MACRA Roadmap: An Overview of the Quality Payment Program in 2019

Suzanne Falk, MPPSenior Associate, Regulatory Affairssfalk@acponline.org

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Today’s Game Plan:

At a Glance: Major Proposed QPP Changes

QPP Deep Dive: What you need to know in 2019

* Not-yet finalized proposals noted throughout

ACP Advocacy in Action: 2019 QPP Proposals

Live Q&A

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But first, a few housekeeping items...

Please save Questions for the end, or...

• Chat with me after the presentation or over lunch

• Email me at sfalk@acponline.org

Yes... slides will be made available!

2019 changes are proposed and subject to change.

Remember: this presentation is a summary!

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Major 2019 MIPS Proposals at a Glance

Increase both MIPS performance thresholds

Expand low-volume threshold and add “opt-in” option

Overhaul Promoting Interoperability scoring

Require 2015 CEHRT

Retire quality measures deemed to be low-value

Add new facility-based scoring option

Increase weight of Cost Category

Introduce 8 new episode-based cost measures

Make changes to reporting terminology

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Just as important… what didn’t change?

Minimum reporting periods (quality still a full-year)

Quality measure data completeness requirements for most reporting mechanisms remains at 60%

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Maintain 8% revenue-based risk threshold through 2024

Allow QP determinations at TIN-level

Increase APM CEHRT threshold to 75%

New All-Payer Combination Option in 2019

Medicaid, MA & CMMI multi-payer models would count in 2019

Strictly private payer APMs would not count until 2020

Allow Other Payer APM determinations to remain in effect for multiple years provided there are no changes

Must provide evidence that CEHRT threshold is being met

Major 2019 APM Proposals at a Glance

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Important Dates/Deadlines

July 12017 MIPS Performance Available in QPP portalusing EIDM credentials

Oct. 12017 MIPS Targeted ReviewRequests Due

Aug. 132018 MIPS Participation & APM QP Status Info Available Through QPP Look-Up Tool

Dec. 31Deadline for 2018 MIPS Hardship Exception Applications

March 31Reporting Deadline for 2018 MIPS Data

Want more? Check out ACP’s Physician Practice Timeline >>

Jan. 12019 MIPS Payment Adjustments & APM QP Bonuses Applied Based on 2017 Data

Oct. 2Last day to start 90-day reporting for PI & IA Categories

Feb. 28Deadline for 2018 CAHPS Data

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QPP Deep Dive: What you Need to Know in 2019

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MIPS

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Who Participates in MIPS?

Physicians, PAs, NPs, CNSs, CRNAs

Proposed Additions for 2019:

Physical Therapists

Occupational Therapists

• Clinical Social Workers

• Clinical Psychologists

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Who does NOT participate in MIPS?

Automatic Exclusions:

1st year enrolled in Part B

QP or Partial QP in AAPM

Proposed: neutral adjustment for ECs who join a TIN in Oct-Dec if the practice is not reporting as a group or TIN is newly formed

Application-Based Exceptions:

Extreme & uncontrollable circumstances hardship exceptions

Due Dec. 31st of performance year

Proposed: Can apply at TIN-level!

MAQI Demonstration for those with “significant participation” in MA alternative payment arrangements

• Below low-volume threshold

• Excluded practitioner types

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Low-volume Threshold

Excluded individuals or groups must meet one

of the following criterion:

≤ $90,000 Part B allowed charges OR

≤ 200 Part B patients OR

≤ 200 covered professional services under the PFS

^ Proposed for 2019!

Proposed: Clinicians, groups or APM Entities could “opt-in” to

MIPS if they meet 1-2 criteria (but not all 3)

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Proposed Streamlined MIPS Determination Period

Aligns with fiscal year & features two segments:

1st: Oct. 2017 - Sept. 2018 (30-day claims run-out) 2nd: Oct. 2018 - Sept. 2019 (no claims run-out)

*Clinicians/groups would only have to qualify during one

Would apply to the following determinations:

Low-volume threshold Non-patient facing Small practice Hospital-based

ASC-based Virtual groups* Facility-based*

*Use only 1st segment

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MIPS Payment Adjustments

Standard MIPS adjustments are budget neutral

Based on allowed charges for Part B covered prof. services

BBA excluded Part B drugs from MIPS $ adjustments & extended MIPS performance threshold flexibility through 2021

5%

9%

-9%2017 2018 2019 2020+

-7%-5%-4%

7%4%

2018

3 pts

15 pts

100 pts

70 pts

max penalty

performance

threshold

Exceptional

performance

threshold

max bonus

2019

7.5 pts

30 pts

100 pts

80 pts

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MIPS Bonuses and Special Scoring Scenarios

MIPS Bonus for Complex Patients

• 1-5 points depending on severity based on HCC score

Small Practices (≤15 eligible clinicians)

• Increased low-volume threshold

• 5-point bonus *CMS proposes to move to Quality

• 3 pts for quality measures that fail data completeness

• 3 pt bonus for reporting at least 1 quality measure

MIPS APM Scoring Standard (more on that later)

Facility-Based Scoring Option…

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New Facility-Based Scoring Option

Clinicians Groups

Eligibility Bill at least 1 service with POS codes 21,23 & furnish 75%+ of covered professional services in POS codes 21,22,23 during a prior determination period

75%+ of cliniciansqualify as individuals

Attribution hospital where they provide services to most patients

hospital where most clinicians are attributed

• Uses data from Hospital VBP Program for performance period• Automatically applied when it benefits a clinician’s/group’s score• CMS would assign corresponding percentile score in MIPS• Groups would need to report data for 1 other category as a group

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Minimum Reporting Period

Performance Category 2018 2019

Quality Full calendar year No change

Cost No reporting

required

No change

Improvement Activities 90 consecutive

days

No change

Promoting Interoperability 90 consecutive

days

No change

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Reporting Options

Individual Clinician under an NPI number and TIN where they reassign benefits

Group 2+ clinicians who have reassigned their billing rights to a single TIN

Virtual Group 10 or fewer ECs who come together “virtually” (regardless of specialty or location) to participate in MIPS for a performance period

Proposed for 2019: can inquire about eligibility prior to making an election through QPP Portal

APM Entity

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Proposed Terminology Changes

MIPS CQMs: formally registry measures (since other vendors can report them)

Collection type: set of quality measures with specs & completeness criteria (e.g. eCQMs, MIPS CQMs, QCDR measures, claims measures, Web Interface measures, CAHPS measures & admin claims measures)

Submitter type: MIPS eligible clinician, group, or 3rd party intermediary

Submission type: mechanisms that submit data to CMS (e.g. direct log in, upload, attestation, Part B claims & Web Interface)

3rd party intermediaries: Entities that have been approved to submit data on behalf of a MIPS EC, group, or virtual group (e.g. QCDRs, qualified registries, health IT vendors & CMS-approved survey vendors)

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Proposed Changes to Data Submission

Oversight: CMS proposes to strengthen oversight of & penalties for vendors who submit inaccurate, unusable, or compromised data.

Part B claims: would ONLY be available to small groups (regardless whether they reported at NPI or TIN level)

Web Interface: would no longer report IA or PI data; no more high priority bonus pts; soliciting input on expanding to groups of 16+ clinicians & incorporating specialty-specific measures

QCDRs and Qualified Registries: new vendor criteria proposed

CAHPS: measures that don’t meet sampling req’s would = 0 pts but Quality would be scored out of 50 pts (valid for 1 year only)

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Data Submission Types: Individual Reporters

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Data Submission Types: Group Reporters

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• Reports data for PI, Quality & Cost Categories

• Performance results & measure feedback

• National benchmark& peer specialty comparisons

Genesis Registry

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Performance Category Weighting

Performance Category 2018 2019

Quality 50% 45%

Cost 10% 15%

Improvement Activities 15% 15%

Promoting Interoperability 25% 25%

* BBA extended flexibility for setting weight of Cost Category

through 2021 (though it cannot be <10%)

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Quality: What hasn’t changed?

* All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases.

Must report 6 measures OR specialty set (or all applicable)

Points scored /10 pts based on performance against benchmarks*

At least 1 outcome or high-priority measure

Potential bonus points worth up to 10% of Quality score

Can earn points for quality improvement if fully participate

60% data completeness for most submission mechanisms

* Measures that fail = 1 point for most; 3 points for small practices

Topped out measures: 4-year process to remove; max 7 pts*

45%

????

60-70 pts

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Quality: What has changed?

34 “low-value” measures removed (updated inventory)

“Extremely” topped out measure may be removed sooner

QCDR measures wouldn’t qualify as topped-out

Measures significantly impacted by clinical guideline changes/ patient safety concerns would not be scored.

• To compensate, Quality would be scored out of 50 points.

Benchmarks would be based on collection type.

Measure validation would only be applied to MIPS CQMs & claims collection types (not eCQMs).

Opioid-related measures would be considered high-priority.

45%

????

60 pts

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Cost

No reporting required (pulled from admin claims)

BBA: No credit for cost improvement until 2022

MSPB and TPCC measures

Risk adjustment based on HCC scores

8 brand-new episode-based measures proposed... Risk-adjusted and payment-standardized

Based on allowed amount from Parts A & B claims

Case min. = 10 for procedural; 20 for acute inpatient condition episodes

Procedural episodes attributed based on “trigger” HCPCS/CPT codes

Acute inpatient medical condition episodes attributed based on clinician who bills E&M claim lines during “trigger” inpatient hospitalization under TIN that renders 30%+ of inpatient E&M claim lines in that hospitalization

15% ????

20-100 pts

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Proposed 2019 Episode-Based Cost Measures

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Improvement Activities

Yes/no attestation; scored on all-or-nothing basis

Flexible documentation requirements

Only 1 clinician in group has to perform activity

“High-weighted” = 20 pts; “medium-weighted” = 10 pts

Small practices, non-patient facing clinicians & clinicians located in rural/HPSAs get double credit

MIPS APMs, PCMHs & PCSPs get full credit (must attest)

6 new activities added; 1 removed; 5 modified

See Tables A and B in Exhibit 2

15% ????

40 pts

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Promoting Interoperability

2015 CEHRT required

No more separate performance, base & bonus scores

Each measure scored independently; on performance

Must meet all 6 required measures or claim an exclusion

Would remove bonus points for end-to-end reporting, but add new bonus points for opioid-related measures

25%

????

100 pts

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2019 Proposed PI Objectives & Measures

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PI Category Level Exceptions

Automatic Exceptions :

• Non-patient facing (<100 patient-facing encounters or groups where this applies to 75%+ of clinicians)

• Hospital- or ASC-based clinicians (75%+ of services performed in POS 21, 22, 23; or ASC)

• Non-physicians

• Certain extreme circumstances determined by CMS

* Note: PI Category will be scored if you submit data

Application-Based Exceptions:

• Small practices

25% would be redistributed to

Quality Category

• Lack of control over availability of CEHRT

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PI Measure-Specific Exclusions

E-Prescribing

Support Electronic Referral Loops by Sending Health Information

Support Electronic Referral Loops by Receiving & Incorporating Health Information

Provide Patients Electronic Access to Their Health Information

Two Public Health and Clinical Data Exchange measures

If exclusions are claimed, points will be reallocated amongst remaining measures

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Advanced Alternative Payment Models(APMs)

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Step 1: What Makes an Advanced APM?

1. Use CEHRT

Proposed: 75%+ of clinicians must use CEHRT (up from 50%)Proposed: Must provide evidence that threshold is being met

2. Base payment on quality measures comparable to MIPS

3. Either:

• Are a Medical Home Model under CMMI; OR• Bear more than “nominal” financial risk…

• 8% of average estimated Parts A & B revenue; OR• 3% of estimated expenditures (e.g. benchmark)Proposed: maintain 8% revenue-based standard through 2024

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Proposed 2019 Medicare Advanced APMs

Medicare Shared Savings Program Tracks 1+, 2, 3*

Next Generation ACOs

Comprehensive Primary Care Plus (CPC+)

Comprehensive ESRD Care (2-sided risk)

Oncology Care (2-sided risk)

Comp Care for Joint Replacement (CEHRT track)

BPCI Advanced

* A separate proposed rule would drastically restructure MSSP &

solicit applications for a July 1, 2019 start date.

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Step 2: Do I qualify as a Qualified Participant?

Can qualify through…

Medicare Option OR

All-Payer Combination Option *new in 2019!

• Medicaid, MA & CMMI multi-payer models count in 2019

• Private payer APMs would not count until 2020

• Payers and clinicians/practices will be able to begin submitting APMs for approval next year

• Other Payer APM determinations could remain in effect for up to 5 years provided there are no changes to design

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Step 2: Do I qualify as a Qualified Participant?

Payments Patients

QP 50% 35%

Partial QP 40% 25%

Payments Patients

QP 50% (25%)* 35% (20%)*

Partial QP 40% (20%)* 25% (10%)*

2019-2020 Medicare Threshold Option

2019-2020 All-Payer Combination Threshold Option

()* = Medicare Minimum

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QP Status “Snapshot” Dates

3 “snapshots” all start Jan 1 & end Mar 31, June 30, or Aug 31

Must surpass threshold during at least 1 snapshot

4th snapshot added on Dec. 31st for MIPS APMs only

Proposed for 2019: QP determinations at TIN level

Check your QP status: https://data.cms.gov/qplookup

#1

#2

B#3

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

#4 MIPS APMs only!

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Step 3: What’s the incentive?

1. NOT subject to MIPS

2. Receive 0.5% higher PFS update for 2026 onward

3. Share in rewards of APM

4. Receive 5% lump sum bonus in 2019-2024

1. Have the option to participate in MIPS

2. Receive favorable scoring if they do

3. Share in rewards of APM

Qualified Participants (“QPs”): Partial QPs:

2017 2018 2019

QP StatusBonus Calculated Bonus

Paid

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APMs: A Visual Breakdown

APMs

QPs

Advanced APMs

MIPS APMs

Partial QPs

Not a QP

MIPS APM scoring

standard

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More About the MIPS APM Scoring Standard

Streamlines certain MIPS reporting & scoring…

• Ex: ACO reports quality data (*but not PI data!!)

MIPS scores aggregated at the APM entity level

Performance Categories are weighted differently

Quality: 50% Cost: 0% IA: 20% PI: 30%

Generally full credit toward IA

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ACP Advocacy in Action

Stay tuned for 2019 PFS/QPP comments

APM stakeholder coalition

Patients Before Paperwork Initiative

Feedback; Statement to Ways and Means Subcommittee on Health for Medicare Red Tape Relief Initiative

Meetings with senior CMS staff including CMS Administrator Seema Verma & CMMI Director Adam Boehler

Group of 6 coalition released principles; held fly-in on reducing admin. burdens

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ACP Top QPP Advocacy Asks:

Reduce admin. burden in MIPS; implement consistent 90-day min. reporting period across categories & provide more opportunities for cross-category credit.

Reduce MIPS complexity; streamline scoring across categories.

Maximize MIPS participation, including finalizing the proposed “opt-in” option for those currently excluded under the low-volume threshold.

Increase MIPS flexibility, including a set of optional measures for the PI Category and expanded opportunities for Advanced APM participation.

Allow for a more gradual implementation of 2015 CEHRT.

Avoid low-reliability measures, including proposed new cost measures.

Implement MIPS gradually; don’t rush to increase Cost weight while adding new measures or double MIPS performance threshold based on non-MIPS data.

Provide more opportunities for small and rural practices to succeed.

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Resources

CMS fact sheet (with comparison chart)

CMS press release

FR version of proposed rule

ACP press release

CMS QPP Resource Center

CMS QPP Participation Lookup Tool

ACP Physician Practice Timeline

ACP QPP Resource Page

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Questions?

1. Got a good question for the group? Ask me now!

2. Chat with me later today. (I’ll be hanging out immediately following the presentation and will be at lunch.)

3. E-mail me at sfalk@acponline.org.