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Quality Payment Program Year 4:Final Rule Overview
The information contained in this presentation is for general information purposes only. The information is provided by UK HealthCare’s Kentucky Regional Extension Center and while we endeavor to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to content.
UK’s Kentucky REC is a trusted advisor and partner to healthcare organizations, supplying expert guidance to maximize quality, outcomes and financial performance.
To date, the Kentucky REC’s activities include:
• Assisting more than 5,000 individual providers across Kentucky, including primary care providers and specialists
• Helping more than 95% of the Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) within Kentucky
• Working with more than 1/2 of all Kentucky hospitals
• Supporting practices and health systems across the Commonwealth with practice transformation and preparation for value based payment
Physician Services
1. Promoting Interoperability (MU) & Mock Audit
2. HIPAA SRA, Project Management & Vulnerability Scanning
3. Patient Centered Medical Home (PCMH) Consulting
4. Patient Centered Specialty Practice (PCSP) Consulting
5. Value Based Payment & MACRA Support
6. Quality Improvement Support
7. Telehealth Services
Hospital Services
1. Promoting Interoperability (Meaningful Use)
2. HIPAA Security Analysis & Project Management
3. Hospital Quality Improvement Support
Kentucky REC Description
Kentucky Regional Extension Center Services
On November 1st, 2019 CMS released the QPP Final Rule • These changes are set to go into effect starting on January 1st, 2020*
2020 QPP Final Rule
*Some changes are retrospective
Year 4 Quality Payment Program Overview
Merit-Based Incentive Payment System (MIPS) Track Updates
MIPS Value Pathways (MVPs)
Alternative Payment Model (APM) Track Updates
Questions
Objectives
QPP Y4: Final Rule
Name of Legislation or Regulation:
Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies…
Links for More Information:
Final Rule Full Text: https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other
Those Impacted: Will impact Medicare Part B payments to eligible clinicians beginning in 2022.
Effective: Begins January 2019 with affected payments based on those measures beginning in 2021.
2020 Quality Payment Program (QPP) Overview
QPP Y4: Glossary of TermsMACRA (Medicare Access & CHIP Reauthorization Act)
• Legislation that replaced Sustainable Growth Rate, with a goal for CMS to pay for quality and value, rather than volume (fee for service).
QPP (Quality Payment Program)• Created by the MACRA legislation which pays for quality and value rather than volume. Providers will choose
between MIPS and APM.MIPS (Merit-Based Incentive Payment System)
• Medicare pay-for-performance system created by MACRA that consolidates several existing Medicare pay-for-performance programs.
APM (Alternative Payment Model)• CMS Model that pays providers for services based on quality, outcomes, and cost-containment; 5% annual
bonus payment to Qualified Physicians who are participating in APMs, and exempts them from participating in MIPS.
MVPs (MIPS Value Pathways)• A conceptual participation framework that would apply to future proposals beginning with the 2021
performance year. The goal is to move away from siloed activities and measures and move towards an aligned set of measure options more relevant to a clinician’s scope of practice that is meaningful to patient care.
QPP Y4: Program TracksBy law, MACRA requires CMS to implement an incentive program, referred to as the
Quality Payment Program, which provides two participation tracks for clinicians:
If you are a MIPS EC, you will be subject to a performance-based payment adjustment through MIPS
If in an Advanced APM, you may earn an incentive payment for participating in one of these models
QPP Y4: QPP Clinician Eligibility
Merit-Based Incentive Program(MIPS)
$90KPart B
200 Medicare Patients
200 PFS
Advanced Alternative Payment Model(APMs)
Advanced APM
Participant
50% Payment
or
35% Medicare Patients
QPP Track Eligibility Requirements
Eligible Clinician Types: Physician, PA, NP, CNS, CRNA, PT, OT, Qualified Speech-Language Pathologist, Qualified Audiologist, Clinical Psychologist, Registered Dietitian or Nutrition Professional
QPP Y4: Virtual Groups
Virtual Groups
No Changes
Reminder:Data aggregation required for Virtual Groups across all
TINs
2020 Merit-Based Incentive Payment System
QPP Y4: MIPS Thresholds
0 Points =Full 9% Penalty
45 Points Minimum
Threshold =No Penalty, No Reward
Between 46-84 Points =
No Penalty
85+ = Exceptional Performance
Split $500M Pool
Year 5 Minimum Threshold = 60 Points
QPP Y4: MIPS Overview
Program Year
Payment Year
Quality ImprovementActivities
Promoting Interoperability
CostAdjustment
Factor+ / -
2020(Y4) 2022 45% 15% 25% 15% 9%
Reporting Timeframes
365-Days
90-Day Minimum
90-Day Minimum
365-Days
Applied During
Payment Year
Must Submit by March 31st, 2021
QPP Y4: Data Submission Types
Performance Category
Submission Type Submitter Type Collection TypeThe mechanism by which a submitter type submits data
The MIPS EC, group, or third party intermediary acting on behalf of a MIPS EC or group
Set of quality measures with comparable specifications and data completeness criteria
QualityDirectLog-in & UploadCMS Web Interface Medicare Part B Claims (Small)
IndividualGroup3rd Party Intermediary
eCQMsMIPS CQMsQCDR MeasuresCMS Web Interface MeasuresCMS Approved Survey Vendor MeasureMedicare Part B Claims (small practices)Administrative Claims Measures
PromotingInteroperability
DirectLog-in & UploadLog-in & Attest
IndividualGroup3rd Party Intermediary
ImprovementActivities
DirectLog-in & UploadLog-in & Attest
IndividualGroup3rd Party Intermediary
Cost No data submission required IndividualGroup
QPP Y4: Reporting Options
Individual
Under an NPI number & TIN
where they reassign benefits
Group
> 2 clinicians (NPIs) who
have reassigned their billing rights to a single TIN
As an APM Entity
Virtual Group
Combination of > 2 TINs
assigned to > 1 individual MIPS ECs, or to > 1
groups consisting of <10 ECs with > 1
MIPS EC
Quality:6 Measures Required except for: CMS Web Interface report 10 quality measures
At least 1 Outcome measure
7th Measure based on claims for large groups
IA:40 points raw score required• Combination of
medium & highly weighted activities
• 50% ECs must participate in same activity
• 50% of the locations under the TIN are Certified PCMH/PCSP
Cost:Score is based on Medicare claims, including:Measure 1: Medicare Spending per Beneficiary (MSPB)
Measure 2: Total per capita costs (TPCC) for all attributed beneficiaries
18 Episode-Based Measures
QPP Y4: Reporting Categories: Basics
PI:100 points raw score required
• 4 Objectives, 5 Measures
Scoring:• Performance
Score• Bonus
2015 CEHRT Required
Year 4: Minimum Threshold = 45 Points; 9% Risk
QPP Y4: Changes to Quality
Final Score:• 45% for 2020• TBD for 2021 • 30% for 2022 & Beyond
Submission:• No Significant Changes to
the Reporting Requirements or Submission Mechanisms
Measures
• Adding:• 3 New Measures• 7 New Specialty Measure Sets• Add 1 New Measure to the
CMS Web Interface Set• Added Claims-Based Measure
for PY21 • Removing:
• 42 Measures• Altering:
• 83 Significantly for 2020+• 1 Retroactive Change for
2019+
Requirements
• Increase of Data Completeness Requirement to 70%
• Scoring:• Flat percentage benchmarks
Controlling High Blood Pressure & A1C Poor Control
QPP Y4: Changes to Improvement Activities (IA)
Final Score:• 15% of Final Score
Submission:• No Significant Changes to
the Reporting Requirements or Submission Mechanisms
Measures
• Removing:• 15 Activities
• Annual registration in PDMP• Adding:
• 2 New Activities• Modifying:
• 7 Existing Activities
Requirements
• No Proposed Changes to Scoring• 40 Category Points Needed
Across 2-4 Activities• 50% ECs perform same activity• > 90 consecutive day reporting
timeframe
QPP Y4: Changes to Promoting Interoperability (PI)
Final Score:• 25% of Final Score• Maintained EC type
reweights
Submission:• No Significant Changes to
the Reporting Requirements or Submission Mechanisms
Measures
• Maintained 4 Objectives• Removed Verify Opioid
Treatment Agreement• Modified PDMP to Y/N*• e-Rx measure will be worth 10
points • Clarified HIE exclusion reweight*• Hospital-Based as 75% or more
of ECs under TIN
Requirements
• Use of 2015 CEHRT • > 90 consecutive day reporting
timeframe• Scoring:
• Maintained Performance-based measurement
• Maintained 100 raw category points for full credit
QPP Y4: Changes to Cost
Final Score:• 15% for 2020• TBD for 2021 • 30% for 2022 & Beyond
Submission:• No Submission Required
Measures
• Measure 1: Spending per Beneficiary
• Measure 2: Total per capita costs
• Adding 10* episode-based measures
Requirements
• MSPB: 35 cases• TPCC: 20 cases• Procedural: 10 cases• Inpatient: 20 cases
MSPB Clinician
• Updated the attribution methodology
• Medical vs surgical episode
• Added service exclusions
TPCC
• Updated the attribution methodology
• New terms-Candidate Event and risk window
• Multiple TINs to one beneficiary*
• Service category and specialty exclusions
• Change to Risk Adjustment methodology
• Evaluate costs on a monthly basis
Episode-Based Measures
• No change in attribution method• 8 Procedural Measures• 2 Inpatient Measures• No change in case thresholds
QPP Y4: Attribution Method Update
Attribution will be to each MIPS EC who renders a trigger service as identified by HCPCS/CPT procedure codes.
Acute Kidney Injury Requiring New IP Dialysis Elective Primary Hip Arthroplasty Femoral or Inguinal Hernia Repair Hemodialysis Access Creation Lumbar Spine Fusion for DDD, 1-3 Levels Lumpectomy Partial Mast, Simple Mast Non-Emergent CABG Renal or Ureteral Stone Surgical Tx
Attribution will be to each MIPS EC who bills inpatient E&M claim lines during a trigger inpatient hospitalization under a TIN that renders > 30%.
Inpatient COPD Exacerbation Lower Gastrointestinal Hemorrhage *
*Lower GI Hemorrhage will only be measured at the group level
QPP Y4: New Episode Measures
Procedural Episodes Acute Inpatient Medical Condition Episodes
Quality• Quality
measures will not be publicly reported for the first two years in use, starting with Performance Year 2
Cost• Cost
measures will not be publicly reported for the first two years in use
PI• Includes an
indicator of “Successful”
• A “high-performing” indicator will not be reported
IA• IAs will be
publicly reported if all other public reporting criteria are satisfied
QPP Y4: MIPS Public Reporting
MIPS Value Pathways (MVPs)
QPP Y4: MIPS Value Pathways (MVPs)
MIPS Historical Categories
Quality, Cost, Improvement
Activities
Promoting Interoperability (Foundational)
Administrative Claims-Based
Quality Measures
Population & Public Health
Priorities
Condition Specific
Measures
Enhanced Data & Feedback
Increase in Comparable Performance
Data
Fewer Variations in Submissions
A conceptual participation framework that would apply to future proposals beginning with the 2021 performance year. The goal is to move away from siloed activities and measures and move towards an aligned set of
measure options more relevant to a clinician’s scope of practice that is meaningful to patient care.
QPP Y4: MVPs Framework
2020 APM Updates
QPP Y4: APM Overview
Program Year
Payment Year
Quality ImprovementActivities
Promoting Interoperability
Cost
2020(Y4) 2022 60% 20% 30% 0%
Reporting Timeframes 365-Days 90-Day
Minimum90-Day
Minimum 365-Days
Must Submit by March 31st, 2021
QPP Y4: Advanced APMsBundled Payments for Care Improvement (BPCI) Advanced
Comprehensive Care for Joint Replacement (CJR) Payment Model - Track 1 CEHRT
Comprehensive End-Stage Renal Disease (ESRD) Care (CEC)
Comprehensive Primary Care Plus (CPC +)
Next Generation ACO (Next Gen)
Oncology Care Model (OCM)
Medicare ACO Track 1+
Medicare Shared Savings Program (SSP) Track 2
Medicare Shared Savings Program (SSP) Track 3
Vermont All-Payer ACO (Vermont Medicare ACO Initiative) *Not in KY
Qualifying Participant Status• Partial QPs will now be deemed Partial with the one TIN
• May be eligible for MIPS with other TIN/NPI combinations
MIPS APMs• Other Payer MIPS APMs
• Due to reporting issues the practice may submit Quality data • Will receive a score > 50% of the Quality category total points
QPP Y4: APMs
Alignment of MSSP & Web Interface Measure Sets
• Significantly Altering:• ACO 14 Preventative Care & Screening Influenza Immunization• Preventative Care & Screening Tobacco Use: Screening & Cessation
Non-ACO Group Reporters
• ACO would receive a score for each of the measures they report & zero points for those they do not
QPP Y4: Changes to Medicare Shared Savings
• Increasing the CEHRT use criterion threshold for Advanced APMs• Must require > 75% of ECs in each APM Entity use CEHRT
Minimum CEHRT Threshold:
• Effective CY 2020, quality criteria to state that > one of the quality measures upon which an Advanced APM bases payment must be:• On the MIPS final list• Endorsed by a consensus-based entity• Otherwise determined to be evidence-based, reliable, and valid by CMS
MIPS Comparable Measures:
• Allowing all payer types to be included in the 2019 Payer Initiated Process for the 2020 QP Performance Period
Payer-Initiated Process for Remaining Other Payers:
• Maintain 8% revenue-based nominal amount standard through 2024
Revenue-Based Nominal Amount Standard:
QPP Y4: Advanced APM Summary
Individual EC Information
• To include final & category performance scores• Names of ECs in Advanced APMs
• APM Name & performance
Facility-based ECs
• Indicator on Physician Compare Profile page or downloadable database
• Link to facility-based measure-level information• Physician Compare link to Hospital Compare available
late CY2019
Finalized Disclaimer
• Including a statement for each EC page • “The publicized information may not be representative of an eligible clinician’s
entire patient population, the variety of services furnished by the EC, or the health conditions of individuals treated”
QPP Y4: Public Reporting
Finalized Physician Compare Updates
45 Points Threshold; 60 for Year 5
50% IA
85 Points to be Exceptional Performer
Expanded Cost Measures; defined at measure level
MVPs 2021; Mandatory 2022
QCDR Push
Removal of IA’s PDMP
Quality Measures adjustments and removal
70% Data Validation
No Weight shifts
QPP Y4: Top 10 Final Rule Impacts
QPP Y4: Questions
Upcoming QPP Webinars
12/5/19 @ 12:30 Eastern
Time
Preparing for Attestation
1/16/20 @ 12:30 Eastern
Time
QPP Y4: Action Planning for
Success
Value-Based Payment Support Services
QPP SURS Technical Assistance:Free, high-level resources for organizations with 15 or fewer eligible clinicians as they navigate the Quality Payment Program. The Resource Center include: straightforward, self-directed resources and tools, up-to-date materials, and access to expert Quality Improvement Advisors. Sign up: www.qppresourcecenter.com
VBP Individualized Assistance: 12 months of planning and transformation support tailored to meet specific client needs and support success in value-based payment. This includes current state analysis, recommendations for action, collaborative goal setting and project planning, education, strategic decision support and ongoing advisory services.
Advanced APM Support:Ongoing support, research, work plan development and application support for transition to advanced alternative payment models (APM).
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