quality payment program (qpp): mips vs. apms and ... · measure. if fewer than six measures apply,...

QUALITY PAYMENT PROGRAM (QPP): MIPS vs. APMs and considerations for success?

SETH EDWARDS

Principal, Population Health

November 18, 2016

©2016 Premier Inc. Proprietary and confidential

INTRODUCTIONS / PURPOSE

2

3

Introductions and Purpose-Agenda

The Evolving Market-The Burning Platform

Medicare Access and CHIP Reauthorization Act (MACRA)Overview and Timeline

• Merit Based Incentive Payment System (MIPS)

• Alternative Payment Models (APMs)

Strategic Considerations for Success

Questions and Next Steps

TODAY’S AGENDA

THE BURNING PLATFORM

4

HEALTHCARE SPENDING IS INCREASINGNATIONAL HEALTH EXPENDITURES PER CAPITA, 1960-2010

Notes: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas.

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2010; file nhegdp10.zip).

5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.1% 16.2% 16.4% 16.8% 17.9% 17.9%

National Health Expenditures as a Share of Gross Domestic Product

http://www.cms.hhs.gov/NationalHealthExpendData/

6

MEDICARE ENROLLMENT CONTINUES TO GROW

48.3 50.355.3

63.7

72.8

80.685.2

0

10

20

30

40

50

60

70

80

90

2011 2012 2015 2020 2025 2030 2035

Projected Medicare Enrollment

ProjectedMedicareenrollment(in millions)

Source: 2012 Annual Report of the Boards of Trustees for the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds

• 10k new

beneficiaries enroll

in Medicare every

day.

• Number of

beneficiaries in

Medicare is

projected to double

by 2035.

BETTER CARE. SMARTER SPENDING. HEALTHIER PEOPLE

Encourage the integration and coordination of clinical care services

Improve population health

Promote patient engagement through shared decision making

Volume

to

ValueTrack 2:

Alternative payment models*

Track 1:

Value-based payments 85% of all Medicare payments 90% of all Medicare payments

30% of all Medicare payments 50% of all Medicare payments

2016 2018

Focus Areas Description

Incentives

Promote value-based payment systems

– Test new alternative payment models

– Increase linkage of Medicaid, Medicare FFS, and other payments to value

Bring proven payment models to scale

Care Delivery

Information Create transparency on cost and quality information

Bring electronic health information to the point of care for meaningful use

8

CURRENT CMS PROGRAMS THAT IMPACT PART B PAYMENT

Program2016 performance /

2018 potential payment impact

Value Modifier

10+ Physicians: -4% to +4% Medicare part B

<10 Physicians: -2% to +2% Medicare part B

CRNA/NP/PA/CNS: 0 to +2% Medicare part B

Physician Quality Reporting

System (PQRS)-2% Medicare part B if fail to report

Meaningful Use – Eligible Provider -4% Medicare part B

These programs are additive! -10% to +4%

PQRS - Eligible providers = anyone who bills CMS under an independent NPI; MU – Eligible Provider = physicians, dentists, psychologists

Last

Performance

Year

MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015

The formula does not incentivize high-quality, high-value care

Most of $170B in ‘patches’ financed by

health systems

SGR creates uncertainty and disruption for

physicians and other providersOn 3/26/15, the House passed H.R. 2 by 392-37

vote.

On 4/14/15, the Senate passed the House bill by

a vote of 92-8, and the President signed the bill.

Since 2003, Congress has passed 17 laws

to override SGR cuts

Created in 1997, the SGR capped

Medicare physician spending per

beneficiary at the growth in GDP

* SGR = Sustainable Growth Rate

MACRA REFORM TIMELINE

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025Permanent repeal of SGRUpdates in physician payments

Advanced Alternative Payment Model (APM) participating providers exempt from MIPS; receive annual 5% bonus (2019-2024)

Merit-Based Incentive Payment System (MIPS) adjustments 2019

+/-4%

2020

+/- 5%

2021

+/- 7%

Tra

ck

1

2022 & beyond

+/- 9%

2018

4%

PQRS pay for reporting2015

-1.5%2016 & beyond

-2.0%

Meaningful Use Penalty (up to %)2015

-1.0%

2016

-2.0%

2017

-3.0%

2018

-4.0%

Value-based Payment Modifier 2015

+/-1.0%

2016

+/-2.0%

2017

+/-4.0%

MIPS exceptional performance adjustment; ≤ 10% Medicare payment (2019-2024)

2026

0.5% (7/2015-2019) 0% (2020-2025)

0.75% update

2017

-3.0%

2018 +/- 4%

Tra

ck

2

Measurement period

Measurement period

0.25% update

11

Practice SizeNumber of MIPS

Eligible Clinicians

% with positive

or neutral

adjustment

% with

negative MIPS

adjustment

All practice

sizes676,722 94.70% 5.30%

1 - 9 eligible

clinicians147,739 90.00% 10%

10 - 24 eligible

clinicians63,829 90.00% 10%

25 - 99 eligible

clinicians132,406 92.60% 7.40%

100+ eligible

clinicians332,748 98.50% 1.50%

PROJECTED IMPACT OF MIPS (2019)

12

MIPS OVERVIEW

60%

0%

15%

25%

50%

10%

15%

25% 30%

30%

15%

25%

2019

Quality — PQRS Measures, PQIs (Acute & Chronic), Readmissions

Cost — MSPB, Total Per Capita Cost, Episode Payment

Advancing care information (ACI) — Modified Meaningful Use Objectives & Measures

Improvement activities — Expanded access, population management, care coordination,

beneficiary engagement, patient safety, social and community involvement, health equity, emergency

preparedness, behavioral and mental health integration and Alternative payment models.

• Sets performance targets

in advance, when feasible

• Sets performance

threshold at 3; median or

mean in later years.

• Improvement scores in

later years

2020 2021

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Measurement

period

Merit-Based Incentive Payment System (MIPS) adjustments

2019

+/-4%

2020

+/- 5%

2021

+/- 7%

2022 & beyond

+/- 9%

MIPS exceptional performance adjustment; ≤ 10% Medicare payment (2019-2024)

Any continuous

90-days in

CY 2017 is

performance

period for

CY 2019

CY 2018 is

performance period

for CY 2020.

Cost/quality-

Full year;

ACI/Improvement-

any 90 days

13

MIPS OPTIONS FOR PARTICIPATION IN 2017

$$

$

--

Don’t Participate

• Not participating in the Quality Payment Program: If you do not send in any 2017 data, then you receive a negative 4% payment adjustment.

Submit Something

• Test: If you submit a minimum amount of 2017 data to Medicare (for example one quality measure or one improvement activity), you can avoid a downward payment adjustment.

Submit a Partial Year

• Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment.

Submit a Full Year

• Full: If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment.

14

MIPS: ELIGIBLE CLINICIANS

Years 1 and 2

• Physician,

• Physician Assistants,

• Nurse Practitioners,

• Certified-Nurse Specialists,

• Certified Registered Nurse Anesthetists

Years 3+

• Physical or occupational therapist,

• Speech-language pathologists,

• Audiologists,

• Nurse midwives,

• Clinical social workers,

• Clinical psychologists,

• Dieticians,

• Nutritional professionals

Exclusions• New Medicare-enrolled eligible clinicians

• Enrolled during the performance year

• Not previously part of a group or billing under a different Tax Identification Number (TIN)

• Qualifying APM Participants

• Partial Qualifying APM Participants

• Clinicians below the low-volume threshold• Less than or equal to $30,000 in charges or

• Provides care for fewer than 100

beneficiaries

• Threshold determination periods:

• September 1, 2015 - August 31, 2016


15

MIPS: ELIGIBLE CLINICIANS (continued)

Non-Patient Facing MIPS ECs

• Individuals: bill 100 or fewer patient-facing encounters

• Groups: More than 75% of NPIs under the TIN meet the individual threshold

• Non patient-facing determination made in two-segment claims analysis:



CAHs

• Method I- MIPS adjustment applies to payments for items and services under PFS, not facility payment

• Method II- MIPS adjustment applies when clinicians assign their billing rights to the CAH

RHC/FQHC

• MIPS Adjustment does not apply to facility payment or items and services billed under all-inclusive payment methodology

• MIPS eligible clinicians who bill for services under PFS are subject to MIPS adjustment

16

• Report up to 6 quality measures, including an outcome

measure, for a minimum of 90 days.

• Groups using the web interface: Report 15 quality

measures for a full year.

• Groups in APMs:

• Qualifying for special scoring under MIPS, such as Shared

Savings Program Track 1 or the Oncology Care Model: Report

quality measures through your APM. You do not need to do

anything additional for MIPS quality.

• Key changes from PQRS• Reduced from 9 to 6 measures with no domain requirements• Emphasis on outcome measurement

MIPS: QUALITY PERFORMANCE CATEGORY

17

Measure

Type

Submission

MechanismReporting Period Submission Criteria Data Completeness

Individual Part B Claims 2017:

90 days or more

2018: one year

6 measures at least 1 outcome

If an outcome measure is not available, report another high priority

measure.

If fewer than six measures apply, then report on each measure that

is applicable.

Measures selected from all MIPS Measures or a specialty-specific

measure set

50% of Medicare Part

B patients seen during

the performance period

to which measure

applies

2018 - 60%

Individual

or Groups

Qualified Clinical

Data Registries

(QCDR)

Qualified

Registry

Electronic Health

Records

2017:

90 days or more

2018: one year

6 measures at least 1 outcome

If an outcome measure is not available, report another high priority

measure.

If fewer than six measures apply, then report on each measure that

is applicable.

At least one measure must include at least one Medicare patient

Measures selected from all MIPS Measures or a specialty-specific

measure set.*

50 percent of MIPS

eligible clinician’s or

groups patients that

meet denominator

criteria (all-payer)

2018 - 60%

Groups CMS Web

Interface

One year All measures included in the CMS Web Interface and

First 248 consecutively ranked and assigned Medicare beneficiaries

If less than 248, then the group would report on 100 percent of

assigned beneficiaries.

Sampling requirements

for their Medicare Part

B patients

Groups Consumer

Assessment of

Healthcare

Providers and

Systems

(CAHPS) for

MIPS Survey

One year The survey would fulfill the requirement for one measure or a high

priority measure if an outcome measure is not available

Survey will only count for one measure; must use another reporting

mechanism to reach 6 measures

Administration November- February of reporting year, with a 6-

month look back

Sampling requirements

for their Medicare Part

B patients

MIPS: QUALITY DATA SUBMISSION REQUIREMENTS

18

• Assessment under all available resource use measures, as applicable to the clinician

• CMS calculates based on claims so there are no reporting requirements for clinicians

• Key Changes from Current Program (Value Modifier):• Adding 10 episode specific measures to address specialty

concerns

NOT CALCULATED IN 2017

MIPS: COST (RESOURCE USE) CATEGORY

19

MIPS: COST PERFORMANCE CATEGORY

2017 (2019 payment)- 0% Feedback Reports Provided

2018 (2020 payment) 10%

2019 (2021 payment) and later- 30%

Measure Description

Medicare

Spending per

Beneficiary

Attribution: TIN providing plurality of Medicare Part B claims

Evaluate observed to expected costs at the episode level

Measure is average of assigned ratios

35 minimum cases

Total per Capita

Cost

Attribution: Two-step process:

TIN of PCP providing plurality of primary care services

TIN of Non-PCP providing plurality of primary care services

20 minimum cases

10 Episode-based

payment

measures

20 minimum cases

Included in 2014 and 2015 sQRUR and reliability of 0.4 for majority of clinicians

Acute condition: All MIPS eligible clinicians that bill at least 30% of inpatient E&M visits during trigger

event; more than one clinician can be attributed

Procedural: MIPS eligible clinicians billing a part B claim with a trigger code during the trigger event

– Inpatient- inpatient stay triggering the episode plus day prior to admission

– Outpatient Method A- day before triggering claim- two days after triggering event

– Outpatient Method B- day of triggering event

20

40 points total• High-weighted activities (14) = 20 points

• Medium-weighted activities (79) = 10 points

• Activities in Table H of final rule

Small practice, rural, health professional shortage area or non-patient facing: 1 high-weighted or 2 medium-weighted activities to receive full credit

At least 90 consecutive days for each activity

CMS Improvement Activities and Measurement Study• Participants receive 40 points in recognition of burden associated with study

MIPS: IMPROVEMENT ACTIVITIES CATEGORY

21

IMPROVEMENT ACTIVITIES: EIGHT SUB-CATEGORIES

Expanded Practice Access

Population Management

Care Coordination

Beneficiary/Patient Engagement

Patient Safety and Practice Assessment

Achieving Health Equity

Emergency Response and Preparedness

Integrated Behavioral and Mental Health

22

MIPS: IMPROVEMENT ACTIVITIES, PCMH AND APMS

PCMH Recognition- Full credit (40 points)

• Patient-centered medical home or comparable specialty practice recognition

• Certification or recognition from a national program, regional/state program, or private payer that certifies at least 500 or more practices

• Examples of nationally-recognized accredited programs

• Accreditation Association for Ambulatory Health Care

• National Committee for Quality Assurance (NCQA) PCMH Recognition

• NCQA Patient-Centered Specialty Recognition

• The Joint Commission Designation

• Utilization Review Accreditation Commission (URAC)

APM Participation- At least half credit (20 points)

• On an APM Entity Participant List

• CMS will evaluate each MIPS APM model against improvement activities to determine if more points are awarded

• For FY 2017 performance, all current models receive full credit

23

• Reduced the number of required measures in the base score from eleven

in the proposed rule to five in the final policy. Other measures are optional.

• 10% bonus for attesting to complete at least one improvement activities

using certified electronic health record technology (CEHRT).

• Flexible scoring for all measures to promote care coordination for better

patient outcomes

• Key Changes from Current Program (EHR Incentive):

• Removed redundant measures to alleviate reporting burden.

• Eliminated Clinical Provider Order Entry and Clinical Decision Support objectives

• Reduced the number of required public health registries to which clinicians must

report

MIPS: ADVANCING CARE INFORMATION (ACI) CATEGORY

24

MIPS: ACI PERFORMANCE CATEGORY SCORINGB

ase

Sco

re 50 Points

Pe

rfo

rma

nce S

co

re 90 Points

Bo

nu

s P

oin

t

Up to 15 points

Com

po

site

Sco

re 100 points or more receive full score

• Protecting Patient Health Information is a Must Pass Element

• Failure to meet will result in 0 points for the entire performance category

• Reweighting ACI to 0% for certain clinicians• Hospital-based clinicians- more than 75% of care furnished in an inpatient hospital, on campus outpatient

hospital or ED

• Hardship Exemption

• NP, PA, CNS, CRNA- must submit application by March 31, 2018

25

MIPS: ACI PERFORMANCE CATEGORY SCORING

Protect Patient Health Information (required)

Electronic Prescribing (numerator/denominator)

Patient Electronic Access (numerator/denominator)

Coordination of Care Through Patient

Engagement (numerator/denominator)

Health Information Exchange

(numerator/denominator)

Public Health and Clinical Data Registry Reporting

(required)

Base Score Objectives (50 points)CMS proposes six objectives and their measures that would require reporting for the base score:

Patient Electronic AccessCoordination of Care

Through Patient Engagement


Performance Score (90 points) Physicians select the measures that best fit their practice from the following objectives, which emphasize patient care and

information access:

26

MIPS: ACI SCORING STAGE 3 OBJECTIVES AND MEASURES

Objective MeasureBase Score (50%)

Requirement

Performance Score (up

to 90%)

Protect Patient Health

InformationSecurity Risk Analysis MUST PASS Must attest “yes” 0

Electronic Prescribing ePrescribing 0

Patient Electronic AccessProvide Patient Access Up to 10%

Patient-Specific Education Up to 10%

Coordination of Care Through

Patient Engagement

View, Download or Transmit (VDT) Up to 10%

Secure Messaging Up to 10%

Patient-Generated Health Data Up to 10%


Send a Summary of Care Up to 10%

Request/Accept Summary of Care Up to 10%

Clinical Information Reconciliation Up to 10%

Public Health and Clinical Data

Registry ReportingImmunization Registry Reporting 0 or 10%

BONUS

Syndromic Surveillance Reporting

Bonus 5%Electronic Case Reporting

Public Health Registry Reporting

Clinical Data Registry Reporting

Improvement Activities Using CEHRT Bonus 10%

MIPS: ENCOURAGING A MOVEMENT TO POPULATION HEALTH

Model

MIPS

Performance

Category

Alternative Payment Entity Data

Submission RequirementPerformance Score

Category

Weight

Medicare

Shared

Savings

Program

(MSSP)

Quality

Shared Savings Program

Accountable Care Organizations

(ACOs) submit quality measures

to the CMS Web Interface on

behalf of their participating MIPS

eligible clinicians.

MIPS quality performance category

requirements and benchmarks will be

used to determine the MIPS score at the

ACO level.

50%

Cost Not assessed N/A N/A

Improvement

Activities

MSSP ACOs automatically

receive the full credit for this

category.

CMS will assign the same improvement

activities score to each APM Entity group

based on the activities required of

participants in the Shared Savings

Program. The minimum score is one half

of the total possible points.

20%

ACI

Submit according to the MIPS

requirements; ACI performance

assessed as a group through

TINs associated with the ACO.

All of the ACO participant TIN scores will

be aggregated as a weighted average to

yield one APM Entity group score.

30%

TRACK 2: 5% BONUS FOR ADVANCED APMS

Uses certified EHR technology,

Pays based on MIPS comparable quality

measures, and

25%

50%

75%

2019-20

2021-22

2023 +

Total payments exclude payments made by the Secretaries of Defense/Veterans Affairs

and Medicaid payments in states without medical home programs or Medicaid APMs.

* Minimum of 25% of Medicare payments must be in APM in all years, unless partial

qualifying thresholds are met with no 5% bonus and a choice of MIPS

Threshold of payments in an Advanced APM

Requires more than “nominal” financial risk for

losses.

Advanced Alternative Payment Models (APM) Entities Must:

1

2

3

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Measurement period

Advanced APM participating providers

exempt from MIPS; receive annual 5% bonus

(2019-2024) TR

AC

K 2

0.75%

update

(2026)

CMS Innovation

Center Model

Medicare

ACO

Health Care Quality

Demonstration

Demo Required by

Federal Law*

Expanded Medical

Home Model

New programs TBD

Alternative Payment Models (APM) are defined in MACRA as:

Inclusion in

Advanced APMs

triggers exclusion

from MIPS.

Medicare only

Medicare* and all-payer

Medicare* and all-payer

Or, 20% beneficiary count

Or, 35%

Or, 50%

29

1. Model requires at least 50% of eligible clinicians to use Certified EHR Technology (CEHRT) in 1st performance period (2017)

• Applicable to hospital in models where it is the participant

• CEHRT definition to match MIPS; 2014 in 2017 and 2015 in 2018

• The EHR Incentive Payment participation quality metric will count for Medicare Shared Savings Program (ACO-11)

2. Model pays, at least in part, based on 1 outcome measure and 1 MIPS comparable quality measure that are evidence-based, reliable and valid of the following types:

• Quality measures applicable under MIPS;

• Proposed annual list of MIPS quality measures;

• Endorsed by a consensus-based entity;

• Submitted in response to the MIPS Call for Quality Measures; or

• Any other quality measures that CMS determines to have an evidence-based focus and be reliable and valid.

ADVANCED APMs - STEP 1: DOES THE MODEL QUALIFY?

30

ADVANCED APMS STEP 1: DOES THE MODEL QUALIFY? (CONT’D)

3. There is more than a nominal amount of risk for monetary losses (withhold, reduce or clawback payments):• Total Risk (maximum exposure) must be at least the lower of:

• 4% 3% of APM spending benchmark or target, or

• 8% of average estimated total Medicare A/B revenue of entity in 2017/2018

• Marginal Risk (% of spending above APM benchmark or target price for which Advanced APM Entity is responsible – aka “sharing rate”) must be at least 30%

• Minimum Loss Rate (the amount spending can exceed APM benchmark or target price before Advanced APM entity bears loss) must be no more than 4%

• Or, is a full capitation risk arrangement

Medical home models must meet same CEHRT and quality requirements, but have slightly different nominal risk standard, unless it is certified and “expanded” by Innovation Center

X

X

WHAT QUALIFIES FOR ADVANCED APM

Comprehensive ESRD Care (CEC)

Comprehensive Primary Care Plus (CPC +)

Medicare Shared Savings Program

tracks 2 & 3*

Next Generation ACO Model*

Oncology Care Model (OCM) two-sided

risk arrangement & Other select Bundles

* Known to Have Upcoming Open Enrollment & Encompass Majority of Medical Staff

Proposed for 2018• Medicare Shared Savings Program track 1+

• Advancing Care Coordination through Episode Payment

Models (EPMs) Track 1

• Comprehensive Care for Joint Replacement

• New voluntary bundled payments program

STEP 2: IS THE ENTITY IN A DESIGNATED ADVANCED APM?

32

Types of Eligible Professionals

Track 1 Track 2

Value-Modifier MIPS APM

Medicare Physicians:

Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatric

Medicine, Doctor of Optometry, Doctor of Oral Surgery, Doctor of

Dental Medicine, Doctor of Chiropractic

2017

(2015 performance)

2019 2019

Practitioners:

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist,

Certified Registered Nurse Anesthetist

2018

(2016 performance)

2019 2019

Practitioners:

Certified Nurse Midwife, Clinical Social Worker, Clinical

Psychologist, Registered Dietician, Nutrition Professional,

Audiologists

N/A 2021 2019

Therapists:

Physical Therapist, Occupational Therapist, Qualified Speech-

Language Therapist

N/A 2021 2019

ADVANCED APM STEP 3: ARE YOU AN ELIGIBLE CLINICIAN IN THE ADVANCED APM ENTITY?

Exclusions: New Medicare-enrolled eligible clinicians; Clinicians below the low-volume threshold

33

ADVANCED APM STEP 3 & 4: AND, CAN YOU MEET THRESHOLDS TO BE A QUALIFYING OR PARTIAL QUALIFYING APM PARTICIPANT?

Qualifying Participant (QP) status will be determined based on either a percent of Part B professional revenue or patients, whichever is advantageous, in Advanced APM to demonstrate commitment.

Calculations at the aggregate level using data for all eligible clinicians participating in an Advanced APM Entity.

• Hospital-led APM where clinicians not on Participation list able to use an Affiliates list (e.g. CJR) and assess at National Provider Identifier (NPI) level

• Clinicians participating in more than one APM that fails will have payments and patient counts combined across APMs for NPI

• Entities in more than one program will not be able to combine payments, but will be able to combine patient counts

CMS will notify each Entity and clinician and post publicly

If miss QP thresholds, there are a separate set of slightly lower Partial QP thresholds where the Entity can opt-in to MIPS

• Individual assessed at NPI level would just need to report to opt in

CMS TABLE 36 & 37: QP PAYMENT AMOUNT AND PATIENT THRESHOLDS (ALL-PAYER COMBINATION OPTION)

All-Payer Combination Option – Payment Amount Method

Payment Year 2019 2020 2021 2022 2023 2024 and later

QP Payment Amount Threshold N/A N/A 50% 25% 50% 25% 75% 25% 75% 25%

Partial QP Payment Amount

ThresholdN/A N/A 40% 20% 40% 20% 50% 20% 50% 20%

To

tal

Me

dic

are

To

tal

Me

dic

are

To

tal

Me

dic

are

To

tal

Me

dic

are

All-Payer Combination Option – Patient Count Method

Payment Year 2019 2020 2021 2022 2023 2024 and later

QP Patient Count Threshold N/A N/A 35% 20% 35% 20% 50% 20% 50% 20%

Partial QP Patient Count

ThresholdN/A N/A 25% 10% 25% 10% 35% 10% 35% 10%

To

tal

Me

dic

are

To

tal

Me

dic

are

To

tal

Me

dic

are

To

tal

Me

dic

are

35

QP AND PARTIAL QP DETERMINATION TIMEFRAME

§ Three snap shots: March 31, June 30 and August 31

§ Will assess claims for 3, 6 or 8 months

§ Will use 3 month run out, so determination 4 months post

§ Only need to be in and pass in one snap shot

§ Will notify clinicians in time to report under MIPS if needed

FIGURE F: Determining the APM Entity Group Through Participation List Snapshots

Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017

+ =APM

Entity

group

Group

from

snapshot

#1

APM

Entity

group

Group

from

snapshot

#2

+ =

Participants added

since snapshot #1

Participants added

since snapshot #2 FINAL

APM

Entity

group

Snapshot #1 Snapshot #2 Snapshot #3

CONSIDERATIONS TO POSITION YOUR ORGANIZATIONS FOR SUCCESS

The financial impact of the chosen path can impact

up to 9% of reimbursements. Organizations must

consider the operating infrastructure required.

Impact of MIPS on

Eligible Clinicians

Impact of MIPS Track

+ Cost of Upside ACO

Impact of integrating

providers and care

TOTAL MIPS TRACKTOTAL NON-QUALIFIED

APM TRACK

TOTAL QUALIFIED

APM TRACK

Advanced

Alternative Payment

Models

MIPS +

Non-Qualified

APM Track

MIPS

Track

WHAT IS THE RIGHT MODEL NOW, AND IN THE FUTURE?

38

Important Links

• Premier Resources

Premier detailed summary

Premier's Flash Update

Premier June 2016 MACRA comments

• CMS Resources

Final rule

CMS QPP Website CMS press release

CMS blog post by Andy Slavitt

ONC fact sheet: QPP and Health IT

https://premierconnect.premierinc.com/WorkplaceXT/getContent?id=release&vsId=DD4C458E-8CDF-4C30-A04F-6B7AD9C49FF6&objectStoreName=OBJStore1&objectType=document

https://communities.premierinc.com/display/PNA/2016/10/14/CMS+Releases+Final+MACRA+Rule+to+Create+Quality+Payment+Program

https://www.premierinc.com/premier-inc-submits-comments-macra-rule/

https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-and-alternative-payment-model-incentive-under

https://qpp.cms.gov/education

http://www.hhs.gov/about/news/2016/10/14/hhs-finalizes-streamlined-medicare-payment-system-rewards-clinicians-quality-patient-care.html

https://blog.cms.gov/

https://www.healthit.gov/sites/default/files/macra_health_it_fact_sheet_final.pdf

QUESTIONS?

SETH EDWARDS, MHAPrincipal, Population Health

Collaborative

202-879-8006

[email protected]

APPENDIX

41

MIPS: ELIGIBLE CLINICIANS

Non-Patient Facing MIPS ECs

• Individuals: bill 100 or fewer patient-facing encounters

• Groups: More than 75% of NPIs under the TIN meet the individual threshold

• Non patient-facing determination made in two-segment claims analysis:



CAHs

• Method I- MIPS adjustment applies to payments for items and services under PFS, not facility payment

• Method II- MIPS adjustment applies when clinicians assign their billing rights to the CAH

RHC/FQHC

• MIPS Adjustment does not apply to facility payment or items and services billed under all-inclusive payment methodology

• MIPS eligible clinicians who bill for services under PFS are subject to MIPS adjustment

42PROPRIETARY & CONFIDENTIAL – © 2016 PREMIER, INC.

MIPS: 2019 PAYMENT YEAR/ 2017 PERFORMANCE YEAR

60%

0%

15%

25%

Quality:

60 points*

6 measures (one outcome)

Readmissions (groups of

16+ only)

Bonus points:

Outcome, appropriate

use, patient safety,

patient experience, care

coordination measures

Report measures using

end-to-end reporting

3-point floor: Report

measure data that cannot be

scored and avoid payment

adjustment

Cost:

Not Assessed- Feedback Reports OnlyMSPB, Total Per Capita Cost, Episode Payment

Improvement

activities:

40 points

High Weight: 20 points

Medium Weigh: 10 points

PCMH: 40 points

APM Participation:

At least 20 points

Advancing care

information:

100 points

Base Score

Security Risk Analysis

ePrescribing

Provide patient access

Send summary of care

Receive summary of care

Performance Score

Bonus Points

* Total points possible vary by provider type and available measures

2019

Payment

2017

Performance


MIPS: QUALITY PERFORMANCE CATEGORY: 60%

Measure Scoring No successful reporting requirements, each

measure submitted is awarded points

Topped out measure policy does not apply

until year 2 of measure being topped out

(2018 performance period is earliest)

Transition Year Policy

– Class 1 measure: 3-10 points

• Has a benchmark

• At least 20 cases

• Meet data completeness standard

– Class 2 measure: 3 points

• Does not have a benchmark

• Does not have at least 20 cases

• Does not meet data completeness standard

Bonus Points High Priority Measures

(up to 10% of total possible score)

– 2 points for each outcome and patient

experience measure (excludes required

outcome measure)

– 1 point for each high priority measure (patient

safety, efficiency, appropriate use, care

coordination)

End to End Reporting

(up to 10% of total possible score)

– 1 point for each measure

– CEHRT is used to record measures

demographic and clinical information

– Measure data is electronically submitted to 3rd

party intermediary (e.g. QCDR)

– 3rd party intermediary calculates and submits

data electronically to CMS

44

MIPS: QUALITY BENCHMARKS Baseline period is two years prior (2015 for 2017 reporting)

Each benchmark must have 20 MIPS eligible clinicians meeting data completeness

New measure benchmarks derived from performance period (2017 for CY 2019 payment) and have 3-point floor

Separate benchmarks for each reporting mechanism

Web Interface benchmarks same as MSSP

Decile

Sample Quality

Measure

Benchmarks

Possible Points with

3-Point Floor

Possible Points

without 3-Point Floor

Benchmark Decile 1 0-9.5% 3.0 1.0-1.9

Benchmark Decile 2 9.6-15.7% 3.0 2.0-2.9

Benchmark Decile 3 15.8-22.9% 3.0- 3.9 3.0-3.9

Benchmark Decile 4 23.0-35.9% 4.0-4.9 4.0-4.9






Benchmark Decile 10 85.0%-100% 10 10

45

Measure Measure TypePoints Based on

Performance

Total

Possible

Points

Quality Bonus

Points for High

Priority

Quality Bonus

Points for

CEHRT

1Outcome Measure

using CEHRT4.1 10 0 (required) 1

2Outcome Measure

using CEHRT9.3 10 2 1

3Patient Experience

using CEHRT10 10 2 1

4High Priority using

CEHRT10 10 1 1

5Outcome Measure

using CEHRT9 10 2 1

6Outcome Measure

using CEHRT8.4 10 2 1

Total: 50.8 60 9 6

Cap applied to Bonus Categories

(10%x total possible points):6 6

Total with High Priority CEHRT

Bonus:60

MIPS: QUALITY PERFORMANCE SCORING EXAMPLE

46

MIPS: COST PERFORMANCE CATEGORY

2017 (2019 payment)- 0% Feedback Reports Provided

2018 (2020 payment) 10%

2019 (2021 payment) and later- 30%

Measure Description

Medicare

Spending per

Beneficiary

Attribution: TIN providing plurality of Medicare Part B claims

Evaluate observed to expected costs at the episode level

Measure is average of assigned ratios

35 minimum cases

Total per Capita

Cost

Attribution: Two-step process:

TIN of PCP providing plurality of primary care services

TIN of Non-PCP providing plurality of primary care services

20 minimum cases

10 Episode-based

payment

measures

20 minimum cases

Included in 2014 and 2015 sQRUR and reliability of 0.4 for majority of clinicians

Acute condition: All MIPS eligible clinicians that bill at least 30% of inpatient E&M visits during trigger

event; more than one clinician can be attributed

Procedural: MIPS eligible clinicians billing a part B claim with a trigger code during the trigger event

– Inpatient- inpatient stay triggering the episode plus day prior to admission

– Outpatient Method A- day before triggering claim- two days after triggering event

– Outpatient Method B- day of triggering event

47

MIPS: ACI PERFORMANCE CATEGORY SCORING POST 2017 EXAMPLE

Objective Measure Base Score Performance Score Reporting Requirement

Protect Patient

Health InformationSecurity Risk Analysis Required 0 Yes / No Statement

Electronic

Prescribinge-Prescribing Required 0 Numerator / Denominator

Patient Electronic

Access

Provide Patient Access Required Up to 10 Numerator / Denominator

Patient-Specific Education Not Required Up to 10 Numerator / Denominator

Coordination of

Care Through

Patient

Engagement

View, Download, or Transmit (VDT) Not Required Up to 10 Numerator / Denominator

Secure Messaging Not Required Up to 10 Numerator / Denominator

Patient-Generated Health Data Not Required Up to 10 Numerator / Denominator

Health Information

Exchange

Send a Summary of Care Required Up to 10 Numerator / Denominator

Request/Accept Summary of Care Required Up to 10 Numerator / Denominator

Clinical Information Reconciliation Not Required Up to 10 Numerator / Denominator

Public Health and

Clinical Data

Registry Reporting

Immunization Registry Reporting Not Required 0 or 10 Yes / No Statement

Syndromatic Surveillance

ReportingNot Required Bonus Yes / No Statement

Electronic Case Reporting Not Required Bonus Yes / No Statement

Public Health Registry Reporting Not Required Bonus Yes / No Statement

Clinical Data Registry Reporting Not Required Bonus Yes / No Statement

48

MIPS: IMPROVEMENT ACTIVITIES, PCMH AND APMS

PCMH Recognition- Full credit (40 points)

• Patient-centered medical home or comparable specialty practice recognition

• Certification or recognition from a national program, regional/state program, or private payer that certifies at least 500 or more practices

• Examples of nationally-recognized accredited programs

• Accreditation Association for Ambulatory Health Care

• National Committee for Quality Assurance (NCQA) PCMH Recognition

• NCQA Patient-Centered Specialty Recognition

• The Joint Commission Designation

• Utilization Review Accreditation Commission (URAC)

APM Participation- At least half credit (20 points)

• On an APM Entity Participant List

• CMS will evaluate each MIPS APM model against improvement activities to determine if more points are awarded

• For FY 2017 performance, all current models receive full credit

49

MIPS: APM SCORING STANDARD

50%

20%

30%

MSSP 50%

20%

30%

Next

Gen

25%

75%

Other

APM

Quality — Measures reported by APM

Web Interface measures: 14 measures, 4 receive a bonus point 2017: 11 measures

Cost— Not assessed

Advancing care information — Average of individual clinicians submitting as individuals or groups

MSSP: Weighted average of score for TINs

Improvement activities — Automatically receive half of the points

Models awarded full points: Shared Savings, Next Gen, Comprehensive ESRD Care (all arrangements), Oncology

Care Model (all arrangements), CPC+

50

MIPS: PAYMENT ADJUSTMENT FOR 2019

Final

Score

How to Achieve Score MIPS Adjustment

0- 0.75 Fail to Report Negative 4%

0.76-

2.69

Unlikely to occur -4 to 0%

3.0 Submit 1 quality measure that does not

meet data completeness standards

Submit 1 low-weighted improvement activity

0%

3.1- 69.9 Submit additional information to full

reporting with low performance

0-4% x scaling factor

70.0- 100 Fully participate with high performance 0-4% x scaling factor AND

MIPS exceptional performance adjustment

0.5%- 10% x scaling factor

51

ESTIMATED PARTICIPATION IN ADVANCED APMS

Proposed rule estimated 30,000 to 90,000 clinicians would be excluded from MIPS as QPs in Advanced APMs in 2017.

Final rule estimates between 70,000 and 120,000 clinicians excluded from MIPS as QPs in Advanced APMs in 2017. • Approximately 5-8 percent of all clinicians billing under

Medicare Part B

Incentive payments for QPs expected to total between $333M and $571M in 2019 (2017 performance)

Also estimates 125,000 to 250,000 clinicians excluded from MIPS as QPs in Advanced APMs in 2018.


Qualifying APM

Participants (QPs) are

excluded from MIPS

and get a lump sum

5% incentive payment

equal to the prior

year’s Part B covered

professional services,

applies from 2019 –

2024. In 2026 and

beyond, QPs get a

0.75% update

vs. 0.25%.

ADVANCED APM

FIGURE B: Program Overview

ALTERNATIVE

PAYMENT MODEL

(APM)

APM model meets

Advanced APM

criteria

ADVANCED APM

ENTITY

APM Entity

participates in

Advanced APM model

QUALIFYING APM

PARTICIPANT (QP)

Eligible Clinicians

in Advanced APM

Entity collectively meet

either revenue or

beneficiary count QP

thresholds

of participation

PARTIAL QP

Eligible Clinicians in

Advanced APM Entity

collectively meet either

revenue or beneficiary count

Partial QP thresholds with

no bonus and chose

whether to be in MIPS

01 02

04 03

53

FIGURE C: QP DETERMINATION TREE, PAYMENT YEARS 2019-2020

Is threshold score ≥20%?

Is threshold score ≥25%?

QP

Partial QP

MIPS eligible clinician

Yes

Yes

No

No

Medicare Only


CMS Tables 32 and 34: QP Payment Amount and Patient Thresholds—Medicare Option

Medicare Option – Payment Amount Method

Payment Year 2019 2020 2021 2022 2023

2024 and

later

QP Payment Amount Threshold 25% 25% 50% 50% 75% 75%

Partial QP Payment Amount Threshold 20% 20% 40% 40% 50% 50%

Medicare Option – Patient Count Method

Payment Year 2019 2020 2021 2022 2023

2024 and

later

QP Patient Count Threshold 20% 20% 35% 35% 50% 50%

Partial QP Patient Count Threshold 10% 10% 25% 25% 35% 35%

55

QP AND PARTIAL QP CALCULATION: ALL- PAYER COMBINATION

Starts with Medicare only, but allows private payers to supplement the calculation in 2021

• Medicare option will be calculated first then the All-Payer Combination Option

• Statute generally follows Medicare criteria, but with some flexibility

Medicare Advantage not counted in Medicare Option, but rather part of All-Payer Combination Option

Excludes payments made by DOD/VA and Medicaid in states without medical home programs or Medicaid APMs.

Finalized models and process for EC identification for Medicare, but seeking comments on private payer process

56

OTHER PAYER ADVANCED APM: RISK STANDARD

Other Payer Advanced APM must, if actual aggregate expenditures exceed expected aggregate expenditures in a specified performance period:• Withhold payment for services to the APM Entity or the APM Entity’s

eligible clinicians;

• Reduce payment rates to the APM Entity or the APM Entity’s eligible clinicians; or

• Require direct payment by the APM Entity to the payer.

The risk arrangement must have:• A marginal risk rate of at least 30%,

• Maximum allowable minimum loss rate of 4%,

• Total potential risk of at least 3% of expected expenditures; or

• Capitation.

• Intend to establish a criterion based on A/B revenue in the future.

57

MEDICAID MEDICAL HOME MODEL: RISK STANDARD

§ Except when fewer than 50 eligible clinicians in the parent APM entity owner of a Medicaid Medical Home Model then one or more of the following must apply:• Withhold payment for services to the APM Entity or the APM Entity’s

eligible clinicians;

• Require direct payment by the APM Entity to the payer;

• Reduce payment rates to the APM Entity or the APM Entity’s eligible clinicians, or

• Require the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments.

§ Entity must potentially owe or forego:• In 2019, 4% of the APM Entity’s revenue under the payer;

• In 2020 and later, 5% of the APM Entity’s revenue under the payer.

quality payment program (qpp): mips vs. apms and ... · measure. if fewer than six measures apply,...

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