Michigan Osteopathic AssociationAnnual Conference

Grand RapidsNovember 3, 2017

What You Should Know About MACRA

Learning Objectives

❖ Explain MACRA

❖ Identify two payment tracks

❖ Illustrate how the PCMH model and existing Value-

based reimbursement (VBR) support Clinical Practice

Improvement Activities

❖ Give examples of what a practice can do to prepare

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What Do You See?

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Observations

❖ Medicare Access and CHIP Reauthorization Act

(MACRA) signed into law April 16, 2015: (Fix-It Bill)

❖ ACA was signed into law on March 23, 2010

❖ MACRA and ACA are often confused

❖ MACRA is complex

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Observations

❖ MACRA, MIPS, and AAPM are used interchangeably

❖ Many of the “new” requirements are revisions to the

current FFS program

❖ One goal of MACRA is to simplify administrative

processes and reduce administrative burden

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Observations

❖ MACRA has strong bipartisan support

❖ Repeals are unlikely due to the continued strong

bipartisan support for MACRA

❖ The Senate and the House voted in favor of

MACRA 92-8 and 392-37 respectively

❖ Critically, any delay to MACRA would have to go

through Congress and due to the strong bipartisan

support this is also unlikely

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Building MACRA

❖ Uses the Triple Aim as a unifying strategy

Better Care

Healthier People

Smarter Spending

❖ CMS Quality Strategy is to optimize health

outcomes by leading clinical quality improvement

and health system transformation

Builds upon the three National Quality Strategy Goals and applies six priorities

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Building MACRA

❖ Six priorities: Make care safer by reducing harm caused while care

is delivered

Strengthen person and family engagement as partners in their care

Promote effective communication and coordination of care

Promote effective prevention and treatment of chronic illness

Work with communities to help people live in better health

Make care affordable

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What We Know So Far

❖ The Quality Payment Program makes Medicare

better by helping physicians focus on care quality

and the one thing that matters most – making their

patients healthier

❖ The Quality Payment Program ends the Sustainable

Growth Rate formula and gives physicians new

tools, models, and resources to help them give their

patients the best possible care

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What We Know So Far

❖ MACRA was designed to offer physicians a choice

between two payment pathways:

A modified fee-for-service model (MIPS)

New payment models that reduce costs of care and/or support high-value services not typically covered under the Medicare fee schedule (APMs)

❖ CMS named the physician payment system created

by MACRA the Quality Payment Program (QPP)

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What We Know So Far

❖ Physicians can choose how they want to participate

based on their practice size, specialty, location, or

patient population

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MACRA Revised Opportunities

Bonus opportunities (APMs and MIPS)

Greater support for physicians that want to pursue new models

Improvement Activities requirement

PQRS, MU and VBM

Penalties reduced in absolute terms & through partial credit

Reduce net administrative burdens

Greater flexibility for physicians

Low score in one area can be made up by high score in other components

No more double jeopardy for failing PQRS (trigger VBM failure)

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What Happens If You Choose MIPS

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❖ Physicians can now pick their own reporting

options

❖ There are exemptions

Medicare allowed charges of $30,000

100 or fewer Medicare patients

MIPS

❖ Started January 2017

❖ Leverages and expands PQRS, Value-Based

Modifier (VBM) and Meaningful Use

❖ Increases and consolidates financial impacts

❖ Ranks peers nationally and reports scores publicly

❖ MIPS is budget neutral

Incentives to high performers will be funded by

penalties applied to low performers

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MIPS

❖ Beginning July 1, 2018, CMS must make available

to each MIPS EP information about items and

services furnished to the EP’s patients by other

providers and suppliers for which payment is

made under Medicare

❖ Information about the performance of MIPS EPs

must be made available on Physician Compare

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MIPS Eligible Clinicians

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Medicare Part B Clinicians Affected

❖ MIPS approximately 800,000 out of 1.25 million

providers

❖ MIPS “new default” for Medicare Part B

participating providers

❖ Advanced APM < 20,000 providers

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Pick Your Pace: 2017 Transitional Performance Reporting Options

• Report some data at any point in CY 2017 to demonstrate capability

• 1 quality measure, or 1 improvement activity, or 4/5 required ACI measures

• No minimum reporting period

• No negative adjustment in 2019

MIPS Testing

• Submit partial MIPS data for at least 90 consecutive days

• 1+ quality measure, or 1+ improvement activities, or 4/ 5 required ACI measures

• No negative adjustment in 2019

• Potential for some positive adjustment ( < 4%) in 2019

Partial MIPS reporting

• Meet all reporting requirements for at least 90 consecutive days

• No negative adjustment in 2019

• Maximum opportunity for positive 2019 adjustment ( < 4%)

• Exceptional performers eligible for additional positive adjustment (up to 10%)

Full MIPS reporting

• No MIPS reporting requirements (APMs have their own reporting requirements)

• Eligible for 5% advanced APM participation incentive in 2019

Advanced APM

participation

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The only physicians who will experience negative payment adjustments (-4%) in 2019 are those who report no data in 2017

Low-volume Threshold Exemption

❖ Physicians with Medicare allowed charges of $30,000 or less or 100 or fewer Medicare patients

❖ Eligibility calculated by CMS

Notification should occur in December (notification for 2017 is late)

Based on recent 12-month historical data (September-August)

Includes Part B drug costs, but not Part D

❖ Exempted physicians receive annual fee schedule updates, but no bonuses or penalties

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Components of the CY2017 MIPS Score

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MIPS Components

Quality Reporting (was

PQRS)

Cost (was Value-based

Modifier)

Advancing Care Information

(was MU)

Improvement Activities

MIPS

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MIPS aims:• Align 3 current independent programs• Add 4th component to promote

improvement and innovation• Provide more flexibility and choice of

measures• Retain a fee-for-service payment

option

Clinicians exempt from MIPS:• First year of Part B participation• Medicare allowed charges < $30K or <

100 patients • Advanced APM participants

Improvement Activities Categories

Expanded Practice Access

Population Management

Care Coordination

Beneficiary Engagement

Patient Safety and Practice Assessment

Achieving Health Equity

Emergency Response and Preparedness

Integrated Behavioral and Mental Health

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Improvement Activities (CPIA)

❖ New component, intended to provide credit for

practice innovations that improve access and quality

Over 90 activities that cross 8 categories

No required categories

❖ 40 points required for medium and large practices

(2-4 activities)

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Improvement Activities (CPIA)

❖ Only 1-2 activities required for groups < 15, rural and

HPSA practices, non-patient facing specialists

Most physicians fall into this category

❖ Participation in 2017 MIPS APMs and non-advanced

medical homes worth 40 points

PCMH definition expanded to include national, regional, state, private payer, and other certifications

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Milestones

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2017Jan 1: First transitional performance period begins

Spring: PQRS, VBM, MU pay adjustments (2015 performance)

Oct 1: Last chance to start 90-day reporting period

Nov 1: 2018 performance threshold announced

Dec: Notification of LVT exception (9/1/16-8/31/17)

2018Jan 1: Second transitional performance period begins

Jan 2-Mar 31: Submission period for 2017 performance data

Spring: Final PQRS, VBM, MU pay adjustments (2016 performance)

Nov 1: 2019 performance threshold announced

Dec: Notification of LVT exception (9/1/17-8/31/18)

2019 Jan 1: QPP transitional reporting completed

Spring: First QPP pay adjustments implemented (2017 performance)

Check if You’re in MIPS

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Check if You’re in MIPS

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Check if You’re in MIPS

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Check if You’re in MIPS

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Many MACRA Checklists Available

✓ Are you exempt from MIPS?✓ Low volume provider?

✓ Qualified participant in an advanced APM?

✓ Do you want to participate as an individual or as a group?

✓ Do you meet requirements for small, rural, non-patient-facing accommodations?

✓ Do you/can you participate in a qualified clinical data registry?

✓ Do your PQRS and QRUR reports reveal areas for improvement?

✓ Which Improvement Activities are you engaged in now? What are you interested in doing?

✓ Is your EHR certified? If so, is it the 2014 or 2015 edition?

✓ Does your vendor support Medicare quality reporting?

CMS Measure Selection Tool

www.qpp.cms.gov Explore Measures Explore Quality Measures

MIPS Adjustment/Bonuses

❖ Based on composite performance score EPs may

receive an upward, downward or no payment

adjustment

❖ Exceptional Performers see significant opportunities

for additional bonuses/adjustments on top of

traditional MIPS incentives

Available in 2019 through 2024

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Clinical Practice Improvement Activity (CPIA) Scoring

❖ Each area in CPIA activity list is worth a certain

number of points

Most are worth 10 points

Some activities have higher weight

❖ To get maximum credit EP must achieve 60 points

❖ Certified PCMHs receive highest potential score

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CPIA Capabilities

❖ Expanded Practice Access

Same day appointments for urgent needs

After hours clinician advice

Patient experience of care survey

❖ Population Management

Monitoring health conditions and providing timely intervention

Participation in a qualified clinical data registry

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CPIA Capabilities

❖ Care Coordination

Timely communication of test results

Timely exchange of clinical information with patients AND providers

Use of remote monitoring

Use of telehealth

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CPIA Capabilities

❖ Beneficiary Engagement

Establishing care plans for complex patients

Beneficiary self-management assessment and training

Employing shared decision making

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Advancing Care Information

❖ Scoring based on HIT interoperability promoting

exchange and patient/caregiver engagement

❖ Flexible scoring to promote care coordination

❖ Medicare Meaningful Use

Dropped “all or nothing” threshold for measure

Eliminated Computerized Provider Order Entry (CPOE) and Clinical Decision Support (CDS)

Reduced number of required public health registries reported

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Advancing Care Information: Base Score 6 Measures

❖ Protect Patient Health Information

❖ E-Rx

❖ Patient access to EHR

❖ Care coordination with pat8ient engagement

❖ HIE

❖ Public health and clinical data

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Advancing Care Information: Performance Score

❖ Physicians select measures that fit their practice:

Patient access to EHR

Care coordination through patient engagement

HIE

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Performance Period Determinations

❖ During the performance period of a calendar year,

CMS will make eligibility determinations using data

from PECOS on a quarterly basis (if technically

feasible) to identify new Medicare-enrolled eligible

clinicians who will be exempt from MIPS

participation for the applicable performance period.

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PECOS

❖ Provider Enrollment, Chain and Ownership System

(PECOS) is an electronic Medicare enrollment

system through which providers and suppliers can:

Submit Medicare enrollment applications

View and print enrollment information

Update enrollment information

Complete the enrollment revalidation process

Voluntarily withdraw from the Medicare Program

Track the status of a submitted Medicare enrollment application

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CMS Website: MIPS Measures and Activities

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CMS Website: MIPS Measures and Activities

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CMS Website: MIPS Measures and Activities

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CMS Website: MIPS Measures and Activities

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What If I’m Not Included in MIPS

❖ Won’t be subject to a positive or negative

Medicare Part B payment adjustment in 2019

under MIPS

❖ No further action is required unless your TIN

decides to participate as a group and is above one

of the low volume thresholds

❖ Can voluntarily participate in the program

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Pick Your Pace

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Five Things to Do Now to Prepare for MIPS

❖ Educate your team or organization

❖ Estimate your MIPS score

❖ Optimize MU (ACI) and PQRS/VBM Quality to

maximize MIPS score

❖ Evaluate staff, resources and organizational

structure

❖ Focus on QI and how 2017 impacts reimbursement

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Summary

❖ MACRA greatly influenced by practice transformation

success

❖ Quality performers receive substantially higher

bonuses

❖ There is significant financial penalty

❖ Current rules are still in effect until December 2018

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What Should You Do?

❖ Fee for service payment methods are blurring and

morphing into new payment models

❖ Increased focus on accountability for total cost of

care, while maintaining quality

❖ Growing emphasis on care coordination, health IT

and patient satisfaction

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What Should You Do?

❖ Practices with a sophisticated understanding of

financial and clinical analytics will be best

positioned for evolving payment models

❖ Stay ahead of the curve and thoughtfully consider

if certain voluntary programs are right for your

practice

❖ Be aware of the changing landscape by engaging

with your PO

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What Practices Can Do Now

❖ Expect MACRA implementation to proceed

Elections estimated to have limited impact

❖ Assess your performance under current programs

Review how your group perform in PQRS and MU

Download your Quality and Resource Use Report

❖ Engage in ongoing learning about MACRA

Look to the MOA and AOA for more information and resources

Look to other sources

❖ Consider participating in a public or private value-based

payment initiative

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Assistance for PCPs

❖ Engage in evolving ‘value-based’ reimbursement

programs

❖ Review and become familiar with defined, but

limited set of quality measures

❖ POs provide transformation resources to support

development of advanced primary care capabilities

over time

❖ Focus on quality measurement and identifying costs

for the practice’s population

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MACRA Resources

❖ CMS Innovation Center

http://innovation.cms.gov/

❖ MACRA

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

http://www.aafp.org/practice-management/payment/medicare-payment/faq.html

http://waysandmeans.house.gov/UploadedFiles/HR_1470_Section_by_Section.pdf

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Failure Isn’t an Option

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Open Discussion

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