MACRA… What is it? Why Do I Need to Be in the Know? · MACRA… What is it? Why Do I Need to Be...

MACRA… What is it? Why Do

I Need to Be in the Know?

Jim Brulé, Solutions Director - Regulatory

Copyright © 2016 Allscripts Healthcare Solutions, Inc. 2

First, a word.The information contained within this presentation is intended for informational purposes only. While the information and recommendations presented in this presentation are good-faith interpretations made by Allscripts based on the publicly available information referenced within, it does not constitute legal advice or guidance. Thus, any decisions, and associated risks, made by the client pertaining to the information within this presentation are solely the responsibility and liability of the client. Clients are strongly advised that such decisions be made in consultation with their legal representatives.

The information presented within this presentation (1) should not be considered complete, exhaustive, or customized to an individual client’s needs; and (2) is subject to change due to new laws, regulations, or Department of Health and Human Services policies issued after May 18, 2016.

This presentation neither modifies any signed agreements Allscripts has with the client nor creates any Allscripts attestations, representations, warranties, guarantees or covenants related to MU or MACRA compliance, meeting MU or MACRA standards and requirements, whether Allscripts EHR software will meet new or modified requirements for certified EHR technology, or for any other matter.

Overview


“Bending the Cost Curve”


MACRA: Medicare Payment Reform• Repeals the Sustainable Growth Rate formula

– Archaic method of determining Medicare payments to providers

• Creates value-based framework for payment

– Moving directly away from volume-based payments

• Combines quality-based systems into one system

– Streamlining calculations and introduction of new measures

• Provides bonus payments

– Eligible Alternative Payment Models

MACRA: Medicare Access and CHIP Reauthorization Act | SGR: Sustainable Growth Rate


Shifting to increased quality & risk

Anticipated distribution of Medicare payments. Source: CMS

• FFS: Fee for Service

• APMs: Alternative

Payment Models

• MIPS: Merit-based

Incentive Payment

System


Two paths

QPP: Quality Payment Program | MIPS: Merit-based Incentive Payment System | APMs: Alternative Payment Models

MIPSDefault for

Medicare EPs

Advanced

APMs

QPP


Who does this affect?• Medicare Eligible Clinicians

– Physicians

– Physician assistants

– Nurse practitioners

– Clinical nurse specialists

– Certified registered nurse anesthetists

– Groups that include such clinicians

NOT

• Medicaid Eligible Professionals

• Eligible Hospitals (Medicare or Medicaid)


MIPS vs APMs• Merit-Based Incentive Payment System (MIPS)

– Default plan for all Medicare EPs

– Lower incentives; less certainty of incentive outcome

– Designed to be unattractive

• Advanced Alternative Payment Systems (APMs)

– Optional plan

– Carries higher risk, higher potential reward

• CMS anticipated initial participation:

– MIPS = 89%

– APMs = 11%

– Hoping for shift to APMs


• MACRA: Medicare Access and CHIP

Reauthorization Act

• NPRM: Notice of Proposed Rule-

Making


4/28 6/27 Oct? 11/1 1/1/17

ProposalCMS issues the

public inspection

version of the

proposed rule.

Federal Register

date: 5/9

Final RuleThis is anyone’s

guess. MU took

5+ months –

there’s not time

for that.

CommentsComments are

due to CMS by

5pm.

MeasuresThe final measures

for use in 2017

are due 11/1.

They take effect 2

months later.

QPP Active

2017 is the

performance year

for payment

adjustments in

2019.

The next 8 months


MIPS: Lower incentives, less desirable• Attempts to combine four drivers into one program:

– Quality of outcomes

– Cost of outcomes

– Use of Health IT

– Better process

• Moves the incentive/penalty bar each year based on national performance

– Participants won’t know the threshold for success until after the year is over


MIPS: Old and New Programs• Quality:

– PQRS measures (fewer required)

– VM measures (quality only)

• Cost:

– VM measures (cost only)

• Use of Health IT

– Meaningful Use measures, now called “Advancing Care Information” (ACI)

• Better process

– Clinical Practice Improvement Activities (CPIA) – New program

• PQRS: Physician Quality

Reporting System

• VM: Value-Based

Modifiers


MIPS: Integrating previous programs

Quality50%

ACI25%

CPIA15%

Cost10% • Quality: Formerly PQRS (Physician

Quality Reporting System)

• Cost: Formerly VM (Value Modifier Program)

• ACI: Advancing Care

Information, formerly MU (Meaningful Use)

• CPIA: Clinical Practice

Improvement Activities, New

Performance measurement begins in 2017;

affects payments two years later


Advanced Alternative Payment Models (APMs)• A category of payment models designed to “bend the cost curve”

• Each model is unique

• Shared characteristics:

– Assumed risk

– Some financial benefit for achieving quality

– Generally requires sharing of information across care locations

– Often creates new organizational systems for clinical and financial management

• May be actual or virtual organization


Advanced APMs: Eligible for 2017

• Medicare Shared Savings

Program—Track 2

• Medicare Shared Savings

Program—Track 3

• Next Generation ACO Model

• Comprehensive Primary Care

Plus (CPC+)

• Comprehensive ESRD Care

Model (Large Dialysis

Organization arrangement)

List will be updated by CMS annually


Surprise omissions• Medicare Shared Savings Program – Track 1

• Comprehensive Joint Replacement

• Patient Centered Medical Homes

– Only count for MIPS so far…


MIPS: Who participates?• Medicare Eligible Clinicians (ECs):

– Physicians

– Physician assistants

– Nurse practitioners

– Clinical nurse specialists

– Certified registered nurse anesthetists

– Groups that include such clinicians

• May participate as individual or group

– Members of a group must report on identical measures/activities


MIPS scoring• Creates a composite score from performance against:

– Quality (50%) formerly PQRS and VM

– Cost (10%) formerly VM

– Use of Health IT (25%) “Advancing Care Information”, formerly MU

– Process improvements (15%) CPIA: Clinical Practice Improvement Activities

• Maintains budget neutrality (mostly)

– Sum of penalties = sum of rewards

• Rewards and Penalties are proportional to distance from performance threshold


MIPS calculation

ACI(MU)

Cost (VM)

Quality (PQRS+VM)

50

10

25

15 CPIA

ACI

Cost

Quality

ACI: Advancing Care Information | CPIA: Clinical Practice Improvement Activities

VM: Value-Based Modifiers | PQRS: Physician Quality Reporting System

MIPS Score(100 pts)

Category

CPIA


MIPS Percentages over Time

25% 25% 25%

15% 15% 15%

10% 15%30%

50% 45%30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2019 2020 2021+

ACI CPIA Cost Quality


MIPS Incentives/Penalties

-4%-5%

-7%

-9%

4%5%

7%

9%

2017 2018 2019 2020

2019 2020 2021 2022

Performance Year

Payment Year

• The more participants who do well, the lower their incentive.

• MIPS is budget neutral: total incentives must equal total penalties

• A performance threshold is set after the year closes; likely set to median score nationwide.

• Adjustments are calculated after the year closes, based on how much the individual score is above or below the performance threshold


Scenario 1

Scoring Curve

Payment Adjustments

85% of participants

+/- 1%

Many participants

doing well


Scenario 2

Scoring Curve

Payment Adjustments

95% of participants

+/- 1%

Flatter, more

“mediocre”

performance

Composition of Scores


Scoring Strategy• There are four categories

– Quality

– Cost

– Clinical Practice Improvement Activities (CPIA)

– Advancing Care Information (ACI)

• Each has its own scoring rules

– Ways of accumulating points

– A “maximum” score that can be exceeded

– A percentage that each contributes to the MIPS score


For example:• Quality category has 8-9 measures

– Depends on practice size

• Each measure is worth up to 10 points

– Each scored proportionally based on performance

• Theoretic maximum is 90 points

• However, the most that can be contributed to MIPS is 50 points


Scoring summary

CategoryNumber of

Measures

Value of Each

Measure

Potential

Maximum

Score

Actual

Maximum

Score

Contribution to

MIPS score

Quality 8-9 10† 80-90 80-90 50%

CPIA 90 10 or 20 Hundreds 60 15%

Cost 40 10† * 10 10%

ACI – Base

ACI – Performance

ACI - PHR

6

8

3

All or nothing

10†

>0 = 1

50

80

1

100 25%

† These measures are scored proportionally; value is maximum for perfect score

* Score is based on percentage achieved for each measure selected averaged across all measures selected by CMS

131

Quality Category

Formerly PQRS (Physician Quality Reporting System)


Quality Category• Choose 6 measures to report (currently 9) (PQRS)

– Pool of hundreds of measures

– 80% of measures tailored for specialists

• CMS calculates 2-3 population measures based on claims data (no participant reporting

required) (VM)

– 2-9 clinicians = 2 measures

– >=10 clinicians = 3 measures

• Each measure is worth 10 points (proportionally)

• 1 cross-cutting measure required

• Actual maximum is 90 points

• Translates into 50% of MIPS score


Quality Measures• Individual: 273 measures – may be performed by anyone

– 18 New

– 70 Substantially Changed

– 185 Unchanged

• Cross-cutting: 10 measures – involves multiple modalities


– 7 Unchanged

• Specialty: 293 measures – tailored for specialists


– 4 New

– 218 Unchanged


Specialty areas • Allergy (16)

• Anesthesiology (7)

• Cardiology (12)

– Electrophysiology Cardiac (3)

• Gastroenterology (7)

• Dermatology (6)

• Emergency Medicine (9)

• General / Family (36)

• Internal Medicine (27)

• Obstetrics/Gynecology (14)

• Ophthamlogy (15)

• Orthopedic Surgery (14)

• Otolaryngology (10)

• Pathology (8)

• Pediatrics (10)

• Physical Medicine (7)

• Plastic Surgery (3)

• Preventive Medicine (8)

• Neurology (18)

• Mental/Behavioral Health (12)

• Radiology (14)

• Interventional Radiology (4)

• Radiation Oncology (4)

• Surgery

– Vascular Surgery (6)

– General Surgery (8)

– Thoracic Surgery (9)

• Urology (6)

Cost Category

Formerly Value-Based Measures


Cost Category• Claims-based calculation: no reporting necessary

• 40 episode-specific measures

• Each measure worth up to 10 points

– based on cost efficiency

– 20-patient sample minimum for each measure

• Score is based on average performance across all calculated measures


CPIA Category

Clinical Practice Improvement Activity


CPIA Category• 94 potential activities in 9 categories

• Each activity worth 20 or 10 points, depending on CMS

• Each activity is all or nothing

• Actual maximum is 60 points


Expanded Practice

Access (4)

Population

Management (16)

Care

Coordination (14)

Beneficiary

Engagement (24)

Patient Safety and

Practice Assessment (21)

Participation in an APM,

including a PCMH

Achieving Health

Equity (5)

Emergency Preparedness

and Response (2)

Integrated Behavioral

and Mental Health (8)


Nationally recognized PCMHs

• National Committee for

Quality Assurance (NCQA)

PCMH recognition

• Accreditation Association for

Ambulatory Health Care

• The Joint Commission

Designation

• Utilization Review

Accreditation Commission

(URAC)

If a practice is part of a nationally recognized PCMH, it

automatically earns the maximum CPIA score, such as:


Different ranks of measures• High

– Worth 20 points

– High effort to implement

– Greater impact on outcomes

• Medium

– Worth 10 points

– Medium effort to implement

– Moderate impact on outcomes


Samples: Expanded Practice Access• High (20pts): Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice

about urgent and emergent care…

• Medium (10pts): Use of telehealth services and analysis of data for quality improvement…

• Medium (10pts): Collection of patient experience and satisfaction data on access to care and

development of an improvement plan…

Advancing Care Information

Formerly “Meaningful Use”


Basic Scoring Process

Base Measures

50 points

Performance

Measures

Up to 80 points

Registry Bonus

1 point

Primary option: 11 measures

many Stage 3 measures

Alternate option: 16 measures

all Stage 2 measures

50 points, all or nothing

3 Stage 3 measures

up to 10 pts each

5 Stage 2 measures

up to 10 pts each

1 point for doing at least one

extra registry beyond

Immunization

100 points maximum


Advancing Care Information Category• Base score = 50

– 11-16 measures, all or nothing

– Yes/no or num/denom, num >= 1

• Performance score = 80

– Eight measures, up to 10 pts each

– Each measure score = (numerator/denominator) * 10

• Public Health Registry = 1

– Reporting beyond Immunization Registry


– Proportional: ACI score * 0.25 = MIPS score

– >= 100 translates into 25 MIPS points


Performance Score Calculation

Objectives Patient Electronic AccessCoordination of Care Through Patient

EngagementHealth Information Exchange (HIE)

Measures Patient Access

Patient-

Specific

Education

VDTSecure

Messaging

Patient-

Generated

Health Data

Patient Care

Record

Exchange

Request /

Accept Patient

Care Record

Clinical

Information

Reconciliation

Perf

orm

an

ce R

ate

95%

65%

57%

33% 31% 38%

25% 21%

Performance

Points Earned9.5 6.5 3.3 3.1 2.5 2.1 3.8 5.7

Performance Score = 36.5 points


ACI Category Score Calculation

Base Score Performance Score Components

Tota

l Perf

orm

anc

e S

core

Pub

lic

Hea

lth

and

Clini

cal D

ata

Reg

istr

y B

onu

s Poin

t

Total

Points

Pro

tect

Pa

tient

Hea

lth

Info

rma

tion

Ob

ject

ives a

nd M

ea

sure

sPatient Electronic

Access

Coordination of Care

Through Patient

Engagement

Health Information

Exchange (HIE)

Patient

Access

Patient-

Specific

Education

VDTSecure

Messaging

Patient-

Generated

Health

Data

Patient

Care

Record

Exchange

Request /

Accept

Patient

Care

Record

Clinical

Information

Reconciliati

on

50 9.5 + 6.5 + 3.3 + 3.1 + 2.5 + 2.1 + 3.8 + 5.7 = 36.5 1 87.5

87.5 ACI points * 0.25 =

21.88 MIPS points for the ACI category

Base Score


Scoring Principles: Base Score• Worth 50 points

• All-or-nothing

• Each measure is either Yes/No or numerator >= 1

• If Protect Health Information is not achieved, entire ACI score is 0.


Two options: 2017 only• Primary Proposal

– Base score uses Stage 3 measures

• Alternate Proposal

– Base score uses Stage 3 + additional Stage 2 measures

• Choice based on certification edition:

– Use the 2015 Edition all year

• Primary Proposal OR


– Use the 2014 Edition all year


– Use combination of 2014 and 2015 Editions

• Primary Proposal OR



Primary Proposal – Base ObjectivesObjective Measure Stage 2 Stage 3

1 Protect Patient Health Information Security Risk Analysis

2 Electronic Prescribing ePrescribing

3 Patient Electronic Access Patient Access

Patient-Specific Education

4 Coordination of Care Through

Patient Engagement

View, Download or Transmit (VDT)

Secure Messaging

Patient-Generated Health Data

5 Health Information Exchange Patient Care Record Exchange

Request/Accept Patient Care Record

Clinical Information Reconciliation

6 Public Health and Clinical Data

Registry Reporting

Immunization Registry Reporting

(Optional) Syndromic Surveillance Reporting

(Optional) Electronic Case Reporting

(Optional) Public Health Registry Reporting

(Optional) Clinical Data Registry Reporting


Alternate Proposal – Base ObjectivesObjective Measure Stage 2 Stage 3

1 Protect Patient Health Information Security Risk Analysis

2 Electronic Prescribing ePrescribing

3 Clinical Decision Support (CDS) Clinical Decision Support Interactions (CDS)

Drug Interaction and Drug-Allergy Checks

4 Computerized Provider Order

Entry (CPOE)

Medication Orders

Laboratory Orders

Diagnostic Imaging Orders

5 Patient Electronic Access Patient Access

View, Download or Transmit (VDT)

6 Patient-Specific Education Patient-Specific Education

7 Secure Messaging Secure Messaging

8 Health Information Exchange Health Information Exchange

9 Medication Reconciliation Medication Reconciliation

10 Public Health Reporting Immunization Registry Reporting

Syndromic Surveillance Reporting

Specialized Registry Reporting

Performance Measures

Same for Primary and Alternative


Performance Measures Method• Eight measures total

• Calculate percent achievement for each measure across each measure

• Divide each achievement percent by 10

• Maximum score is 80

• Sum all the scores


Performance Measures

Objective Measure StagePatient Electronic Access Timely Access 2

Patient Education 2Coordination of Care View / Download / Transmit 2

Secure Messaging 2Patient Generated Health Data 3

Health Information

Exchange

Patient Care Record Exchange 2Request/Accept Patient Care Record 3Clinical Information Reconciliation 3

Registry Bonus


Registry Bonus Point • May earn 1 point towards ACI score for participation in one or more extra registries

• Maximum score is 1 point, no matter how many registries

• Potential registries:

– Syndromic Surveillance

– Electronic Case Reporting

– Public Health Registry Reporting

– Clinical Data Registry Reporting

Advanced APMs


In review• APMs are a class of risk-based payment models

• Each functions in its own manner

• Incentives are in addition to FFS payments

• Only Advanced APMs qualify for QPP

– Detailed within


Requirements for Advanced APM• CMS Innovation Model or statutorily required model

• Bear more than nominal financial risk

– Advanced medical homes with 50 or fewer clinicians exempt

• Payments based on quality measures similar to MIPS

• Must use certified EHR technology


Financial Impact of APM Participation• Current incentives for APMs remain in place

• 2019-2024:

– MIPS participation waived

– 5% Medicare Part B incentive

• 2026 and forward:

– MIPS participation waived

– Higher fee schedule update


Advanced APMs• Qualify as Advanced APMs via statute:

– Medicare Shared Savings Program—Track 2

– Medicare Shared Savings Program—Track 3

– Next Generation ACO Model

– Comprehensive Primary Care Plus

– Comprehensive End Stage Renal Disease Care Model (Large Dialysis Organization

arrangement)

– Oncology Care Model Two-Sided Risk Arrangement (available in 2018)

• Note: Comprehensive Joint Replacement not included

– CMS seeking comments on how to include


Surprise omissions• Medicare Shared Savings Program – Track 1

• Comprehensive Joint Replacement

• Patient Centered Medical Homes

– Only count for MIPS so far…


Which APMs Qualify?• Will be determined by CMS by January 1 of the performance year…


Qualifying for Incentive Payments• Requires sufficient volume of payments via APMs

• May form group to reach volume

• 2019-2020, Medicare payments or patients only

• 2021 forward, may include non-Medicare

Payment Year 2019 2020 2021 2022 2023 2024+

% Payments 25% 25% 50% 50% 75% 75%

% Patients 20% 20% 35% 35% 50% 50%


Transitional Considerations• All clinicians report via MIPS in 2019 payment year

– APM participation = CPIA category

• Failure to achieve APM incentives in 2019-2020

– May opt out of APM, participate in MIPS instead

– Requires 20% of payments or 10% of patients via APM


Other APM Options• If participating in multiple APMs but no single APM performance is “qualifying,” may be assessed

to see if aggregate performance could be used

• Partial Qualifying APM: lower thresholds so no MIPS requirement, but lower bonus as well


Physician-Focused Payment Models (PFPMs)• Recommended by Physician-Focused Payment Model Technical Advisory Committee (PTAC) to HHS

• Includes physician group practices (PGPs) or individual physicians as APM entities

• Targets the quality and cost of physician services

• Don’t have to be an advanced APM

• Initially, test with Medicare as payer (third parties later)


PFPM Criteria• Incentives: Pay for higher-value care

– Value over volume

– Flexibility

– Quality and cost focus (can improve both or at least one)

– Payment methodology

– Scope (broaden the APM portfolio)

– Criteria for evaluation

• Care delivery improvements

– Integration and care coordination

– Patient choice

– Patient safety

• Information enhancements

– Health IT

Transparency


Transparency via Physician Compare• Data published

– Names of clinicians in APMs

– As feasible, names and performance of APMs

– MIPS scores for clinicians

• Aggregate and individual

• Detailed per performance category

• 30-day pre-publication window for clinicians to review and submit corrections

In closing…


Questions


Further information• ClientConnect: MACRA Quality Payment Program (QPP)

– https://clientconnect.allscripts.com/groups/macra/overview

• CMS QPP website:

– https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-

Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html

https://clientconnect.allscripts.com/groups/macra/overview

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html

Thank you!

MACRA… What is it? Why Do I Need to Be in the Know? · MACRA… What is it? Why Do I Need to Be...

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