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MACRA in 2018David HellerIndustry & Government Affairs

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• Overview

• Assistance for small practices

• Reporting and scoring

• Advancing Care Information

• Quality

• Clinical Practice Improvement Activities

• Alternative Payment Models

Agenda


Adjusted Medicare Part B payment to clinician

MIPS Payment Adjustments

2022+

±4% for 2017’s performance



±9% for 2020’s performance and future years

• The potential maximum adjustment % will increase each year from 2019 to 2022.

Maximum adjustments

• Composite performance score, clinicians will receive +/- or neutral adjustments up to the percentages shown here.

Based on MIPS

2021

2020

2019


MACRA’s CY 2018 top takeaways: More flexibility for providers

More measures

and activities to choose from

New reporting options

The transition continues

Other notable impacts

21st Century Cures

Patients over paperwork

Meaningful measures

Extreme and uncontrollable circumstances

Overview

The HouseThe Senate

Bottom line

92 yeas

2 nays

392 yeas

37 nays

2 abstained

MACRA, MIPS, APMs are not going away

MACRA, by the votes


Provider flexibility

Interoperability

Physician burden a serious concern

Looking at possible

scaleback of MU, ACI

Support from both sides of the aisle

Measures cost and quality

It’s here to stay, with some tweaks possible

MACRA

8 I

What is MACRA?

MAC

RA

MIPS (standard)

MIPS (MIPS APMs)

Advanced APMs

Regulatory implementation

2019201820172016

• Final performance period for MU/PQRS/VBM.

• Payment year for 2014 performance period.

MACRA activities

• Payment year MU/PQRS/VBM (2015 performance).

• Final payment year for MU/PQRS/VBM (2016 performance)

• First MIPS performance period.

• Report on either ACI Transition Year (Modified Stage 2) objectives or ACI (Stage 3) objectives.

• 4 reporting options. • Must begin

reporting by Oct. 2.

• 2014 or 2015 CEHRT.

• Report on either ACI Transition Year (Modified Stage 2) objectives or ACI (Stage 3) objectives.

• May elect 90 day ACI/CPIA reporting period.

• Cost implemented.

• Payment year for 2017 MIPS performance period.

• 2015 CEHRT implemented.

• Mean/median scoring.

• Expansion of APM models.

Sunsetactivities


A single MIPS composite performance score will factor in performance in four weighted categories on a scale of 0-100.

What is MIPS?

QUALITY RESOURCE USE/COST

CLINICAL PRACTICE IMPROVEMENT

ACTIVITES

ADVANCING CARE INFORMATION

Replaces PQRS. Accounts for 50%

of total performance score in year

two.

Replaces VBM. Accounts for 10%

of total performance score in year

two.

Accounts for 15% of total

performance score in year

two.

Replaces Medicare MU.

Accounts for 25% of total

performance score in year

two.

Medicaid MU goes on separately

Medicaid meaningful

useMIPS

Regulatory cycle: H1

Jan. Feb. March April May June

• NQF MAP convenes.• Quality MUC

template published.

• Call for ACI measures.

• Call for IA measures.

• Call for quality measures.

• Measures from prior year’s process implemented.

• MACRA notice and comment continues.

• CMMI may issue new innovation models.

• IA measures submission closes EOM.

• MACRA proposed regulation issued, notice and comment begins.

• Closure of call for new quality measures.


• CMMI new innovation models may issue.

• PTAC votes on physician designed APMs (quarterly meetings).

Regulatory cycle: H2

July Aug. Sep. Oct. Nov. Dec.

• MACRA notice and comment closes early in the month.

• Proposed Physician Fee Schedule is issued, notice and comment opens.


• Proposed Physician Fee Schedule notice and comment continues.

• PTAC meets on proposed APMs.



• PTAC issues RFP for new APMs.

• MACRA final regulation issued by Nov. 1, final list of new measures.

• Physician fee schedule finalized (may be combined with MACRA regulation).

• PTAC votes on physician designed APMs (quarterly meetings).

• Proposed Physician Fee Schedule notice and comment closes early in the month.



QualityMore outcomes based quality measures, special emphasis on care coordination, patient/caregiver experience, utilization, and performance gaps.

Advancing Care InformationMore interoperability measures. Specifically, closing the referral loop. Also asking for ways to measure CEHRT workflow disruption for the purpose of health IT specifications.

Improvement ActivitiesMore IAs that line up with PCMH or other existing programs, importance on improving health outcomes, reducing care disparity, broadly applicable, easy to implement, and whether CMS can validate the activity.

APMsMore APMs and Advanced APMs, private payer models, small practice and rural setting APMs.

Physician updates will be measured regularly, with a special emphasis on outcomes and interoperability.

Where’s MACRA going?

Assistance for small practices

Virtual group reporting

Up to 10 ECs per Tax ID.

Election by Dec. 1.

Allows small practices to scale reporting and performance.

Assess Quality and Cost uniformly.

Applications open in September.

No limit on the number of TINs.

Small practice bonus

2024

5 point bonus to

MIPS composite

Less than $90,000 in Medicare revenue

excluded.

Fewer than 200 Medicare

unique patients are excluded.

ACI hardship exemption.

More flexibility for small practices.

Driving flexibility through exclusions and exemptions

Reporting & scoring


Performance thresholds, the MIPS composite score, and your bottom line

0 3 15 70 100

In the 2018 performance period, ECs who earn a composite score between 0-15 are subject to a 0%-5% penalty in 2020. 15 is

the performance threshold, increased from 3 in 2017. CMS estimates $118 million in

penalties will be assessed.

ECs who earn a composite score between 15-70 are eligible for a 0%-5% incentive in

2020. CMS estimates $118 million in incentives for this group.

ECs who exceed 70 are eligible for increased MIPS

bonuses, which will be paid out of a pool of $500 million that is not subject

to budget neutrality.

Who is eligible to participate in MIPS?

Years 1 and 2

Years 3+

Physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals.

HHS Secretary may broaden EC groups to include others,

such as:

Physicians (MD/DO and DMD/DDS), PAS, NPS, clinical nurse specialists, certified registered nurse anesthetists.


MIPS does not apply to hospitals or facilities.

Who is not eligible to participate in MIPS?

First year of Medicare Part B

participation

Below low-patient

volume threshold

Certain participants in Advanced

APMs

Medicare billing charges ≤ $90,000 OR providers care for ≤ 200 patients in one year


Eligible clinicians can participate in MIPS as an individual or group.

Eligible Clinician reporting

GROUPA group, as defined by taxpayer

identification number (TIN), would be assessed as a group practice across all

four MIPS performance categories.

INDIVIDUAL VIRTUALTo be implemented in 2018

performance period, defined with a virtual group identifier,

TIN, and NPI combination.

MIPS 2017 reporting options

Don’t participate and receive a 4% negative adjustment rate.1

Submit one quality measure, one improvement activity, or the required ACI measures for at least 90 days and avoid a negative adjustment.

Submit more than one quality measure, more than one improvement activity, or more than the required ACI measures for at least 90 days, and get no adjustment or a small positive one.

Submit data to MIPS for the full year and get a positive adjustment.

2

3

4

Sample reporting options in 2018

Don’t participate and receive a 5% negative adjustment rate.1

Report on the required ACI measures and one quality measure.

Fully report on and participate in improvement activities.

Submit six quality measures that meet data completeness criteria.

2

3

4

Reporting timelines for 2018

90 days for Advancing Care Information.1

90 days for Improvement Activities.

Full year for Quality.

Full year for Cost.

2

3

4

60%15%

25%

0%Advancing Care Information

Quality

Clinical Practice Improvement Activities

MIPS scoring in 2017

50%

15%

25%

10%Quality


Final Rule: MIPS scoring in 2018

Cost

Advancing Care Information

30%

15%25%

30%

Quality


MIPS scoring in 2019

Cost


More points for complex patients

Bonus based on average

HCC scores

Improvement scoring

80%

45%

30%

Improvement scoring rewards clinicians for

improvement in the Quality and Cost categories

by comparing the current performance period

with the prior performance period.

Quality improvement will be assessed at the

category level because different clinicians may

select very different measures that are not

comparable. Your improvement score is added

onto your Quality performance.

Cost improvement will be assessed at the

measure level because all clinicians are generally

measured on the same measures. Your

improvements score is added onto your Cost

performance.

Facility-based measurement coming in future years


• Medicare Spending per Beneficiary (MSPB) in 2018.

• Introducing episode-based measures in 2019.

How is Cost measured?

Scoring Advancing Care Information

Performance score, where the more you do, the

more you earn (up to 50).

Bonus scores up to 25% for

miscellaneous. Total (up to 100).

Base score to get any credit (50).

Which certified edition?

• 10% bonus to 2018 ACI score.

• May use 2014 CEHRT.

• May Use 2015 CEHRT.

• May report on 2017 Transition Year ACI Objectives (derived from Stage 2).

• May report on ACI Objectives (derived from Stage 3).

Benefits of 2015 CEHRT

2017 performance period

2015 ONC

CEHRT

2017performance

2018 performance

• May use 2014 CEHRT.

• May Use 2015 CEHRT.

• May report on 2017 Transition Year ACI Objectives (derived from Stage 2).

• May report on ACI Objectives (derived from Stage 3).

2018 performance period

The return of exclusions

BUSINESS ECOSYSTEM

Protect patient health information

(yes required)

Electronic prescribing (numerator/denominator)

Health information exchange (numerator/

denominator)

Coordination of care through patient engagement (numerator/

denominator)

Public health and clinical registry reporting Patient electronic access

(numerator/denominator)


A shift in measuring public health reporting

Beyond the performance score

A 5% bonus score is available for submitting to another public health agency or clinical data registry.

Performance score

Connecting to a public health registry gives you 10% to your ACI performance score.

Bonus score

2015 CEHRT

Registry reporting

Reporting improvement

activities through CEHRT

Bonus up to 25%

What’s next with ACI?

New call for measures.

Use case: Closing the

referral loop.

Interoperability in non-office

settings.

What about interoperability?

National Patient Identifier1

21st Century Cures, standards and penalties2

Interopereability and outcomes3

CommonWell to become Carequality implementer.

Future projects and integration.

Working to create Carequality compliant version of CommonWell

record locator service.Initial C-CDA integration.

Carequality and CommonWell Health Alliance partnership

Quality & Clinical Practice Improvement Activities

Data completeness threshold raised from 50% to 60%.

Quality updates

Choice More CQMs available, focused on outcomes and other high priority measures.

Reporting May not submit measures using multiple data submission mechanisms in 2018.

Removing measures

Phase out process introduced for topped out measures.

Floor Three point floor for each measure.

More outcomes measures and more specialist measures.

What’s coming with Quality

COMPANY 47

1

May see continued focus on qualified registry reporting and QCDR reporting.

Preference for outcomes measures over process measures.

National Quality Forum’s Measure Applications Partnership: Call for measures.

2

3

4

More improvement activities, expanding PCMH

50% of practices within a TIN need PCMH recognition

for full CPIA credit.

PCMH definition expanded to

include CPC+.No change to scoring or weight.

More activities in general, and

more activities that relate to

CEHRT.

Expanded subcategories based on contribution to improvements in patient care, cost, and quality.

What’s coming with CPIA

1

More activities to come based on relevance to existing programs, importance towards improving health outcomes, alignment with PCMH, and more.

2

Alternative Payment Models

50%

20%

30%

0%Advancing Care Information

Quality


MIPS APM scoring in 2017

Advanced APM impact to providers

20242026+202020182016

5% Lump Sum

Bonus

Revenue-based risk definition extended for two years

Nominal risk

Revenue standard

8% of average estimated total

Medicare Parts A & B revenue

Benchmark-based standard

3% of expected expenditures the APM is responsible

for

The Medical Home Model – A more gradual ramp

Or

General definition

Quality incentive or PMPM at risk

2018: 2% 2019: 3%

2020: 4%

2021: 5%

RISK

Who’s in the APM track?

201720152024+20232022202120202019

Payments

25%

Patients

20%

Payments

50%

2019-2020

• Medicare APMs only

2021+•Include private payers

Payments

75%

Patients Patients

35% 50%

More ways to qualify coming

1

2

3

All payer combination options

Medicaid & CHIP

CMS Multi-Payer models

Performance thresholds and Cost in the future

0 3 15 70 100

The performance threshold in 2019 will be set as the mean or median of prior MIPS

composite scores, unless Congress amends MACRA.

30%

15%25%

30%

Cost

To change how CMS sets thresholds and Cost’s portion of the score for future years, an act of Congress would be

required.

1

2

3

Measure quality and costFirst, clinicians become accustomed to capturing metrics and measuring performance on quality and cost.

Implement technological and clinical processesAs MIPS ramps up, clinicians are incented to implement process changes that can quanitifiably move the needle on quality and cost.

Prepare for riskBy changing the way the clinicans deliver care over time, clinicans are equipped to take advantage of risk-bearing contracts that reward superior care over volume.

Congress’ vision: From MIPS to APMs


Don’t take the transition year off. Instead, prepare for success.

How to succeed with MACRA

Learn about the programLearn what it means for your bottom line, and what’s coming in the future through qpp.cms.gov and Greenway Health webinars.

Compare your dataLook at your historical data and measures — and focus on what you’re good at, what’s relevant to your patient population, and where you can make the easiest improvements.

Design a planDesign a plan based on your data that accounts for 2017 and 2018. Use the transition year to test your plan. Don’t slack this year or 2018 might catch you off-guard.

Design

Compare

Learn


Are you interested in learning more? Let us know:

a) I would like to pre-register for your webinar on Feb. 28 at 12:00 p.m. Eastern time.

b) I would like to speak with a Greenway Health representative.

c) I'm not interested at this time.

Poll question

Questions


• ACI: Advancing Care Information

• APM: Alternative Payment Model

• CPIA: Clinical Practice Improvement Activities

• EC: Eligible Clinician

• HHS: The US Department of Health & Human Services

• MACRA: Medicare Access & CHIP Reauthorization Act of 2015

• MIPS: Merit-based Incentive Payment System

• MU: Meaningful Use

• NP: Nurse Practitioner

• NPRM: Notice of Proposed Rulemaking

• PA: Physician Assistant

Acronyms cheat sheet


• The Final Rule for 2018

• Year 2 Overview fact sheet

• 2017 Extreme and Uncontrollable Circumstances Policy for MIPS fact sheet

Resources

https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf?utm_campaign=pi%20subscription%20mailing%20list&utm_source=federalregister.gov&utm_medium=email

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Interim-Final-Rule-with-Comment-fact-sheet.pdf

MACRA in 2018 - greenwayhealth.com€¦ · • MACRA notice and comment closes early in the month....

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