15% (NO CHANGE) 15%Improvement Activities

15% 15% (NO CHANGE) 15%


NA 5 points prn




Adjustment to Medicare Payment ($)

2021 2022Threshold 30 points 45 points ()

Below Threshold <30 points <45 points -7% to 0% -9% () to 0%

Above Threshold >30 points >45 points 0% to 7% x scaling factor

Subject to budget neutrality, per law not to exceed 3.

0% to 9% ()x scaling factor

NO CHANGE

“Exceptional” At least 75 points At least 85 points ()

Additional payment adjustment, starts at +0.5% and goes up to +10% x scaling factor not to exceed $500M.

NO CHANGE

Performance Thresholds

Promoting Interoperability (25%,0%)



Weight To Final Score: 25% NO CHANGE

** NOTE is 0% for hospital-based clinician exemption

Performance Period: Minimum 90-day NO CHANGE

Promoting Interoperability (0%)



Certified EHR Technology (CEHRT) Requirements:

Must use 2015 Edition. No Change

Scoring: • A new simplified scoring methodology with no more base, performance, and bonus scores.

• Four overall objectives: e-Prescribing; Health Information Exchange; Provider to Patient Exchange; and Public Health and Clinical Data Exchange

• Clinicians must report measures within each of the four objectives unless they claim an exclusion for a particular measure. Failure to report on one measure would make the clinician receive a score of zero.

• Two new measures to the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement.

One change: CMS is removing the “Verify Opioid Treatment Agreement” measure and keeping the “Query of PDMP” measure as optional.

Promoting Interoperability (0%)

Improvement Activities (15%)



Weight To Final Score: • 15% based on selection of different medium and high-weighted activities.

NO CHANGE

Performance Period: Minimum 90-day NO CHANGE




Number of Activities:

• Maximum of 40 points.

• 4 activities (4 medium or 2 high-weighted activities, or a combination).

• 2 activities (2 medium or 1 high-weighted activity) to earn the full score. For small practices; practices in rural areas, geographic health professional shortage areas (HPSAs); and non-patient facing clinicians.

• Addition of 2 new Improvement Activities.

• Modification of 7 existing Improvement Activities.

• Removal of 15 existing Improvement Activities.

• Group or virtual group can attest to an improvement activity when at least 50% of the clinicians (in the group or virtual group) perform the same activity during any continuous 90-day period within the same performance period.


Improvement Activities



Scoring: • Double points for each high- or medium-weighted activity you submit if you are an individual clinician, group, or virtual group who holds any of these special statuses:

• Small practice• Non-patient facing• Rural• Health Professional Shortage Area (HPSA)

• Participant in a recognized or certified patient-centered medical home or comparable specialty practice will earn the maximum Improvement Activity performance category score

• NO CHANGE

• NO CHANGE


Quality (45%, 70%) REPLACES THE PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)

Quality (70%) 2019

(2021 payment yr)2020

(2022 payment yr)

Weight to Final Score: 45% No Change

Performance Period: 12 Months No Change

Quality (70%) 2019


(2022 payment yr)Data Completeness: •60% for submission mechanisms

except for Web Interface and CAHPS.

•Measures that don’t meet the data completeness criteria will earn 1 point EXCEPT for a small practice, will earn 3 points.

• the data completeness threshold is increasing to 70%.

Quality (70%) 2019


(2022 payment yr)

Scoring: •3-point floor for measures scored against a benchmark.

•3 points for measures that don’t have a benchmark or don’t meet case minimum requirements.

•Bonus for additional high priority measures up to 10% of denominator for performance category.

•Bonus for end-to-end electronic reporting up to 10% of denominator for performance

• NO CHANGE

Quality (70%) 2019


(2022 payment yr)

Improvement Scoring:

• Improvement measured at the performance category level.

• Up to 10% points available.

• CMS will determine improvement score only when there’s sufficient data to measure improvement.(e.g., MIPS eligible clinician uses the same identifier in 2 consecutive performance periods and is scored on the same cost measure(s) for 2 consecutive performance periods).

• If improvement score can’t be calculated (ieinsufficient data) 0% points for improvement score.

• No Changes

Cost (15%)

Cost (15%) 2019


(2022 payment yr)

Weight to Final Score: 15% No Change

Performance Period: 12 months No Change

Cost (15%) 2019


(2022 payment yr)

Measures: Includes the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures.

8 episode-based cost measures

• Still includes the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures, but these measures have been modified.

•NEW: 10 additional episode-based cost measures

Cost (15%) 2019


(2022 payment yr)Reporting/Scoring:

• Do not have to submit any additional information.

• CMS to calculate individual and group’s Cost performance using administrative claims data ….if meet attributed patient minimum and if a benchmark has been calculated for a measure.

• Benchmarks are from performance period NOT based on previous year.

•Performance category score is the average of the 2 measures.

• If only 1 measure can be scored, that is the score.

NO CHANGE (the 18 new episode-based measures don’t apply to EM)

Translating MIPS Total Composite Score Points into Payment Adjustments

0

Performance Threshold:45 points for 2020

Zero Adjustment

Max Negative

Adjustment

Max Positive

Adjustment

100

Positive adjustment on Linear Sliding Scale

Qualified Clinical Data Registries (QCDR’s)§Third-party intermediaries, help clinicians report under MIPS

§ACEP’s QCDR is the Clinical Emergency Data Registry (CEDR); measures customized to emergency physicians

§ CMS is finalizing the following new QCDR requirements for 2020: §Grant QCDR measures that are potentially duplicative one year of conditional approval; will be removed if not harmonized within that period§ Establish formal guidelines for understanding when a QCDR measure would likely be rejected during the annual self-nomination process

QCDR’s Continued§ For 2021, CMS is finalizing these additional new QCDR requirements:

§Allow submission of data on Quality, Improvement Activities, AND Promoting Interoperability

§Mandated quarterly reports on how participants compare to other clinicians who report through QCDR.

§Identify linkage between QCDR measures and a cost measure, Improvement Activity, or CMS developed MVP.

§Remove QCDR measures that do not meet case minimum and reporting volumes required for benchmarking after being in the program for two consecutive years.

§Grant CMS the ability to approve QCDR measures for two years.

§Completely develop and test measures so that they are ready for implementation at the time of self-nomination.

§Only approve a QCDR measure if it is available to clinicians reporting through QCDRs other than the QCDR measure owner.

Looking Forward: The MVP Framework§ CMS proposed and finalized the MIPS Value Pathways (MVPs) framework beginning with the 2021 performance/2023 payment year. § An MVP would connect measures and activities across 3 MIPS categories: Quality, Cost, and Improvement Activities.

§Initially, a uniform set of Promoting Interoperability measures would be included in all MVPs. §Organized around a specialty, specific episode of care, or health condition

§ CMS will work with specialty societies to design MVPs and will formally implement them through rulemaking.

Thank YouCONTACT:[email protected]

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