The Quality Payment Program - MOQC...2017/06/22 · Quality Payment Program Timeline Taking a look...
23
The Quality Payment Program Preparing for 2017 Participation Bruce Maki, MA M-CEITA / Altarum Institute Regulatory & Incentive Program Analyst
Transcript of The Quality Payment Program - MOQC...2017/06/22 · Quality Payment Program Timeline Taking a look...
The Quality Payment ProgramPreparing for 2017 Participation
Bruce Maki, MAM-CEITA / Altarum InstituteRegulatory & Incentive Program Analyst
MACRA: What is it?• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
• Bipartisan legislation (yes, really) that replaced the flawed Sustainable Growth Rate (SGR) formula by paying clinicians for the value and quality of care they provide
• MACRA is more predictable than SGR. It will increase the number of physicians participating in alternative payment models (APMs), with those in high quality, efficient practices benefiting financially
• Extends funding for Children’s Health Insurance Program (CHIP) for two years
• And introduces us to…
Presenter
Presentation Notes
MACRA is the Medicare Access and CHIP Reauthorization Act of 2015. This bipartisan legislation replaced the flawed Sustainable Growth Rate or SGR formula by creating a program that pays clinicians for the value and quality of care they provide. MACRA is more predictable than the SGR. It will increase the number of physicians participating in alternative payment models or APMs, with those in high quality, efficient practices benefiting financially in this new program. Among other things, as the name would suggest, MACRA extends funding for the Children’s Health Insurance Program for an additional two years, and the main thing it brings us is….
The QPP is part of a broader push from
CMS towards paying for VALUE and
QUALITY
Presenter
Presentation Notes
…The Quality Payment Program or QPP, part of a broader shift from CMS towards paying for Value and Quality. There are 2 participation tracks to choose from in the QPP, Advanced Alternative Payment Models or APMs and MIPS, the Merit-based Incentive Payment System. I’ll touch more on each of these paths in a minute but first I want to give you a conceptual model of MACRA to aid in your understanding of what is a fairly complex program.
Conceptual Model of MACRA
For CY 2017, out of 1.3M Part B Clinicians, CMS projects:~ 600,000 MIPS Eligible Clinicians
~ 100,000 Advanced APM Clinicians
Quality Payment Program (QPP)
Non-Advanced APMs (aka MIPS APMS)
Merit-based Incentive Payment System (MIPS)
Alternative Payment Models (APMs)
Advanced APMs
MACRA
MANY other regulatory changes
Presenter
Presentation Notes
Here at the top we have MACRA. There were MANY regulatory and legislative changes contained in MACRA, but what you need to be concerned about most, and what’s most relevant to today’s discussion of value-based reimbursement is the QPP. Under the QPP we have the 2 paths I just mentioned, the Merit-based Incentive Payment System or MIPS and Alternative Payment Models or APMs. Finally, within APMs we have 2 types that are relevant to the QPP, Advanced APMs and non-Advanced APMs, otherwise known as MIPS APMs in this program. Initially, we’ll see the vast majority of clinicians participating in the MIPS track, but over time, CMS expects to see that scale tip, with more clinicians moving into the Advanced APM track, especially as more options become available to join.
Who Participates in the Quality Payment Program?
Who is Exempt from Participation?
Presenter
Presentation Notes
To participate in MIPS in 2017, a clinician must be over something called the “Low-volume Threshold”, which is billing more than 30,000 dollars in Medicare Part B allowable charges and providing care to more than 100 Medicare Part B patients during a 12 month determination period. Also, in the first 2 program years, the only provider types eligible to participate in MIPS are Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists. Clinicians who are in their first year of Medicare Part B participation, are below the low volume threshold or are significantly participating in an Advanced alternative payment model are exempt from MIPS participation.
*MACRA does not alter or end the Medicaid EHR Incentive Program
What is MIPS?• Combines multiple Medicare Part B programs into a single program
• This new, single program is based on:
• Quality (PQRS/VM-Quality Programs)
• Cost (VM-Cost Program)
• Advancing Care Information (Medicare MU*)
• Improvement Activities (New Category)
Presenter
Presentation Notes
Under track one, MIPS combines multiple Medicare Part B programs, which you may already be familiar with, into a single program. It takes the Medicare EHR Incentive Program, otherwise known as Medicare Meaningful Use, the Physician Quality Reporting System or PQRS, the Value-Based Payment Modifier or VM, it adds a fourth new category called Improvement Activities and combines them into this new program called MIPS. In MIPS, Meaningful Use has undergone a name change and is now referred to as the Advancing Care Information performance category. Also, please note that MIPS does not end or affect the Medicaid EHR Incentive Program. That program is scheduled to continue into Stage 3 and run through the year 2021. Participating in Medicaid Meaningful Use and MIPS concurrently requires separate attestations. PQRS is now referred to as the Quality performance category of MIPS. And the Value-based Payment Modifier is now the Cost performance category.
Alternative Payment Models (APMs)• Alternative Payment Model or APM is a generic term describing a
payment model in which providers take responsibility for cost and quality performance and receive payments to support the services and activities designed to achieve high value
• According to MACRA, APMs in general include:
• Medicare Shared Savings Program (MSSP) ACOs• Demonstrations under the Health Care Quality Demonstration
Program• CMS Innovation Center Models• Demonstrations required by Federal Law
• MACRA does not change how any particular APM pays for medical care and rewards value
• MIPS APM participants may receive favorable scoring under certain MIPS performance categories
• Only some APMs are “Advanced” APMs
Presenter
Presentation Notes
Track two of the QPP brings us to Alternative Payment Models or APMs. APM is a generic term describing a payment model in which providers take responsibility for cost and quality performance and receive payments to support the services and activities designed to achieve high value. According to MACRA, APMs in general include Medicare Shared Savings Program ACOs, demonstrations under the Health Care Quality Demonstration Program, CMS Innovation Center Models such as the Qualified Medical Home and demonstrations required by Federal Law. When you see APM, think ACO or Medical Home as those make up the majority of APM types. The Quality Payment Program does not change how any particular ACO or Medical Home model pays for medical care and rewards value. Instead, the QPP enhances that payment methodology by adding additional incentives for clinicians. And if applicable, APM participants may receive favorable scoring under certain MIPS performance categories. The long term goal of the Quality Payment Program is to significantly increase participation in the highest level of APMs, those meeting the criteria to be defined as Advanced APMs.
Alternative Payment Models• “Advanced” APMs – Term
established by CMS; these have the greatest risks and offer potential for greatest rewards
• Qualified Medical Homes have different risk structure but are otherwise treated as Advanced APMs
• MIPS APMs, which make up the majority of ACOs today, receive favorable MIPS scoring
Presenter
Presentation Notes
So at the top of this model we have Advanced APMs, a term established by CMS which denotes those APMs which have the greatest financial risks for providers and also offer the greatest potential for rewards. Three criteria need to be met for an APM to be deemed an Advanced APM. First, 50% or more of the APMs participants must use certified EHR technology or CEHRT. The entity must report and at least partially base clinician payments on quality measures which are comparable to those available to participants of MIPS. Finally, and perhaps most importantly, to be an Advanced APM, participants must bear “more than nominal risk” for monetary losses for poor performance. This level of risk is defined as the lesser of 8% of total Medicare revenues or 3% of total Medicare expenditures. Current examples of Advanced APMs include, but are not limited to, Medicare Shared Savings Program ACOs Tracks 2 and 3 and Next Generation ACOs. Qualified Medical Homes have different risk structures but are otherwise treated as Advanced APMs. Today, only CPC+ qualifies for this designation. Finally we have MIPS APMs, which are alternative payment models which meet certain requirements but don’t place enough financial risk on clinicians to reach Advanced APM status. The vast majority of ACOs today, including MSSP Track 1 ACOs, are MIPS APMs.
How will the QPP Affect Payments?• Advanced APM Track− 5% lump sum bonus payment of 2018 Medicare Part B
reimbursements• MIPS Track− Performance-based payment adjustment (+ / - / null) based on
the amount and quality of data submitted (budget neutral)• In either track, the first payment adjustments or bonuses based on
performance in 2017 go into effect on January 1, 2019
Presenter
Presentation Notes
Clinicians significantly participating in an Advanced APM may earn a 5% lump sum bonus payment through Medicare Part B. Clinicians who participate in the MIPS track will earn a performance-based payment adjustment – up, down, or not at all – based on the data that’s submitted. In either track, the first payment adjustments based on performance in 2017 go into effect on January 1, 2019
Potential MIPS Financial ImpactMedicare Part B Annual Revenue
2017 Projected
0.7%2017
+/- 4%2018
+/- 5%*2019
+/- 7%
2020 and beyond +/- 9%
$ 10,000,000 $ 70,000 $ 400,000 $ 500,000 $ 700,000 $ 900,000 $ 9,500,000 $ 66,500 $ 380,000 $ 475,000 $ 665,000 $ 855,000 $ 9,000,000 $ 63,000 $ 360,000 $ 450,000 $ 630,000 $ 810,000 $ 8,500,000 $ 59,500 $ 340,000 $ 425,000 $ 595,000 $ 765,000 $ 8,000,000 $ 56,000 $ 320,000 $ 400,000 $ 560,000 $ 720,000 $ 7,500,000 $ 52,500 $ 300,000 $ 375,000 $ 525,000 $ 675,000 $ 7,000,000 $ 49,000 $ 280,000 $ 350,000 $ 490,000 $ 630,000 $ 6,500,000 $ 45,500 $ 260,000 $ 325,000 $ 455,000 $ 585,000 $ 6,000,000 $ 42,000 $ 240,000 $ 300,000 $ 420,000 $ 540,000 $ 5,500,000 $ 38,500 $ 220,000 $ 275,000 $ 385,000 $ 495,000 $ 5,000,000 $ 35,000 $ 200,000 $ 250,000 $ 350,000 $ 450,000 $ 4,500,000 $ 31,500 $ 180,000 $ 225,000 $ 315,000 $ 405,000 $ 4,000,000 $ 28,000 $ 160,000 $ 200,000 $ 280,000 $ 360,000 $ 3,500,000 $ 24,500 $ 140,000 $ 175,000 $ 245,000 $ 315,000 $ 3,000,000 $ 21,000 $ 120,000 $ 150,000 $ 210,000 $ 270,000 $ 2,500,000 $ 17,500 $ 100,000 $ 125,000 $ 175,000 $ 225,000 $ 2,000,000 $ 14,000 $ 80,000 $ 100,000 $ 140,000 $ 180,000 $ 1,500,000 $ 10,500 $ 60,000 $ 75,000 $ 105,000 $ 135,000 $ 1,000,000 $ 7,000 $ 40,000 $ 50,000 $ 70,000 $ 90,000 $ 500,000 $ 3,500 $ 20,000 $ 25,000 $ 35,000 $ 45,000
*Advanced APM Bonus = 5%
Quality Payment Program Timeline
Presenter
Presentation Notes
Taking a look at the Quality Payment Program timeline, we see that the Medicare Physician Fee Schedule will still see modest rate increases through 2019. Between the years 2020 and 2025 the only way to receive Medicare rate increases will be to participate in one of the 2 tracks of the Quality Payment Program. In 2026, the Medicare Fee Schedule will once again see annual positive adjustments, with the rate of increase dependent on whether or not the clinician is significantly participating in an Advanced APM. In the MIPS track, reimbursement rates will be adjusted within the range of plus or minus 4% in the first year and increasing to 9% in 2022 and beyond. Those clinicians significantly participating in an Advanced APM will receive lump sum incentive payments equal to 5% of their Medicare reimbursements and are exempt from participating in MIPS.
Preparing for 2017 MIPS Participation
Preparing for 2017 MIPS Participation Determine your eligibility and understand the requirements
Choose whether you want to submit data as an individual or as a part of a group
Choose your submission method and verify its capabilities
Verify your EHR vendor or registry’s capabilities before your chosen reporting period
Prepare to participate by reviewing practice readiness, ability to report, and the Pick Your Pace options
Choose your measures. Visit www.qpp.cms.gov and www.qppresourcecenter.comfor valuable measure selection resources
Verify the information you need to report successfully
Care for your patients and record the data
Submit your data between 1/1/18 – 3/31/18
Determine Your Eligibility
How Do I Do This?
• Calculate your annual patient count and billing amount for the 2017 transition year• Review your claims for services provided between September 1, 2015
and August 31, 2016, and where CMS processed the claim by November 4, 2016
• Did you (or group) bill more than $30,000 AND provide care for more than 100 Medicare patients between 9/1/15 - 8/31/16?
• Yes: You’re eligible• No: You’re exempt
• Between April – May, CMS sent letters to each practice which details participation options for each associated EC• Additionally, www.qpp.cms.gov now offers the ability to query EC
eligibility by NPI
Choose to Submit Data as an Individual or as Part of a Group
How Do I Do This?
• Perform a detailed analysis to determine which option is best• Many factors must be considered to make this determination
• TIN structure• Technology available• Are you a multi-specialty group?• Past performance in legacy programs• Others
• Individual: • Submit the data under each unique TIN/NPI combination using the
chosen submission method(s)• Group:
• All eligible clinicians under a single TIN collectively submit performance data across all MIPS performance categories
Choose a Submission Method and Verify its Capabilities
How Do I Do This?• Review the available submission options for 2017
• Speak with your specialty society or others about your options (QOPI® Reporting Registry)
• Consider using a Technical Assistance program (TCPI, QIN-QIOs, QPP-SURS) for decision support
• Visit qpp.cms.gov and qppresourcecenter.com for information on submission options
• Choose a data submission option• For Qualified Registries, QCDRs, and CAHPS for MIPS Survey:
• Check that each of the submission options are approved by CMS• For EHR reporting:
• Check that your EHR is certified by the Office of the National Coordinator for Health Information Technology https://chpl.healthit.gov/#/search
Prepare to Participate
How Do I Do This?
• Consider your practice readiness
• Have you previously participated in a quality reporting program?
• Evaluate your ability to report
• What is your data submission method?
• Are you prepared to begin reporting data between January 1, 2018 and March 31, 2018?
• Review the Pick-Your-Pace options for Transition Year 2017
• Test (send something)
• Partial Year (Submit under all 3 categories for 90-364 days)
• Full Year (Submit under all 3 categories for entire calendar year)
Choose Your Measures and Activities
How Do I Do This?
• Go to www.qpp.cms.gov
• Click on the tab at the top of the page
• Select the performance category of interest
• Review the individual Quality and Advancing Care Information measures as well as Improvement Activities
Choose Your Measures and Activities2017 Oncology Quality Measures
Presenter
Presentation Notes
Also Care Plan and Closing the Referral Loop
Choose Your Measures and Activities
Tips for Reviewing and Selecting Measures/Activities
• Consider the following:
• Your patient population and the clinical conditions that you treat
• Your practice improvement goals
• Quality data that you may submit to other payers
• If you’re currently participating in one of the legacy quality programs, consider your current billing codes and Quality Resource Use Report (QRUR) to help identify suitable measures
• PQRS Feedback Reports and QRURs can be accessed at https://portal.cms.gov using the same EIDM account.
Verify the Information You Need to Report Successfully
How Do I Do This?• Review the specifications for any Quality measure you intend to report, including:
• Measure number, NQF number (if applicable), Measure title and domain
• Submission method option
• Measure type
• Measure description
• Instructions on reporting including frequency, timeframes, and applicability
• Denominator statement, denominator criteria and coding
• Numerator statement and coding options
• Definition(s) of terms where applicable
• Rationale
• Clinical recommendations statement or clinical evidence supporting the measure intent
Submit Your Data
How Do I Do This?
• Care for your patients and record the data
• Submit your data to CMS prior to the March 31, 2018 deadline using your chosen submission method
• CMS anticipates the data submission window to open January 1, 2018• You are encouraged to submit as early as possible following this date to
ensure the timely receipt and accuracy of your data
• If relying on someone else to submit on your behalf (Staff, EHR Vendor, Qualified Registry, QCDR, etc.), seek confirmation of data submission
