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The Quality Payment Program Update
Holly Arends, Program Manager
SDAHO
Sept 20, 208
Our Time Together
• 2017 Follow Up
• QPP Year 2, 2018‐Mainly Cost Category Focus
• QPP Year 3, 2019 Planning
This Photo by Unknown Author is licensed under CC BY‐SA
2017 Follow Ups
What we learned in 2017
• Expectations did not meet reality
• 91% Participation Rate
• Projected incentives at 2.3% came out at 2.2% for maximum points 100
• Feedback Performance Statement
• Physician Compare results will be posted later 2018
• Targeted Review by Oct 15, 2018– Data issues
– Not understand/agree the feedback
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2017 Targeted Review
• What?– A request to have CMS review MIPS EC’s 2017 adjustment factor
• Who?– MIPS EC‐ individual or group
• Recommend at level of 2017 submission
• Why?– Data issues– Eligibility issues– Reweighting– Erroneous exclusion from APM Participant list
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Physician Compare Website
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February 2014 2012 PQRS group and ACO data publicly reported
December 2014 2013 PQRS group and ACO data publicly reported
December 2015 2014 PQRS group & clinician and ACO data publicly reported
December 2016 2015 PQRS group & clinician, QCDR, and ACO data publicly reported
December 2017 2016 PQRS group & clinician, QCDR, and ACO data publicly reported
Late 2018 2017 Quality Payment Program data targeted for public reporting
Physician Compare
• First year of star rating
• Achievable Benchmark of Care (ABC™)
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Rank Groups
Select the subset of top groups
Calculate the no. of pts.
Divide the no. of pts.
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Equal Ranges Method
One Star Two Stars Three Stars Four Stars Five Stars
> Three quarters of the distance between ABC™ and lowest performance score
Three quarters of the distance between ABC™ and lowest performance score
Two quarters of the distance between ABC™ and lowest performance score
One quarter of the distance between ABC™ and lowest performance score
≥ ABC™ Benchmark
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QPP Year 2
Working to reduce burdenWorking to
reduce burden
Continue to be flexible to
prepare for full implementation
in Year 3
Continue to be flexible to
prepare for full implementation
in Year 3
• Patients Over Paperwork
• Meaningful Measures
QPP Year 2: Eligibility
IMPACTTargeted for Medium and Large Practices
•SD ‐ decreased MIPS eligible providers by nearly 50%
•National‐ 80% of MIPS EC will be in practices with 25+ providers
Raised the low volume threshold
Excluded
• Individual or group has ≤$90,000 in Part B allowed charges and/or ≤200 Part B beneficiaries
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QPP Year 2: Virtual Groups
Solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter what specialty or location)
Solo practitioners and small groups may only participate in a Virtual Group if you exceed the low‐volume threshold.
Many different scenarios Election process for 2018 ran from October 11 –December 31, 2017
Year 3 Oct –Dec 31 2018
QPP Year 2: Performance
• Threshold– Raised to 15 points‐ To avoid a negative payment adjustment, the 2018 MIPS final score must be ≥ 15
• Reporting Period– PI, IA‐min continuous 90 day period– Quality, Cost – 12 month period
• ‐5% to 0%
• Fail to report ‐5%
0 Points
• 0% up to 5%
• No Penalty
15 Points
Exceptional Performance
Bonus
70 Points
Maximum Score
100 Points
QPP Year 2: Small Practice Strategy
Quality Category‐ 50% Cost Category‐ 10% Promoting Interoperability Category‐25%
Improvement Activities Category‐ 15%
• Not able to meet the 60% data completeness requirement – 3 points are given for the measure
• No bonus or exceptions
• Apply for hardship exception
• Open from Aug 6‐ Dec 31, 2018
• https://cmsqualitysupport.service‐now.com/exception_application.do
• 2 med or 1 high weighted activities
This Photo by Unknown Author is licensed under CC BY‐NC‐ND
Bonus Points added to MIPS Final Score
If PI is reweighted, Quality = 75%; Cost = 10%; IA = 15%
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QPP Year 2: Cost Category
• Two Measures
– Total Per Capita Costs (TPCC) measure
– Medicare Spending Per Beneficiary (MSPB) measure
• Claims submission – no need to submit additional data
• Medicare Part A and B final action claims
– Inpatient hospital, outpatient hospital, SNF, HHA, Hospice, DMEPOS, Medicare Part B Carrier. Medicare Part D NOT included.
ECs in MIPS APMs subject to APM scoring NOT assessed on Cost Category
Year 2: TPCC and MSPB
Benchmarks‐ TBD, 2018 claims data
Attribution‐ At the TIN‐NPI Level
Payment Standardized
health care delivery choices
exclude geographic differences
exclude payment adjustments from special Medicare
programs.
Year 2: TPCC and MSPB
Scored on decile scale, TBD Case Minimums
TPCC‐ 20 cases
MSPB ‐ 35 cases
• If not met for either, the category weight (10%) will be reweighted to the Quality category
Scoring
1‐ 10 points for each measure, based on comparison with other MIPS ECs and groups during the performance period
Final Score
• Total points scored on each measure/Total Possible Points Available
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QPP Year 2: TPCC Measure
Evaluates overall cost of care of attributed
beneficiaries
Evaluates overall cost of care of attributed
beneficiaries
Reported at TIN or TIN‐NPI levelReported at TIN or TIN‐NPI level
Provides meaningful information about the costs associated with delivering care
to attributed beneficiaries
Provides meaningful information about the costs associated with delivering care
to attributed beneficiaries
Was used in the 2015 Value
Modifier program,
QRUR data in 2017
Was used in the 2015 Value
Modifier program,
QRUR data in 2017
TPCC Measure Structure
• Sum of the annualized, risk‐adjusted, specialty‐adjusted Medicare Part A and Part B costs across all beneficiaries attributed to a TIN‐NPI, within a TIN or TIN‐NPI (depending on the level of reporting).
• Sum of the annualized, risk‐adjusted, specialty‐adjusted Medicare Part A and Part B costs across all beneficiaries attributed to a TIN‐NPI, within a TIN or TIN‐NPI (depending on the level of reporting).
Measure Numerator
• The number of all Medicare beneficiaries who received Medicare‐covered services and are attributed to a TIN‐NPI, within a TIN or TIN‐NPI (depending on the level of reporting), during the performance period.
• The number of all Medicare beneficiaries who received Medicare‐covered services and are attributed to a TIN‐NPI, within a TIN or TIN‐NPI (depending on the level of reporting), during the performance period.
Measure Denominator
QPP Year 2: TPCC Measure : TPCC
• Methodology
– Calculation of the TPCC measure is divided into seven steps:
1. Attribute beneficiaries to TIN‐NPI, 2. Calculate payment‐standardized per capita costs, 3. Annualize costs, 4. Risk‐adjust costs, 5. Specialty‐adjust costs, 6. Calculate the TPCC measure for the TIN‐NPI or TIN,
and 7. Report the TPCC measure for the TIN‐NPI or TIN.
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Step 1: Attribution
• Primary Care Services(PCS) during the performance period are assigned to the TIN‐NPI. 2 Step process
1. Received more PCS– PCPs, PAs, NPs, CNSs at TIN‐NPI – PCPs, PAs, NPs, CNSs at CCNs
2. Received more PCS‐Non Primary Care
• PCS– E/M services– Office, other non‐inpatient, non‐emergency room settings
– Initial Medicare visits and annual wellness visits MSPB
Step 2: Calculate Payment Standardized Per Capita Costs
• Takes into accounts factors that have no bearing on costs
– Geography
–Medicare initiatives
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Step 3: Annualize Costs
$2700
Annualized costs = = $ 3600.00
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9 months__________
12 months
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Step 4: Risk Adjust Costs
• Winsorization applied• Accounts for beneficiary‐level risk factors that can affect medical costs, regardless of the care provided
• Risk Model ‐measure the influence of health status (measured by dx) on the treatment provided (costs incurred)– CMS Hierarchal Condition Category (CMS‐HCC) risk score• Summarizes each beneficiary’s expected cost of care relative to other beneficiaries
• Models for new and continuing enrollees
CMS HCC
– HCC1 HIV/AIDS – HCC2 Septicemia, Sepsis, Systemic Inflammatory Response
Syndrome/Shock – HCC6 Opportunistic Infections – HCC8 Metastatic Cancer and Acute Leukemia – HCC9 Lung and Other Severe Cancers – HCC10 Lymphoma and Other Cancers – HCC11 Colorectal, Bladder, and Other Cancers – HCC12 Breast, Prostate, and Other Cancers and Tumors – HCC17 Diabetes with Acute Complications – HCC18 Diabetes with Chronic Complications – HCC19 Diabetes without Complication
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Step 4: Risk Adjust Costs
• Compute the ratio
– TIN‐NPI observed – to – expected ratio
• Multiply the ratio by the avg non‐risk‐adjusted cost across all TIN attributed benes.
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Step 5: Specialty Adjust Costs
• Costs vary across specialty and specialty mixes
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Sample of Medical Specialists
Other PhysiciansAddiction Medicine (79)Anesthesiology (05)Allergy/Immunology (03)Chiropractic (35)Cardiac Electrophysiology (21)Diagnostic Radiology (30)Cardiology (06)Emergency Medicine (93)Critical Care (Intensivists) (81)Interventional Radiology (94)Dermatology (07)
MANY MORE ON THE CMS LIST
Step 6 & 7: Calculate and Report the Measure
• Step 6
– Calculate the numerator / denominator
• Step 7
– Attributed at TIN‐NPI, can be reported at TIN or TIN‐NPI level.
– CASE MINIMUM is 20 episodes
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QPP Year 2: MSPB Measure
• Assesses the cost to Medicare of services performed by an individual clinician during an MSPB episode, which comprises the period immediately prior to, during, and following a patient’s hospital stay.1
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QPP Year 2: MSPB Measure
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Assesses the cost to Medicare of
services performed by an
individual clinician during an MSPB episode
Assesses the cost to Medicare of
services performed by an
individual clinician during an MSPB episode
Reported at TIN or TIN‐NPI level
Reported at TIN or TIN‐NPI level
Measure attributed
to individual clinician
Measure attributed
to individual clinician
Uses Medicare Part A and B claims data
Uses Medicare Part A and B claims data
MSPB Measure Structure
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• Sum of the ratio of payment‐standardized observed to expected MSPB episode costs for all MSPB episodes for the TIN‐NPI or TIN. The sum of the ratios is then multiplied by the national average payment‐standardized observed episode cost, to convert the ratio to a dollar amount.
• Sum of the ratio of payment‐standardized observed to expected MSPB episode costs for all MSPB episodes for the TIN‐NPI or TIN. The sum of the ratios is then multiplied by the national average payment‐standardized observed episode cost, to convert the ratio to a dollar amount.
Measure Numerator
• Total number of MSPB episodes for the TIN‐NPI or TIN
• Total number of MSPB episodes for the TIN‐NPI or TIN
Measure Denominator
QPP Year 2: MSPB Measure
• Methodology
– Calculation of the MSPB measure is divided into seven steps:
• 1) Define the population of index admissions,
• 2) Calculate payment‐standardized episode costs
• 3) Calculate expected episode costs
• 4) Exclude outliers
• 5) Attribute episodes to a TIN‐NPI
• 6) Calculate the MSPB measure for the TIN‐NPI or TIN
• 7) Report the MSPB measure for the TIN‐NPI or TIN The
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Step 1: Define the Population
3 days priorHospital Admission
30 Days Post Discharge
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Care Coordination
Step 2: Calculate Payment Standardized Per Capita Costs
• Takes into accounts factors that have no bearing on costs
– Geography
–Medicare initiatives
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Step 3: Calculate Expected Episode Costs
• CMS Hierarchal Condition Category
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Step 4: Exclude Outliers
• Winsorization at the 0.5th percentile
• Renormalize the costs
• Exclude
– residuals that fall above the 99th percentile or below the 1st percentile
• Renormalize again
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Step 5: Attribute Episodes to TIN‐NPI
• Each MSPB episode is attributed to the TIN‐NPI responsible for the plurality of Part B Physician/Supplier services during the index admission
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Step 6 & 7: Calculate and Report the Measure
• Calculated for each TIN‐NPI or TIN by
– (i) calculating the ratio of standardized observed episode costs to winsorized expected episode costs and
– (ii) multiplying the average cost ratio across episodes for each TIN‐NPI or TIN by the national average episode cost.
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This Photo by Unknown Author is licensed under CC BY‐SA
2018 Alternative Payment Models (APM)
• Second path to Value Based healthcare
• Qualified Participants (QP) annual 5% incentive (2019‐2024)
• Exempt from MIPS
• 2026‐ accrue a higher annual Part B PFS increase of 0.75%
– 0.25% other clinicians
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List of APMs
• 39 APMs
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Advanced APMs
Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)
Comprehensive Primary Care Plus (CPC+) Model
Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 ‐ CEHRT)
Medicare Accountable Care Organization (ACO) Track 1+ Model
Comprehensive ESRD Care (CEC) Model (LDO arrangement)
Medicare Shared Savings Program Accountable Care Organizations —Track 2
Comprehensive ESRD Care (CEC) Model (non‐LDO two‐sided risk arrangement)
Medicare Shared Savings Program Accountable Care Organizations —Track
Next Generation ACO Model Oncology Care Model (OCM) (two‐sided Risk Arrangement)
Vermont Medicare ACO Initiative (as part of the Vermont All‐Payer ACO Model)
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QPP YEAR 3:PROPOSED RULECOMMENTS CLOSED 10 SEPT 2018EXPECT FINAL RULE IN NOV‐DEC 2018
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This Photo by Unknown Author is licensed under CC BY
QPP Year 3 Proposed
• Eligibility– New eligible clinicians types
• physical therapists, occupational therapists, clinical social workers, and clinical psychologists
• 3rd element to low volume threshold– Dollar Amount ($90,000)
– Number of Beneficiaries (200)
– Number of Covered Professional Services (200)
– If ECs exceed one or two elements
• Opt‐in to MIPS if they meet or exceed one or two, but not all, of the low‐volume threshold criteria
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QPP Year 3 Proposed
• CMS Projections:
– 650,000 MIPS ECs ↑ 50K from 2018
– 200,000 AAPM Qualified Participants
• Current projections
– Max 2.0% to 5.7% incentive
– Max ‐5% penalty
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QPP Year 3 Proposed
• CEHRT 2015 version • Payment adjustments
– ONLY covered Prof Services paid under or based on PFS
• Low Volume Threshold– based on allowed charges for covered professional services and the number of covered professional services furnished to patients.
• Cost Category 15%• Performance Threshold 30 points• Exceptional Performance 80 points• Quality Reporting Period remains at 365 days
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QPP Year 3 Proposed
• Promoting Interoperability– Eliminated the base score + performance
• One scoring scale, simplified• Impact‐ score on 10 point scale, base score had lower thresholds and gave you 50 points
GET READY FOR HIE MEASURES!!!!– All measures are required to be reported to score higher than 0
– Yes/No measures – must report YES– SRA is still required‐ not on formal scorecard– CEHRT 2015 required
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QPP Year 3 Proposed
• What could impact your 2019 score?
– Opt‐in: ↑ in your MIPS ECs
– New eligible professions: ↑ MIPS ECs
– Promoting Interoperability: HIE Measures
– 2015 CEHRT required
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QPP Year 3: Planning
Identify additional eligible clinicians, hospital based
Identify those eligible clinicians that could Opt‐In
Calculate cost benefit analysis of additional eligible clinicians
QPP Year 3: Planning
• CEHRT Vendor Contact‐ schedule upgrade to 2015
• Low volume threshold group and individuals
• Review Quality Measures (10 new 34 removed)performance and focus in on areas for improvement
• Review performance on PI measures
• Review costs going back a couple years‐ plot those costs, analyze
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QPP Year 3: APMs
• 75% of ECs using CEHRT
• All‐Payer Combination Option and Other Payer Advanced APMs for non‐Medicare payers‐ flexibility and expansion
• Medicare Advantage MIPS‐exclusion Demonstration (MAQI) – contract with MA payer meets AAPM and total $ at risk is large enough (25%)
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Technical Support
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Questions and Discussion
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THANK YOU
Holly Arends
605.660.5436
Holly.arends@area‐a.hcqis.org
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