macra: the implications for health care it vendors...•extra $500m for exceptional performers under...
TRANSCRIPT
MACRA The Implications for
Health Care IT Vendors
Health Care Industry Committee
Health Care IT Advisor
Ye Hoffman
Senior Analyst
June 22 2016
2
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
3
MACRA Details to Be Finalized in Coming Months
Sources CMS The Advisory Board Company research and analysis
1) Centers for Medicare amp Medicaid Services
2) Merit-Based Incentive Payment System
3) Alternative Payment Model
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Implementation Timeline
MACRA-in-Brief
bull Legislation passed in April 2015 that repealed the Sustainable Growth Rate (SGR)
bull Locks Medicare Part B payment rates at near zero growth 05 increase from
2015ndash2019 00 increase from 2020ndash2025 025 increase from 2026 and on
bull Extra $500M for exceptional performers under MIPS APM bonuses range from
$146M to $429M
Fall 2016
CMS expects to release
final rule by November 1
2016
April 27 2016
CMS1 released proposed rule with
details for MIPS2 and APM3 tracks
and call for comments
January 2017
Performance period begins that
will determine applicable MIPS
or APM track Today
June 27 2016
Comment period on proposed
rule closes
January 2019
First Year of physician
payment adjustment
under MIPS or APM
April 16 2015
MACRA signed into law
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
4
From Standalone Programs to an Integrated Initiative
Source Advisory Board research and analysis
MACRA Reduced Total Maximum Penalties for Near-Term
-4
Prior to MACRA maximum penalty rate among separate quality programs1
-9
Under MACRA 2019 maximum penalty rate based on 2017 MIPS performance
MACRA Consolidates Previous Quality Reporting Programs
for Medicare Clinicians
1) Based on -2 PQRS -4 VBPM -3 MU
2015 2024 2019
Physician Quality Reporting System
(PQRS)
MIPSAPM
Future Years 2011 2007
EHR Incentive Programs
(aka Meaningful Use)
Value-Based Payment Modifier
(VBPM)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
5
MACRA Creates CMS Quality Payment Program
Alternative Payment
Models (APM)
Merit-Based Incentive
Payment System (MIPS)
Exempt from MIPS payment
adjustments
Financial incentives 5 annual bonus
in 2019ndash2024 and 075 annual payment
increase from 2026 on
Payment adjustments reach
-9 +27 by 2022
Performance based on 4 categories
Quality Resource use ACI1 CPIA2
MU Under MACRA Does Not Impact Hospitals Medicaid-Eligible Professionals (EPs)
bull 2016 not impacted for any provider in MU including Medicare EPs
bull MU as defined by Modified Stage 2 and Stage 3 regulation continues on as is for eligible hospitals (EHs)
and Medicaid EPs
bull CMS indicates in a recent blog post that they are planning to work with EHs and Medicaid EPs to
determine whether they could align ACI with existing MU requirementsmdashtimeline not clear
1) Advancing Care Information (ie EHR use)
2) Clinical Practice Improvement Activities
CMS Quality Payment Program
Sources HR 2 Medicare Access and CHIP Reauthorization Act of
2015 CMS blog ldquoMoving toward improved care through informationrdquo
April 2016 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
6
A Sweeping Impact Across Providers
Whorsquos Included and Who Is Exempt
Sources CMS Advisory Board research and analysis
1) Physician assistants
2) Nurse practitioners
3) Affordable Care Act
Included
Medicare Part B payments
(ie clinician professional
payments)
Clinicians groups that fall under
low volume threshold
bull $10000 or less in Medicare
charges AND
bull 100 or fewer Medicare patients
Providers in their first year
billing Medicare
Physicians PAs1 NPs2
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Groups that include any of
the above clinicians
MACRA is to care delivery
reform what the ACA3 was
to coverage reformrdquo
Andy Slavitt CMS Acting Administrator
Excluded
Estimated number of clinicians affected by
MACRA changes in first performance year
836000
Medicare Part A (ie inpatient
outpatient technical hospital
payments)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
7
APM Payment Track Looks Enticing
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
0
1
2
3
4
5
6
2015 2020 2025
2015ndash2019
05 annual
update
2020ndash2025
Frozen
payment rates Alternative Payment Model
Track 2026 and on 075
annual update
The Merit-Based Incentive
System 2026 and on 025
annual update
Baseline Payment Adjustments Under Each Track
2019ndash2024
APM track participants
receive 5 annual bonus
Annual Bonus for APM
Participation
Bonus awarded each
year from 2019ndash2024
to clinicians who qualify
for the APM track
5
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
2
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
3
MACRA Details to Be Finalized in Coming Months
Sources CMS The Advisory Board Company research and analysis
1) Centers for Medicare amp Medicaid Services
2) Merit-Based Incentive Payment System
3) Alternative Payment Model
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Implementation Timeline
MACRA-in-Brief
bull Legislation passed in April 2015 that repealed the Sustainable Growth Rate (SGR)
bull Locks Medicare Part B payment rates at near zero growth 05 increase from
2015ndash2019 00 increase from 2020ndash2025 025 increase from 2026 and on
bull Extra $500M for exceptional performers under MIPS APM bonuses range from
$146M to $429M
Fall 2016
CMS expects to release
final rule by November 1
2016
April 27 2016
CMS1 released proposed rule with
details for MIPS2 and APM3 tracks
and call for comments
January 2017
Performance period begins that
will determine applicable MIPS
or APM track Today
June 27 2016
Comment period on proposed
rule closes
January 2019
First Year of physician
payment adjustment
under MIPS or APM
April 16 2015
MACRA signed into law
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
4
From Standalone Programs to an Integrated Initiative
Source Advisory Board research and analysis
MACRA Reduced Total Maximum Penalties for Near-Term
-4
Prior to MACRA maximum penalty rate among separate quality programs1
-9
Under MACRA 2019 maximum penalty rate based on 2017 MIPS performance
MACRA Consolidates Previous Quality Reporting Programs
for Medicare Clinicians
1) Based on -2 PQRS -4 VBPM -3 MU
2015 2024 2019
Physician Quality Reporting System
(PQRS)
MIPSAPM
Future Years 2011 2007
EHR Incentive Programs
(aka Meaningful Use)
Value-Based Payment Modifier
(VBPM)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
5
MACRA Creates CMS Quality Payment Program
Alternative Payment
Models (APM)
Merit-Based Incentive
Payment System (MIPS)
Exempt from MIPS payment
adjustments
Financial incentives 5 annual bonus
in 2019ndash2024 and 075 annual payment
increase from 2026 on
Payment adjustments reach
-9 +27 by 2022
Performance based on 4 categories
Quality Resource use ACI1 CPIA2
MU Under MACRA Does Not Impact Hospitals Medicaid-Eligible Professionals (EPs)
bull 2016 not impacted for any provider in MU including Medicare EPs
bull MU as defined by Modified Stage 2 and Stage 3 regulation continues on as is for eligible hospitals (EHs)
and Medicaid EPs
bull CMS indicates in a recent blog post that they are planning to work with EHs and Medicaid EPs to
determine whether they could align ACI with existing MU requirementsmdashtimeline not clear
1) Advancing Care Information (ie EHR use)
2) Clinical Practice Improvement Activities
CMS Quality Payment Program
Sources HR 2 Medicare Access and CHIP Reauthorization Act of
2015 CMS blog ldquoMoving toward improved care through informationrdquo
April 2016 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
6
A Sweeping Impact Across Providers
Whorsquos Included and Who Is Exempt
Sources CMS Advisory Board research and analysis
1) Physician assistants
2) Nurse practitioners
3) Affordable Care Act
Included
Medicare Part B payments
(ie clinician professional
payments)
Clinicians groups that fall under
low volume threshold
bull $10000 or less in Medicare
charges AND
bull 100 or fewer Medicare patients
Providers in their first year
billing Medicare
Physicians PAs1 NPs2
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Groups that include any of
the above clinicians
MACRA is to care delivery
reform what the ACA3 was
to coverage reformrdquo
Andy Slavitt CMS Acting Administrator
Excluded
Estimated number of clinicians affected by
MACRA changes in first performance year
836000
Medicare Part A (ie inpatient
outpatient technical hospital
payments)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
7
APM Payment Track Looks Enticing
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
0
1
2
3
4
5
6
2015 2020 2025
2015ndash2019
05 annual
update
2020ndash2025
Frozen
payment rates Alternative Payment Model
Track 2026 and on 075
annual update
The Merit-Based Incentive
System 2026 and on 025
annual update
Baseline Payment Adjustments Under Each Track
2019ndash2024
APM track participants
receive 5 annual bonus
Annual Bonus for APM
Participation
Bonus awarded each
year from 2019ndash2024
to clinicians who qualify
for the APM track
5
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
3
MACRA Details to Be Finalized in Coming Months
Sources CMS The Advisory Board Company research and analysis
1) Centers for Medicare amp Medicaid Services
2) Merit-Based Incentive Payment System
3) Alternative Payment Model
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Implementation Timeline
MACRA-in-Brief
bull Legislation passed in April 2015 that repealed the Sustainable Growth Rate (SGR)
bull Locks Medicare Part B payment rates at near zero growth 05 increase from
2015ndash2019 00 increase from 2020ndash2025 025 increase from 2026 and on
bull Extra $500M for exceptional performers under MIPS APM bonuses range from
$146M to $429M
Fall 2016
CMS expects to release
final rule by November 1
2016
April 27 2016
CMS1 released proposed rule with
details for MIPS2 and APM3 tracks
and call for comments
January 2017
Performance period begins that
will determine applicable MIPS
or APM track Today
June 27 2016
Comment period on proposed
rule closes
January 2019
First Year of physician
payment adjustment
under MIPS or APM
April 16 2015
MACRA signed into law
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
4
From Standalone Programs to an Integrated Initiative
Source Advisory Board research and analysis
MACRA Reduced Total Maximum Penalties for Near-Term
-4
Prior to MACRA maximum penalty rate among separate quality programs1
-9
Under MACRA 2019 maximum penalty rate based on 2017 MIPS performance
MACRA Consolidates Previous Quality Reporting Programs
for Medicare Clinicians
1) Based on -2 PQRS -4 VBPM -3 MU
2015 2024 2019
Physician Quality Reporting System
(PQRS)
MIPSAPM
Future Years 2011 2007
EHR Incentive Programs
(aka Meaningful Use)
Value-Based Payment Modifier
(VBPM)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
5
MACRA Creates CMS Quality Payment Program
Alternative Payment
Models (APM)
Merit-Based Incentive
Payment System (MIPS)
Exempt from MIPS payment
adjustments
Financial incentives 5 annual bonus
in 2019ndash2024 and 075 annual payment
increase from 2026 on
Payment adjustments reach
-9 +27 by 2022
Performance based on 4 categories
Quality Resource use ACI1 CPIA2
MU Under MACRA Does Not Impact Hospitals Medicaid-Eligible Professionals (EPs)
bull 2016 not impacted for any provider in MU including Medicare EPs
bull MU as defined by Modified Stage 2 and Stage 3 regulation continues on as is for eligible hospitals (EHs)
and Medicaid EPs
bull CMS indicates in a recent blog post that they are planning to work with EHs and Medicaid EPs to
determine whether they could align ACI with existing MU requirementsmdashtimeline not clear
1) Advancing Care Information (ie EHR use)
2) Clinical Practice Improvement Activities
CMS Quality Payment Program
Sources HR 2 Medicare Access and CHIP Reauthorization Act of
2015 CMS blog ldquoMoving toward improved care through informationrdquo
April 2016 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
6
A Sweeping Impact Across Providers
Whorsquos Included and Who Is Exempt
Sources CMS Advisory Board research and analysis
1) Physician assistants
2) Nurse practitioners
3) Affordable Care Act
Included
Medicare Part B payments
(ie clinician professional
payments)
Clinicians groups that fall under
low volume threshold
bull $10000 or less in Medicare
charges AND
bull 100 or fewer Medicare patients
Providers in their first year
billing Medicare
Physicians PAs1 NPs2
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Groups that include any of
the above clinicians
MACRA is to care delivery
reform what the ACA3 was
to coverage reformrdquo
Andy Slavitt CMS Acting Administrator
Excluded
Estimated number of clinicians affected by
MACRA changes in first performance year
836000
Medicare Part A (ie inpatient
outpatient technical hospital
payments)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
7
APM Payment Track Looks Enticing
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
0
1
2
3
4
5
6
2015 2020 2025
2015ndash2019
05 annual
update
2020ndash2025
Frozen
payment rates Alternative Payment Model
Track 2026 and on 075
annual update
The Merit-Based Incentive
System 2026 and on 025
annual update
Baseline Payment Adjustments Under Each Track
2019ndash2024
APM track participants
receive 5 annual bonus
Annual Bonus for APM
Participation
Bonus awarded each
year from 2019ndash2024
to clinicians who qualify
for the APM track
5
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
4
From Standalone Programs to an Integrated Initiative
Source Advisory Board research and analysis
MACRA Reduced Total Maximum Penalties for Near-Term
-4
Prior to MACRA maximum penalty rate among separate quality programs1
-9
Under MACRA 2019 maximum penalty rate based on 2017 MIPS performance
MACRA Consolidates Previous Quality Reporting Programs
for Medicare Clinicians
1) Based on -2 PQRS -4 VBPM -3 MU
2015 2024 2019
Physician Quality Reporting System
(PQRS)
MIPSAPM
Future Years 2011 2007
EHR Incentive Programs
(aka Meaningful Use)
Value-Based Payment Modifier
(VBPM)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
5
MACRA Creates CMS Quality Payment Program
Alternative Payment
Models (APM)
Merit-Based Incentive
Payment System (MIPS)
Exempt from MIPS payment
adjustments
Financial incentives 5 annual bonus
in 2019ndash2024 and 075 annual payment
increase from 2026 on
Payment adjustments reach
-9 +27 by 2022
Performance based on 4 categories
Quality Resource use ACI1 CPIA2
MU Under MACRA Does Not Impact Hospitals Medicaid-Eligible Professionals (EPs)
bull 2016 not impacted for any provider in MU including Medicare EPs
bull MU as defined by Modified Stage 2 and Stage 3 regulation continues on as is for eligible hospitals (EHs)
and Medicaid EPs
bull CMS indicates in a recent blog post that they are planning to work with EHs and Medicaid EPs to
determine whether they could align ACI with existing MU requirementsmdashtimeline not clear
1) Advancing Care Information (ie EHR use)
2) Clinical Practice Improvement Activities
CMS Quality Payment Program
Sources HR 2 Medicare Access and CHIP Reauthorization Act of
2015 CMS blog ldquoMoving toward improved care through informationrdquo
April 2016 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
6
A Sweeping Impact Across Providers
Whorsquos Included and Who Is Exempt
Sources CMS Advisory Board research and analysis
1) Physician assistants
2) Nurse practitioners
3) Affordable Care Act
Included
Medicare Part B payments
(ie clinician professional
payments)
Clinicians groups that fall under
low volume threshold
bull $10000 or less in Medicare
charges AND
bull 100 or fewer Medicare patients
Providers in their first year
billing Medicare
Physicians PAs1 NPs2
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Groups that include any of
the above clinicians
MACRA is to care delivery
reform what the ACA3 was
to coverage reformrdquo
Andy Slavitt CMS Acting Administrator
Excluded
Estimated number of clinicians affected by
MACRA changes in first performance year
836000
Medicare Part A (ie inpatient
outpatient technical hospital
payments)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
7
APM Payment Track Looks Enticing
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
0
1
2
3
4
5
6
2015 2020 2025
2015ndash2019
05 annual
update
2020ndash2025
Frozen
payment rates Alternative Payment Model
Track 2026 and on 075
annual update
The Merit-Based Incentive
System 2026 and on 025
annual update
Baseline Payment Adjustments Under Each Track
2019ndash2024
APM track participants
receive 5 annual bonus
Annual Bonus for APM
Participation
Bonus awarded each
year from 2019ndash2024
to clinicians who qualify
for the APM track
5
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
5
MACRA Creates CMS Quality Payment Program
Alternative Payment
Models (APM)
Merit-Based Incentive
Payment System (MIPS)
Exempt from MIPS payment
adjustments
Financial incentives 5 annual bonus
in 2019ndash2024 and 075 annual payment
increase from 2026 on
Payment adjustments reach
-9 +27 by 2022
Performance based on 4 categories
Quality Resource use ACI1 CPIA2
MU Under MACRA Does Not Impact Hospitals Medicaid-Eligible Professionals (EPs)
bull 2016 not impacted for any provider in MU including Medicare EPs
bull MU as defined by Modified Stage 2 and Stage 3 regulation continues on as is for eligible hospitals (EHs)
and Medicaid EPs
bull CMS indicates in a recent blog post that they are planning to work with EHs and Medicaid EPs to
determine whether they could align ACI with existing MU requirementsmdashtimeline not clear
1) Advancing Care Information (ie EHR use)
2) Clinical Practice Improvement Activities
CMS Quality Payment Program
Sources HR 2 Medicare Access and CHIP Reauthorization Act of
2015 CMS blog ldquoMoving toward improved care through informationrdquo
April 2016 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
6
A Sweeping Impact Across Providers
Whorsquos Included and Who Is Exempt
Sources CMS Advisory Board research and analysis
1) Physician assistants
2) Nurse practitioners
3) Affordable Care Act
Included
Medicare Part B payments
(ie clinician professional
payments)
Clinicians groups that fall under
low volume threshold
bull $10000 or less in Medicare
charges AND
bull 100 or fewer Medicare patients
Providers in their first year
billing Medicare
Physicians PAs1 NPs2
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Groups that include any of
the above clinicians
MACRA is to care delivery
reform what the ACA3 was
to coverage reformrdquo
Andy Slavitt CMS Acting Administrator
Excluded
Estimated number of clinicians affected by
MACRA changes in first performance year
836000
Medicare Part A (ie inpatient
outpatient technical hospital
payments)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
7
APM Payment Track Looks Enticing
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
0
1
2
3
4
5
6
2015 2020 2025
2015ndash2019
05 annual
update
2020ndash2025
Frozen
payment rates Alternative Payment Model
Track 2026 and on 075
annual update
The Merit-Based Incentive
System 2026 and on 025
annual update
Baseline Payment Adjustments Under Each Track
2019ndash2024
APM track participants
receive 5 annual bonus
Annual Bonus for APM
Participation
Bonus awarded each
year from 2019ndash2024
to clinicians who qualify
for the APM track
5
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
6
A Sweeping Impact Across Providers
Whorsquos Included and Who Is Exempt
Sources CMS Advisory Board research and analysis
1) Physician assistants
2) Nurse practitioners
3) Affordable Care Act
Included
Medicare Part B payments
(ie clinician professional
payments)
Clinicians groups that fall under
low volume threshold
bull $10000 or less in Medicare
charges AND
bull 100 or fewer Medicare patients
Providers in their first year
billing Medicare
Physicians PAs1 NPs2
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Groups that include any of
the above clinicians
MACRA is to care delivery
reform what the ACA3 was
to coverage reformrdquo
Andy Slavitt CMS Acting Administrator
Excluded
Estimated number of clinicians affected by
MACRA changes in first performance year
836000
Medicare Part A (ie inpatient
outpatient technical hospital
payments)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
7
APM Payment Track Looks Enticing
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
0
1
2
3
4
5
6
2015 2020 2025
2015ndash2019
05 annual
update
2020ndash2025
Frozen
payment rates Alternative Payment Model
Track 2026 and on 075
annual update
The Merit-Based Incentive
System 2026 and on 025
annual update
Baseline Payment Adjustments Under Each Track
2019ndash2024
APM track participants
receive 5 annual bonus
Annual Bonus for APM
Participation
Bonus awarded each
year from 2019ndash2024
to clinicians who qualify
for the APM track
5
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
7
APM Payment Track Looks Enticing
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
0
1
2
3
4
5
6
2015 2020 2025
2015ndash2019
05 annual
update
2020ndash2025
Frozen
payment rates Alternative Payment Model
Track 2026 and on 075
annual update
The Merit-Based Incentive
System 2026 and on 025
annual update
Baseline Payment Adjustments Under Each Track
2019ndash2024
APM track participants
receive 5 annual bonus
Annual Bonus for APM
Participation
Bonus awarded each
year from 2019ndash2024
to clinicians who qualify
for the APM track
5
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
8
APM Track Qualification Requirements
Not Just Any APM Must Be an Advanced APM
bull More than nominal financial risk (ie threshold to trigger losses no greater than 4
loss sharing at least 30 and maximum possible loss at least 4 of spending target)
bull Certified EHR use
bull Quality requirements comparable to MIPS
Minimum QP Threshold Minimum Partial QP Threshold
20
40 50
25
50
75
2019ndash2020 2021ndash2022 2023 and on
Payment Patient Count Requirements for Qualifying Participants (QPs) Partial QPs
Year
Pe
rce
nt o
f p
aym
en
t
un
de
r A
dva
nce
d A
PM
10
25
35 20
35
50
2019ndash2020 2021ndash2022 2023 and on
Year
Pe
rce
nt o
f p
atie
nt co
un
t
un
de
r A
dva
nce
d A
PM
Payment Patient Count
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
9
MIPS A Zero-Sum Game for Clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032
Advisory Board research and analysis
1) Eligible clinicians
2) The mean or median (as selected by CMS) of the composite performance scores for all
MIPS-eligible professionals with respect to a prior period specified by the Secretary
3) Payment adjustment size corresponds with how far the score deviates from the PT
4) Additional pool of $500M available for high performers to receive additional incentive of up
to 10 for MIPS-eligible providers that exceed the 25th percentile above the PT
-10
0
10
20
30
Maximum Penalties and Bonuses
2019 2020 2021 2022+
4
-4
5
-5
7
-7
9
-9
12
15
21
27
Budget
neutrality
adjustment
Scaling
factor up to
3x may be
applied to
upward
adjustment
to ensure
payout pool
equals
penalty pool Pa
ym
en
t a
dju
stm
ent
Payment Adjustment Determination
1
2
3
Highest performers
eligible for up to 10
additional incentive4
MIPS ECs1 assigned score of
0ndash100 based on performance
across four categories
Score compared to CMS-set
performance threshold2 (PT)
non-reporting groups given
lowest score
A score above PT results in
upward payment adjustment a
score below PT results in a
downward adjustment3
Year
Stronger Performers Benefit at Expense of Those with Low ScoresNo Data
Non-reporting
participants given
lowest score Basis for Performance Threshold
In 2019 PT based on 2014 and 2015
performance data from PQRS VBPM MU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
10
Preferential Scoring for MIPS APMs
Potential Advantage to Achieve ldquoExceptional Performancerdquo Incentives
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9
2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Medicare Shared Savings Program
2) Accountable care organization
Comparison between MIPS Weighting
and Scoring for MIPS APMs in 2017
25 30 30
75 15
20 20
25
10
50 50 50
MIPS MSSP Next Gen Other APMs
Quality
Resource Use
Clinical Practice Improvement Activities (CPIA)
Advancing Care Information (ACI)
MIPS APM Scoring Standard
Extra pool of incentives for
MIPS ECs whose performance
exceptionally exceeds a
specified threshold
$500M
Reporting
bull Quality measures submitted through CMS Web
Interface by MSSP1Next Gen ACO2 on behalf of
MIPS participants Quality category is not reported
for other MIPS APMs
bull ACI CPIAmdashsubmit data per MIPS requirements
Scoring
bull Performance evaluated collectively at the APM
Entity level
bull Scoring Standard CPS stays at 100 with
readjusted weights for the remaining performance
categories
bull Automatic 30 points for CPIA Resource Use
is not scored
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
11
MIPS Performance Categories Executive Summary
Category Key Components ECrsquos Relative
Difficulty
bull Fewer measures to report than PQRS lots of
measures to choose from
bull No longer pay for reporting performance matters
bull Bonus points for electronic reporting
bull No separate reporting requirement based on claims
bull Many new cost measures assess which conditions
you treat not just whom you treat
bull Part D drug costs may be included in future years
bull Over 90 activities to choose from offers flexibility for
many provider types
bull Preferential scoring for PCMH1 and MIPS APM
participants
bull Applies to all clinicians2 unlike previous Medicare
Eligible Professional MU requirements (which only
applied to physicians)
bull No longer requires ldquoall-or-nothingrdquo measure threshold
reporting clinicians scored on participation and
performance
1) Patient-centered medical homes are recognized if they are accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC) the National Committee for Quality Assurance (NCQA) PCMH recognition The Joint
Commission Designation or the Utilization Review Accreditation Commission (URAC)
2) Eligible clinicians include physicians physician assistants nurse practitioners clinical nurse specialists certified
registered nurse anesthetists and groups that include such clinicians In 2017 ACI category may be reweighted to zero
for non-physician clinicians
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-
Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
Score based
on peer
performance
benchmarks
Score based
on ECsrsquo own
performance
Quality
(Previously
PQRS)
Resource Use
(Previously VBPM
cost component)
Clinical Practice
Improvement
Activities
(New category)
Advancing Care
Information
(Previously MU)
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
12
MIPS Quality Performance Category
Significant Flexibility with Almost 300 Measures Generous Bonus Points
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for
Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
PQRS MIPS Quality
Qu
ali
ty
Measu
res
bull Report 9 measures
across 3 National Quality
Strategy Domains
bull Groups of 100+ EPs
reporting via GPRO1 are
required to also report all
Consumer Assessment of
Healthcare Providers amp
Systems (CAHPS) survey
measures
bull Report 6 measures2
including at least 1 outcome
measure and 1 cross-cutting3
measure
bull CAHPS measure is an
optional quality measure for
groups of 2 or more ECs
bull 3 additional population-based
measures4 based on claims
data
Data
S
ub
mis
sio
n
bull Use 1 of the allowed
reporting mechanisms
bull Use 1 of the allowed reporting
mechanisms (more details on
Slide 32)
bull MSSPNext Gen ACO entities
do not separately report
Data
C
om
ple
ten
ess
bull Varies by type of reporting
mechanism (eg 50 of
the EPrsquos Medicare Part B
fee-for-service patients for
individual claim-based and
qualified registry-based
reporting)
bull 90 of all applicable patients
regardless of payer if using
QCDR5 qualified registry or is
EHR-based
bull 80 for individual ECrsquos
applicable Medicare Part B
patients if using claims-based
Scoring
Special Considerations
Key Considerations for
Quality Public Comment
bull Should CMS provide more specialty-
specific measure sets
bull Should CMS decrease the data
completeness requirement
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement6 is met so the
total possible points can vary between ECs
bull Performance points assigned for a
measure based on benchmark decile range
created from the baseline year7
bull Non-patient-facing ECs do not need to
report cross-cutting measure
bull Generous bonus points8 awarded for
Reporting extra outcome or high-priority
measures9
End-to-end electronic reporting
1) Group practice reporting option
2) Exceptions for certain specialty measure sets ECs without 6 applicable measures andor without applicable outcome
measures and CMS Web Interface reporting
3) ldquoCross-cuttingrdquo measures are broadly available to all clinicians with patient-facing encounters regardless of specialty
4) Incudes all-cause hospital readmission acute conditions composite and chronic conditions composite
5) Qualified clinical data registry
6) Minimum 20 cases for all quality measures except 200 for all-cause hospital readmission for group reporting
7) Baseline year is 2 years before the performance year For example 2015 is the baseline for the 2017 performance year
8) Each type of bonus point is capped at 5 of total possible points
9) High-priority domains are appropriate use patient safety efficiency patient experience and care coordination
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
13
MIPS Resource Use Performance Category
New Cost Measures Performance Assessment Based on Claims
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
1) Diabetes mellitus
2) Chronic obstructive pulmonary disease
3) Coronary artery disease
4) Congestive heart failure
5) Tax Identification NumberNational Provider Identifier
VBPM MIPS Resource Use
Cost
Measures
6 measures
bull Total Per Capita
bull Medicare Spending Per
Beneficiary (MSPB)
bull Four Per Capita Costs for
beneficiaries with four
specific conditions (DM1
CPOD2 CAD3 CHF4)
Total number of measures
assessed depend on
applicable episode-based
measures
bull Total Per Capita
bull MSPB
bull New 41 clinical condition
and treatment episode-
based measures
Data
Submission
ECsgroups do not need to separately report data for this
category CMS uses the data submitted through
administrative claims to assess cost performance
Minimum
Case
Required
bull 20 cases for Total Per
Capita and 4 Per Capita
Costs with specific
conditions
bull 125 cases for MSPB
bull 20 cases for all measures
Attribution
Level of
Analysis
bull Cost measures are
evaluated at a TIN level
bull Individual reporting
TINNPI5 level
bull Group reporting TIN
level
Scoring
Special Considerations
bull Resource use reweighted to ldquo0rdquo for
ndash Non-patient-facing ECs
ndash MIPS APM preferential scoring standard
bull Measures are equally weighted for a
maximum of 10 points each
bull A measure is included in the scoring only if
minimum case requirement is met so the
total possible points can vary between ECs
bull Performance points assigned for a measure
based on benchmark decile range from the
performance year
Key Considerations for
Resource Use Public Comment
bull Should benchmarks be based on the
performance year or earlier baseline year
bull Should CMS include Medicare Part D drug
costs in measures for future years
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
14
MIPS CPIA Performance Category
Brand New Requirement More Than 90 Activities to Choose From
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR
28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research
and analysis
bull If reporting as a group how should CMS give
credit if one practice within the TIN is PCMH
while the other practices in the TIN are not
bull Are there other CPIA activities that could be
added to the proposed list
Reporting Requirements
Scoring
Two Measure Types
H
M
High-weighted activity 20 points
Medium-weighted activity 10 points
bull The activity must be performed for at least
90 days during the performance period
bull Yesno response for CPIA activities
included in the CPIA inventory
bull Maximum score of 60 points
bull Any combination of high-weighted or
medium-weighted activities Key Considerations for CPIA Public Comments
1) Health Professional Shortage Areas
Example Reported Activities Points
Earned
1 50
2 60
3 60
M H M M
M H M H
M H M H H
Special Considerations
Reporting Flexibility The following types of ECs
and groups may report any 2 activities to receive full
credit each activity is worth 30 points
bull Small groups (15 ECs or less)
bull Groups located in rural areas or HPSAs1
bull Non-patient-facing ECs
Scoring Flexibility Certain participants get
preferential scoring
bull MIPS APM Automatic 30 points
bull Certified PCMH Automatic 60 points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
15
MIPS ACI Performance Category
New Name for MU Rewards Participation and Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Health Care IT Advisor research and analysis
1) Certified EHR technology
2) Measures are equally weighted for a maximum of 10 points each Points
are awarded based on numeratordenominator performance rate eg
95 performance equals 95 points
3) Up to one bonus point total is awarded for reporting any public health
measure in addition to Immunization Registry
How Three Key Tenets of MU Change Under ACI
MU ACI Changes
Year 2017 2018+ 2017 2018+
Objectives
and
Measures
Modified Stage 2
OR
Stage 3 (optional)
Stage 3
ACI measures correlating to
Modified Stage 2 OR
ACI measures correlating to
Stage 3
ACI measures
correlating to Stage 3
Slight
changes a
few measures
easier
CEHRT 1
Allowed 2014 andor 2015
Edition
2015 Edition
only 2014 andor 2015 Edition 2015 Edition only No change
CQM
Reporting 9 measures No longer required as it is combined with
the quality category Aligned
Scoring
Type Possible Points
Base 50
Performance1 Modified Stage 2 60
Stage 3 80
Bonus2 1
Total Capped at 100
Special Considerations
bull Hospital-based advanced
practitioners non-patient-
facing and those qualifying for
hardship are not scored (ie ACI
category reweighted to zero)
bull First-time participants do not have
a shorter reporting period in ACI
unlike MU
bull New data submission
mechanisms allow for reporting
alignment
Key Considerations for
ACI Public Comment
bull How should CMS redefine a
ldquomeaningful userrdquo)mdash75 points
or 50 points Affects ifwhen
ACI category reweighted
within MIPS composite score
bull Is there a limitation on the
number of years hardship
exceptions could apply
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
16
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
MIPS ACI Pocket Guide Correlates to Stage 3 MU
Conduct or review a
security risk
analysis
Query for a drug formulary
-AND-
Electronically transmit
prescriptions (EPs)
Clinical decision support
interventions
-AND-
Drug-drug and drug-
allergy interaction
checking
Medication orders
Laboratory orders
Diagnostic imaging
orders
Protect Electronic
Health Information
Electronic
Prescribing
Clinical Decision
Support
Computerized Provider
Order Entry
Patient electronic
access1
through VDT and
application
programming
interface (API)
Actively engaged through any
combination of VDT andor
API actions
Provide outbound
electronic summary of
care Required
bull Immunization registry
Optional2
bull Syndromic surveillance
bull Electronic case reporting
bull Public health registry
bull Clinical data registry
Secure electronic
messaging
Incorporate inbound
electronic summary of
care
Provide electronic
access to patient
education
resources
Incorporate non-clinical
setting data (including
patient-generated data)
Perform clinical
information reconciliation
of patient data
Patient Electronic
Access
Patient
Engagement
Health Information
Exchange (HIE)
Public Health
Reporting
Note The red box indicates ACI measures included in the performance score The dark grey shading indicates the
objectivesmeasures CMS proposes to eliminate
1) All three functionalities (view download and transmit - VDT) and an API must be present and accessible to meet the measure
2) Providers can earn up to one bonus point if they report any of the optional public health measures
3
Performance Measures
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
17
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
18
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
The Most Important
Operational
Action Item
Succeed in MIPS
88 CMS estimate of
Medicare-eligible
clinicians under MIPS
track in 2019
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria
for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016
httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
19
Not Much Time to Prepare for 2017 Performance
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused
Payment Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-
10032 Advisory Board research and analysis
MACRA Implementation Timeline
2017 2016
Providers may not be
certain which track
they will fall into when
reporting in 2017 Today
2018
Merit-Based Incentive
Payment System (MIPS)
Alternative Payment
Models (APM)
Final Rule
Released
Compressed Timeline Between Now and First Performance Period
bull CMS indicates they will release the Final Rule by November 1 2016
bull Not much time until January 2017 for many providers to get involved in Advanced APMs
or prepare for MIPS performance
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
20
Key Considerations for MIPS-Related Policies
Clinicians May Bring Payment Adjustment Baggage with Them
Source Advisory Board research and analysis
bull Clinician onboarding EC affiliation changes
pose challenges for example
ndash Payment adjustmentmdashpractices may ldquoinheritrdquo
an ECrsquos past MIPS performance score and
related payment adjustment
ndash Performance reportingmdashpractices must
onboard ECs quickly and incoming ECs may
require separate individual reporting
bull Group reporting How will CMS account for a
variety of ECs within the group Do all ECs report
the same measures and report every category
even those that qualify for special considerations
bull Performance feedback Will clinicians have
enough information in order to benchmark predict
performance and make course corrections for a
given performance year
bull Public reporting data Which measures should or
should not be made available on the Physician
Compare
2017 2018 2019
Payment Adjustment Two-Year
Look-Back Policy
Performance
period
Payment
adjustment year
Payment Adjustment Applied
at TINNPI Level
If no performance associated with the
TINNPI is available CMS will apply
performance from TIN(s) the NPI billed
under from the performance period
Key Considerations for
Public Comment
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
21
Key Considerations for APM-Related Policies
Potential APM Track Participants Donrsquot Be Caught in MIPS by Surprise
Source Advisory Board research and analysis
Performance period
for track determination
APM
incentive
payment
Track notification
APM incentive base
calculation period
APM Incentive Payment Timeline
bull Partial QP MIPS decision Will ECs have enough
information to determine whether or not to
participate in MIPS if later deemed Partial QPs
bull APM incentive calculation timing How will CMS
calculate the incentive if the APM contract ends
during the calculation base period
bull Definition of Advanced APM CMS seeks public
comment Advanced APM criteria Should CMS
revise the financial risk percentages or otherwise
allow for other payment models to qualify
bull Advanced APM CEHRT use The APM track
requires CEHRT use among the Advanced APMrsquos
participant entities Should the requirement be set
to 50 use CEHRT in the first year and 75 in
future years
bull MSSP MU requirements Currently MSSP
measures MU participation How will the
previously defined MU definition harmonize
with the new definition in MACRA
Key Considerations for
Public Comment
Track Assignment Notification
Occurs After Performance Period
Participants notified 6 months after
the performance period concludes
at the earliest APM Entities that are
not QPs or Partial QPs are subject
to MIPS payment adjustments
2017 2018 2019
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
22
Strategize Your Approach to MACRA
Source Advisory Board research and analysis
1 Nearly all providers are affected and thus should
take notice
2 There is no time to waste with decision making
(and we donrsquot even have the final word)
3 Provider groups should assume they are in the
MIPS track for the first year
4 Under the MIPS providers have a lot of flexibility in
selecting performance measures that align with
their practice
5 APM Scoring in MIPS has a significant upside
6 While it may speed up pace of adoption MACRA
alone is not a sufficient impetus to assume
payment risk
7 MACRA may accelerate physician consolidation
8 Moving forward MACRA is likely to have other
significant downstream effects on medical group
operations and how physicians practice
Eight Strategic Implications
Archived Webconferences on
Strategic Implications
bull MACRA Strategic Implications
for Provider Organizations from
the Proposed Rules
bull MACRA What You Need to
Know Right Now About the
Proposed Rule
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
23
Recognize How IT Is Critical to MIPSAPM Success
Time Has Come for IT and Quality Operational Partnership
Source Advisory Board research and analysis
Keep in Lock-Step with Health IT Vendors
Ask about vendorsrsquo MIPSAPM preparedness and how they plan to stay on
top of evolving requirements as part of their product roadmap
Align Reporting Methods
bull Reporting alignment helps reduce
reporting burden across MIPS
performance categories
Enable Analytics
bull Critical to monitor
performance and identify
improvement opportunities
bull Allows analysis of APM
participation risks and
benefits
Maximize Performance
bull Quality bonus points for end-to-
end electronic reporting
bull ACI focus on interoperability and
patient engagement
bull CPIA credit for telehealth HIE
Expect New IT Requirements
bull Advanced APM CEHRT use
requirement may evolve to
include participation in an HIE
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
24
2
3
1
Road Map
copy2016 Advisory Board bull All Rights Reserved bull 32913
Key Points from the Proposal
Greatest MACRA Challenges for Providers
Considerations for Health Care IT Vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
25
Considerations for Health Care IT Vendors
1 Understand MACRArsquos
impact
Assess implications for portfolio and
future customer needs 4 Serve as source for
MACRA information
Act as trusted information source for
customers 2 Configure reporting
functionality
Enable customers to calculate
performance if applicable 5
Submit public
comment
Voice opinions and suggestions by
June 27
3 Encourage aligned
submission methods
Port customer data using preferred
submission mechanisms 6 Utilize Advisory
Board resources
Tap into your existing Advisory Board
resources for further assistance
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
26
Understand MACRArsquos Impact
1) Understand MACRArsquos Impact
Source Advisory Board research and analysis
Assess
Portfolio Position
Assemble product
management and strategy
staff to assess how and if
MACRA impacts portfolio
position
Identify
Customer Needs Market
SolutionServices
Get your message to
existing and new
relevant audiences once
solutionservices are
developed
Seek out input on product
functions that will support
clientsrsquo transition to MACRA
and add to roadmap if
applicable
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
27
The Math Behind Qualifying Participant Thresholds
2) Configure reporting functionalitymdashAPM example
1) Medicare Part B-covered professional services
2) During the performance period
3) Evaluation and management
Payment threshold
for QPs in 2019
25
Numerator
Denominator
All payments for services1
furnished by ECs in the APM Entity
to attributed beneficiaries2
All payments for services1 furnished
by ECs in the APM Entity to
attribution-eligible beneficiaries2
Patient count threshold
for QPs in 2019
20
Numerator
Denominator
Unique number of attributed
beneficiaries to whom ECs in the
APM Entity furnish services12
Number of attribution-eligible
beneficiaries to whom ECs in the
APM Entity furnish services12
Not enrolled in Medicare
Advantage or Medicare
Cost Plan
Medicare not a
second payer
Medicare Parts A and B
enrollment
At least 18 years old
US Resident
At least 1 EampM3 claim
within the APM entity
Attribution-Eligible Beneficiary Criteria
1 2 3
4 5 6
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161 Federal
Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
28
Category Category Scoring Per Reported Measures Points Weight CPS
Quality Earned 482
Bonus 455
ECrsquos total
possible 70
50
3764
(52770)x50
Resource
Use Earned 252
ECrsquos total
possible 40
10 63
(25240)x10
CPIA Earned 60
CPIA total
cap 60
15 15
(6060)x15
ACI Earned 842
ACI total
cap 100
25 2105
(842100)x25
Complicated Calculations Even for a Simple Example
How Category Scores Convert to 2017 MIPS Score for a Fictional EC
2) Configure reporting functionalitymdashMIPS example
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment
Modelsrdquo 81 FR 28161 Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory
Board research and analysis
1) Not scored below required case minimum
2) Not applicable to individual eligible clinicians
3) These measures are reported via CEHRT so the provider earns 1 bonus point per measure
4) The additional high-priority measure beyond the required outcome measure earns the provider 1 bonus point
5) Two types of bonus points in the quality category end-to-end electronic reporting and high-priority measures
Each category is capped at 5 of the total possible points
1 High Activity 4 Medium Activities
20 Pts 10 Pts 10 Pts 10 Pts 10 Pts
Total per Capita MSPB Up to 41 Episode-Based measures
56 Pts NA 85 Pts 63 Pts 48 Pts NA
Below Case
Threshold No Attributed
Cases
ECrsquos Total MIPS CPS8 7999
Reported 5 of 6 Measures 3 Population-Based Measures
86 Pts 73 Pts NA1 61 Pts NA2 10 Pts 62 Pts 10 Pts 0 Pts
Outcome
Measure3
Process
Measure3
Not
Reported
Process
Measure3
High
Priority34
Cross
Cutting3
Acute Composite
Chronic Composite
All-Cause Readmission
6) Patient Electronic Access
7) Medication Reconciliation
8) Composite Performance Score
50 Pts 91 Pts 36 Pts 76 Pts 15 Pts 97 Pts 27 Pts
Base Score Performance Score
Patient
Education
Secure
Message HIE
Patient
E-Access6 VDT Med
Rec7
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
29
ABCs of Submission Mechanisms in MIPS
3) Encourage aligned submission methods
Sources CMS QCDRs CMS EHR Reporting CMS Qualified
Registries CMS Web Interface Group Reporting Option CAHPS
Vendor Advisory Board research and analysis
Qualified Clinical
Data Registry
Meets specific CMS qualifications
but scope of registry is not limited to
PQRS measures
For more QCDRs available
EHR
Office of the National Coordinator-
certified EHR submits data
directly to CMS
For more certified EHRs available
CMS Web Interface
Group practice reporting option via
CMSrsquo QualityNet website
For more see QualityNet
Qualified Registry
Meets specific CMS qualifications
and scope of registry is limited to
PQRS measures
For more registries available
Attestation or
Claims
Attestation TBD CMS may utilize
existing MU attestation portal
Claims Coded data inputted
through claims
CAHPS Vendor
CMS-certified vendor used for
combined CAHPS and
PQRS reporting
For more see approved vendors
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
30
MIPS Reporting Alignment Options
Vendor Capability Crucial to Alignment Opportunity
3) Encourage aligned submission methods
Sources CMS ldquoMedicare Program Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model
(APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Modelsrdquo 81 FR 28161
Federal Register May 9 2016 httpsfederalregistergova2016-10032 Advisory Board research and analysis
Note the dark outline box denotes submission methods that allow reporting alignment opportunity
1) Available for groups of 25 or more only
2) Available for individual reporting only
3) For groups only must be a CMS-approved survey vendor for MIPS
Submission
Methods QCDR EHR
Qualified
Registry
CMS Web
Interface1 Attestation Claims2 CAHPS
Vendor3
Quality
CPIA
ACI
MIPS Data Submission Mechanisms Report Individually or as a Group
bull Capability to report
measures for all MIPS
performance categories
bull Ongoing compliance with
CMS vendor audits
bull Record data in CEHRT
bull Export and transmit data
electronically
bull Option to use third party
intermediary with automated
software
Vendor
Readiness End-to-end
Electronic
Reporting
Reporting Alignment Quality Bonus Points
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
31
Make Your Voice Heard
Set Aside Resources to Review and Comment on Annual Changes
4) Submit public comment
Source Advisory Board research and analysis
bull Annual updates Health care IT vendors may be
challenged to react to annual updates to
requirements published each November
bull Compressed timeline Full-year 2017 performance
period fast approaching with little time for vendors to
prepare
bull Audit scope Uncertain which types of
documentation vendors must retain and for how long
(10 years)
bull Group reporting for practices with different
EHRs Group practices that do not share a common
EHR platform or vendor may be challenged to
aggregate consistent MIPS data across the TIN
Vendors may wish to offer CMS guidance for those
scenarios
bull Use of CEHRT for APMs CMS seeks comment on
new health IT standards and certification criteria for
future APM track CEHRT requirements
Key Considerations for
Vendorrsquos Public Comment November
CMS proposes to
publish annual
MIPSAPM Final Rule
January
Year-long performance
period starts 2 months after
requirements are finalized
JUN 27
Public comment closes
on June 27 2016 for the
MIPSAPM proposed rule
Annual MIPSAPM Updates
Leave Little Time to React
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
32
Three-Part MACRA Webconference Series
Immediate Strategic and Operational Insights for All Members
5) Serve as source for MACRA information
MACRA What You Need to
Know Right Now About the
Proposed Rule
Available On-Demand
bull Understand the basics of the
MIPS vs APM track
bull Learn the most important
(and surprising) things your
organization needs to know
right away
MACRA Strategic Implications
for Provider Organizations
Available On-Demand
bull Receive key advice on issues
such as maximizing pay-for-
performance navigating the
transition to risk-based
payment and the future of
hospital-physician alignment
bull Evaluate the economics of
physician payment transition
MACRA Operational Action
Items from the Proposed Rule
Available On-Demand
bull Receive detailed reporting
advice including how to
streamline Medicare
physician reporting
bull Assess key quality program
management implications
For More Advisory Board Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
33
Utilize Advisory Board Resources
Consult with experts about
product strategy andor for
orientation on MACRA and
its related regulations
Send a question to confirm
understanding of regulatory
requirements obtain references
for both internal and external use
Request presentation for
customers by Advisory
Board experts education can
make messaging consistent
Access educational resources
for internal staff and strategic
development Cheat Sheet
series very popular
Stay informed of new
regulatory and legislative
implications for your product(s)
with subscription alerts
Contact Your Dedicated Advisor for Assistance
Source Advisory Board research and analysis
6) Utilize Advisory Board resources
Cheat Sheet Series
See Health Care Industry Committee Cheat Sheets
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
34
Key Takeaways for Health Care IT Vendors
MACRA Has Significant
Impact
The law fundamentally
changes how Medicare pays
physicians and other clinicians
Most Providers Will Be in
MIPS
CMS estimates that at least
88 of Medicare providers
nationwide will fall under MIPS
track in 2017
Opportunities Exist to Support
Providers with Your
ServicesSolutions
Health IT systems are critical to
MACRA success providers have
yet to establish clear strategy
Plan for Final Rule and
Annual Rulemaking
Health care IT vendors should
prepare to revisit MACRA
plans in November plan for
yearly updates via rulemaking
MACRA Reflects Broader ldquoSea Changerdquo in Move from Volume to Value
Source Advisory Board research and analysis
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
35
MACRA Resources to Support You
Webconferences Tools Research
bull Three-part on-demand
series
ndash What You Need to Know
Right Now About the
Proposed Rule
ndash Strategic Implications for
Provider Organizations
from the Proposed Rule
ndash Operational Action Items
from the Proposed Rule
bull The Implications for Health
Care IT Vendors
bull How to Align Quality
Reporting Across PQRS
MU and VBPM on-
demand
bull Proposed MIPS
Measures List
bull Your questions about the
MACRA proposed rulendash
answered
bull Health Care IT Advisor
MACRA Cheat Sheet
bull MACRA Cheat Sheet for
Industry
bull Medicares new plan for
paying doctors 10 key
takeaways
bull Meaningful Use gets a
facelift under MACRAmdashbut
is it better Heres our view
bull 2016 Eligible Professional
Quality Reporting CMS
Offers More Flexible
Reporting Options But Itrsquos
Time to Align
For These and Forthcoming Resources on MACRA
httpswwwadvisorycomtopicsstrategymarket-trendsmacra
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
36
Ask a Question
To ask a question please type it into the
ldquoQuestionsrdquo box on your GoTo panel and
press send
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU
copy2016 Advisory Board bull All Rights Reserved bull advisorycom bull 32913
37
Provide Your Feedback on Todayrsquos Presentation
Please note that the survey does not apply to webconferences viewed on demand
bull Once you or the presenter exits the
webconference you will be directed
to an evaluation that will automatically
load in your web browser
bull Please take a minute to provide your
thoughts on the presentation
THANK YOU