9/9/2016

1

Surviving the New Program Requirements

and the Financial Penalties Under MIPS

September 2016

Selena Hood

• Steps to take to prepare for MIPS

• Introduction and Evaluation of the Merit-Based Incentive Payment System (MIPS)− Quality Performance Category− Resource Performance Category− Clinical Practice Improvement Activities Performance Category− Advancing Care Information Performance Category− Data Submission− Payment Adjustment

• Surviving the payment penalties under MIPS

Agenda

9/9/20162

9/9/2016

2

Survival Guide

Things to think about NOW

9/9/20163

1. Check your Medicare PQRS feedback reports.

2. Check your Medicare QRUR reports

3. Review proposed rule’s list of Clinical Practice Improvement Activities (CPIA)

4. Review your place in the EHR Incentive program– Do you have a CEHRT, were you exempt last program year?

5. General Considerations – Determine your Medicare status, do you plan to report as an individual or group, are you a non-patient facing EC?

6. Alternative Payment Models– Confirm whether you are participating in an APM. If not, check with your specialty society to see if there's and

opportunity.

7. How do you plan to submit data?

8. Make sure you submit data!– If you do not submit data, the law requires CMS to give a zero performance score and a negative payment

adjustment (-4% for 2019)

9. Understand the Proposed Rule.

9/9/20164

Proposed Rule:Steps to take to prepare for MIPS:

9/9/2016

3

New Payment Tracks For Provider Groups:

The Merit-Based Incentive Payment System (MIPS)

9/9/20165

• MIPS is a new program

– Streamlines three currently independent programs to work as one and to ease clinician burden

– Adds a fourth component to promote improvement and innovation to clinical activities

– MIPS provides clinicians the flexibility to choose the activities and measure that are most meaningful to their practice to demonstrate performance

9/9/20166

Proposed Rule:

Introduction to MIPS

9/9/2016

4

“MIPS eligible clinicians” replaces the previous use of “Eligible Professional (EP)”

Proposed Rule:Who Will Participate in MIPS

9/9/20167

Years 1 and 2

• Physicians (MD/DO and DMD/DDS), PAs, NPs, Clinical nurse specialists, Certified registered nurse anesthetists.

Years 3+

• Physical or occupational therapists, Speech-language pathologists, Audiologists, Nurse midwives, Clinical social workers, Clinical psychologists, Dietitians/Nutritional professionals.

Proposed Rule:Who will NOT Participate in MIPS

9/9/20168

FIRST year of Medicare Part B

participation

Below low patient volume threshold

Medicare billing charges less than or equal to $10,000 and provides care for 100 or fewer Medicare

patients in one year.

Certain participants in ADVANCED

Alternative Payment Models

Note: MIPS does not apply to hospitals or facilities

9/9/2016

5

Proposed Rule:MIPS: Eligible Clinicians

Eligible Clinicians can participate in MIPS as an:

9/9/20169

Individual  Group

• An individual is a define as a unique NPI or TIN. (Same as before)• A group is 2 or more, as defined by taxpayer identification number (TIN), would be

assessed across all four MIPS performance categories.• “Virtual groups” will not be implemented in year 1 of MIPS.

• All MIPS performance categories are aligned to a performance period of one full calendar year.

• Goes into effect Jan. 1, 2017 (2017 performance period, 2019 payment year).

9/9/201610

Proposed Rule: MIPS Performance Period

2017 2018 2019 2020 2021 2022 2023 2024 2025

Performance Period

PaymentYear

9/9/2016

6

Proposed Rule:MIPS Performance Categories

• A single MIPS composite performance score will factor in 4 weighted performance categories on a 0-100 point scale

9/9/201611

MIPS Composite

Performance Score (CPS)

Proposed Rule:Year 1 Performance Category Weights for MIPS

9/9/201612

Quality

50%

Advancing Care Information 25%

Clinical Practice Improvement activities 15%

Resource Use 10%

9/9/2016

7

Proposed Rule:MIPS: Performance Category Scoring

9/9/201613

9/9/201614

MIPS:

Quality Performance Category

9/9/2016

8

Proposed Rule:MIPS: Quality Performance Category

Summary:

• Selection of 6 measures

• 1 cross-cutting measure and 1 outcome measure, or another high priority measure if outcome is unavailable

• Select from individual measures or a specialty measure set

• Population measures automatically calculated

• Year 1 weight: 50%

9/9/201615

Proposed Rule:Key Changes from Current Program (PQRS)

9/9/201616

Base Score Performance

Score

Bonus Points Composite 

Score

PQRS Quality Performance Category

Scoring Report all required measures to avoid payment adjustment

Report all required measures. Credit received for those measures that meet the data completeness threshold

Data Submission Criteria Required 9 measures across 3 NQS domains

Requires 6 measures; no NQS domain requirement

Face-to-face Encounter 1 encounter required for the cross-cutting measure requirement

25 or less encounters required for cross-cutting requirement

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Requirement

CAHPS required for groups with 100 or more EPs

CAHPS no longer required for groups of 100 or more, bonus points for submitting survey

MAV Secondary outcome to determine successful reporting

Yet to be determined. Open for comments.

9/9/2016

9

Proposed Rule:Assigning Points Based on Deciles

9/9/201617

0% 7% 16% 23% 36% 41% 62% 69% 79% 85% 100%

Proposed Rule:Assigning Points Based on Deciles

McKesson Corporation Confidential and Proprietary18

Benchmark Deciles Benchmark Ranges (Hypothetical)

Points Scored

1 0% ‐ 6.9% 1.0 – 1.9

2 7% ‐ 15.9% 2.0 – 2.9

3 16% ‐ 22.9% 3.0 – 3.9

4 23% ‐ 35.9% 4.0 – 4.9

5 36% ‐ 40.9% 5.0 – 5.9

6 41% ‐ 61.9% 6.0 – 6.9

7 62% ‐ 68.9% 7.0 – 7.9

8 69% ‐ 78.9% 8.0 – 8.9

9 79% ‐ 84.9% 9.0 – 9.9

10 85% ‐ 100% 10 

9/9/2016

10

• Eligible clinicians with performance in the top decile will receive the maximum 10 points.

• Eligible clinicians who do not report enough measures will receive 0 points for each measure not reported, unless they could not report these measures due to insufficient applicable measures.

9/9/201619

Proposed Rule: Converting Measure to Points Based on Deciles

• Up to 10% “extra credit” total in bonus points.

• Additional high priority measure (up to 5% of possible total)− 2 bonus points award for additional outcome/patient experience− 1 bonus point for the other high priority measures

• CEHRT Bonus (up to 5% of possible total)− 1 bonus point for each measure reported using CEHRT for end-to-end

electronic reporting− Not available for claims

9/9/201620

Proposed Rule: Quality Performance Category Score: Bonus Points

9/9/2016

11

Proposed Rule:Scoring: Quality Performance Category

9/9/201621

Each measure is converted to points (1-10)

Zero points for a

measure that is not reported

Bonus for reporting additional outcomes,

patient experience, appropriate use, patient

safety

Bonus for EHR

reportingTotal points

Total points Total possible points

Quality Performance

Category Score

9/9/201622

MIPS:

Resource Use Performance Category

9/9/2016

12

Summary:

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

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

• Key changes from Current Program (Value-Based Payment Modifier):− Adding 40+ episode specific measures to address specialty concerns− Year 1 Weight: 10 points

• Note: No additional submission requirements

9/9/201623

Proposed Rule:MIPS: Resource Use Performance Category

Proposed Rule:Key Changes from Current Program (Value Modifier)

9/9/201624

Base Score Performance

Score

Bonus Points Composite 

Score

Value ModifierProposed MIPS Resource

Use Category

6 measures:

• Total per capita costs for all attributed beneficiaries,

• Medicare Spending per Beneficiary (MSPB),

• Total per capita cost measures for the four condition-specific groups (chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, and diabetes mellitus).

• Attribution to the group practice (TIN)

2 of the 6 VM measures:

• Total per capita costs for all attributed beneficiaries,

• Medicare Spending per Beneficiary (MSPB),

• Removes total per capita cost measures for the four condition-specific groups.

• Attribution to group (TIN) or individual (TIN/NPI)

• Proposes up to 41 other episode based measures

9/9/2016

13

Proposed Rule:Proposed Clinical Episode Groups

9/9/201625

Proposed Rule: Scoring: Resource Use Performance Category Example

9/9/201626

Each measure is

converted to points (1-10))

Minimum Case Volume (20 including for MSPB)

Total Points

Total Points Total Possible points

Quality Performance

Category Score

9/9/2016

14

9/9/2016

MIPS:

Clinical Practice Improvement Activity (CPIA) Performance Category

27

Summary:

• Minimum selection of one CPIA activity (from 90+ proposed activities) with

additional credit for more activities

• Full credit for patient-centered medical home

• Minimum of half credit for APM participation

• Key changes from current program:− Not applicable (new category)

− Year 1 weight: 15 points

− The more activities completed, the more points are rewarded to the clinician

− Examples: care coordination, safety checklist, and after hours care

9/9/201628

Proposed Rule:MIPS: Clinical Practice Improvement Activity Performance Category

9/9/2016

15

Proposed Rule:CPIA Performance Category

9/9/201629

Proposed Rule:Subcategories of Clinical Practice Improvement Activities

9/9/201630

Base Score Performance

Score

Bonus Points Composite 

Score

Subcategories are specified in MACRA

Three additional subcategories are

proposed in the NPRM

9/9/2016

16

In general:

• Each activity in the CPIA activity list is worth a certain number of points − Most are worth 10 points (medium weight)− Some activities have high weight, and are worth 20 points

• To get maximum credit, must achieve 60 points–Can be achieved by selecting any combination of activities:− High-and medium-weight− All high-weight− All medium-weight activities

• Special scoring considerations for specific types of eligible clinicians and groups are discussed later.

9/9/201631

Proposed Rule: CPIA Scoring Overview

Proposed Rule: Scoring: CPIA Performance Category Example

9/9/201632

Total points for high-weight

activities

Total points for medium-weight

activities

Total CPIA Points

Total CPIA Points

Total Possible points

CPIA Performance

Category Score

9/9/2016

17

9/9/201633

MIPS:

Advancing Care Information Performance Category

Summary:

• CEHRT required

• Key changes from current program (EHR Incentive):− Eliminated Clinical Provider Order Entry and Clinical Decision Support

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

report− Year 1 Weight: 25 points

9/9/201634

Proposed Rule:MIPS: Advancing Care Information Performance Category

9/9/2016

18

Proposed Rule: Changes from EHR Incentive Program to Advancing Care Information

9/9/201635

Past Requirements fro the Medicare EHR Incentive Program

New Proposal for Advancing Care Information Category

One-size-fits-all-every objective reported and weighed equally

Customizable – clinicians can choose which categories to emphasize in their scoring

Requires across-the-board levels of achievement or “thresholds,” regardless of practice or experience

Flexible. Allows for diverse reporting that matches clinician’s practice and experience.

Measurements emphasizing process Measurement emphasizing patient engagement and interoperability

Disjointed and redundant with other Medicare reporting programs

Aligned with other Medicare reporting programs. No need to report redundantquality measures.

No exemptions for reporting Exemptions for reporting for clinicians.• Advanced alternative payment model• First year with Medicare• Have low Medicare volumes

Proposed Rule: Who can participate

9/9/201636

Similar exclusions will carry over from EHR incentive. Hardship exceptions.

9/9/2016

19

Proposed Rule:MIPS: Advancing Care Information Performance Category

9/9/201637

CMS Proposes six objectives and their measures that would require reporting for the base score:

Base Score:

• The base score accounts for 50 points of the total Advancing Care Information category score.

• To receive the base score, physicians and other clinicians must simply provide the numerator/denominator or yes/no for each objective and measure. 

9/9/201638

Proposed Rule: MIPS Advancing Care Information Performance Category

9/9/2016

20

Performance Score:

• The performance score accounts for up to 80 points towards the total Advancing Care Information category score.

• Physicians select the measures that best fit their practice from the following objectives, which emphasize patient care and information access:

9/9/201639

Proposed Rule:MIPS: Advancing Care Information Performance Category

• The performance category score is capped at 100 percentage points (out of a possible 131 percentage points).

• 50 percentage points for the base score, which consists of: − Reporting privacy and security− Reporting a numerator/denominator or yes/no statement for each measure as required Note: for numerator/denominator measures, ECs must report at least a one in the numerator; for yes/no

statement measures, ECs must report a yes for credit.

• 80 percentage points for the performance score, which is determined based on achievement above the base score requirements for three objectives:– Patient Electronic Access, Coordination of Care Through Patient Engagement, Health

Information Exchange

• 1 “bonus” percentage point for Public Health and Clinical Data Registry Reporting

9/9/201640

Proposed Rule:Advancing Care Information Break Down

9/9/2016

21

Proposed Rule:MIPS: Advancing Care Information Performance Category

Example Scoring:

9/9/201641

Account for

50 points of the total

Advancing Care Information

Performance Category Score

Account for

80 points of the total

Advancing Care Information

PerformanceCategory Score

Up to

1 pointof the total

Advancing Care Information

Performance category score

Earn 100+ pts receive

Full 25 points

in the Advancing Care Information

Category of MIPS composite

score

Base Score PerformanceScore

Bonus Points

Composite Score

+ + =

The overall Advancing Care Information score would be made up of a base score and a performance score for a maximum score of 100 points.

Proposed Rule: Scoring: Advancing Care Information Performance Category

9/9/201642

Base Score

50 points

Privacy and Security

Performance Score

80 points

Electronic Access, Care Coordination,

Health Information Exchange

Bonus for Public Health and Clinical

Data Registry Reporting

Total Points

Total Points Total Possible points

Advancing Care Performance

Category Score

9/9/2016

22

9/9/201643

MIPS:

Data Submission Options

McKesson Corporation Confidential and Proprietary44

9/9/2016

23

9/9/201645

MIPS:

Payment Adjustment

• Based on a CPS, clinicians will receive +/- or neutral adjustment up to the percentage below.

• MIPS will be a budget-neutral program. Total upward adjustment could

reach 3x the potential adjustment.

9/9/201646

Proposed Rule:How much can MIPS adjust payments?

9/9/2016

24

Composite Performance Score

In review

This is a test Footer47

Proposed Rule: Unified Scoring Principles

9/9/201648

10 point scoring system Actionable and transparent data. Eligible clinicians will know in advance what they need to do to perform well.

Moves away from “all-or-nothing” scoring

Receive scores for submitted information.

Performance at any level would help improve the CPS

Zero scores for any required items that are not submitted

No improvement scoring for year 1.

9/9/2016

25

Proposed Rule:Scoring Rules for each category

9/9/201649

Proposed Rule: Relationship between CPS and Payment

9/9/201650

9/9/2016

26

Proposed Rule: 

Example Performance Threshold = 60

9/9/201651

Proposed Rule: Scoring: Quality Performance Category

9/9/201652

Each measure is

converted to points (1-10)

Zero points for a measure

that is not reported

Bonus for reporting additional outcomes,

patient experience, appropriate

use, pt safety

Bonus for EHR

reportingTotal Points

Dr. Smith has 40.2 points based on

performance

She qualifies for 1 bonus

point for reporting an

additional high priority

measure

She gets 1 bonus points for using their EHR to report

quality

She gets 42.2 total points

Total Points Total Possible points

Quality Performance

Category Score

42.2 Total points

80 total possible points

52.8% Quality Score

9/9/2016

27

Proposed Rule: Scoring: Resource Use Performance Category Example

9/9/201653

Each measure is

converted to points (1-10)

Minimum Case Volume (20 including for MSPB)

Total Points

Dr. Smith has 16.3 points based on

performance

4 measures with

minimum case volume

She gets 16.3 total

points

Total Points Total Possible points

Quality Performance

Category Score

16.3 Total points

40 total possible points

40.8% RU Score

Proposed Rule:

Scoring: CPIA Performance Category Example

9/9/201654

Total points for high‐weight activities

Total points for medium‐weight 

activitiesTotal CPIA Points

Dr. Smith completes 1 high‐weight 

activities (earning her 20 points)

She also completes 2 medium‐weight activities (earning her 20 points)

She gets 40 total points

Total CPIA Points Total Possible points

CPIA Performance Category Score

40 Total points60 total 

possible points66.7% CPIA 

Score

9/9/2016

28

Proposed Rule:

Scoring: Advancing Care Information Performance Category

9/9/201655

Base Score

50 points

Privacy and Security

Performance Score

80 points

Electronic Access, Care Coordination,

Health Information Exchange

Bonus for Public Health and Clinical

Data Registry Reporting

Total Points

Dr. Smith has 36.2 points for her base

score

An additional 40 points for performance

She gets 1 bonus point

She gets 77.2 total points

Total Points Total Possible points

Advancing Care Performance

Category Score

77.2 Total points 100 total possible points 77.2% ACP Score

CPS Calculations

The final Score

9/9/201656

9/9/2016

29

Proposed Rule: Composite Performance Score

9/9/201657

PerformanceCategory

Score Weight Weighted Score

Quality 52.8% 50% 26.4

52.8% x 50% = 26.4

Resource Use 40.8% 10% 4.1

40.8% x 10% = 4.1

CPIA 66.7% 15% 10.0

66.7% x 15% = 10

Advancing Care Information

77.2% 25% 19.3

77.2% x 25% = 19.3

Composite Performance Score(Subtotal x100)

59.8 points

Survival Guide

Things to think about AFTER

9/9/201658

9/9/2016

30

1. Explore the requirements for qualifying as a patient-centered medical home.

2. Look at partnerships and collaboration

3. Work to ensure that incentives align with quality rather than quantity.

4. Review and understand your failures.

5. Enlist QR or QCDR reporting

6. Optimize clinical practice and care delivery

7. Reduce Waste

8. Revenue enhancements

9. Technology

9/9/201659

Proposed Rule:Value-Based Reimbursements

Thank You

9/9/201660

9/9/2016

31

McKesson Corporation Confidential and Proprietary61

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

2. AMA (American Medical Association) “MACRA Checklist: Steps You Can Take Now to Prepare”http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-new-payment-systems.page

3. Health Catalyst “Why you Need to Understand Value-Based Reimbursements and How to Survive it”https://www.healthcatalyst.com/understand-value-based-reimbursement

4. MGMA “Value-Based Payment Modifier Resource Center”http://www.mgma.com/government-affairs/issues-overview/federal-quality-reporting-programs/value-based-payment-modifer-resource-center

Appendix