317-kcnpnm macra mips apms conference...î l î ñ l î ì í õ ð 48$/,7< 0($685(6 • 4xdolw\...

$: 317-KCNPNM MACRA MIPS APMs Conference...î l î ñ l î ì í õ ð 48$/,7< 0($685(6 • 4XDOLW\ 3D\PHQW 3URJUDP ZHEVLWH KWWSV TSS FPV JRY PLSV H[SORUH PHDVXUHV TXDOLW\ PHDVXUHV •$
2/25/2019

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MACRA, MIPS & APMSDR. ELISABETH VOLPERT DNP, APRN, FNP-C

FIRST THING IS FIRST

• I Have No Disclosures

OBJECTIVES

• Explain the definition and purpose of value-based reimbursement:

• The Medicare Access and CHIP Reauthorization Act (MACRA)

• Merit-Based Incentive Payments System (MIPS)

• Alternative payment models (APMs)

• Explain who value-based reimbursement applies to.

• Explain the 2019 updates.

• Explain how to increase reimbursement by meeting benchmarks.

• Clinical workflows shown to aid providers in achieving benchmarks.

• Explain alternative office visits that can increase reimbursement, improve outcomes and achieve

benchmarks.

TERMS

• APM – Alternative payment models

• CMS – Centers for Medicare and Medicaid Services

• EHR – Electronic Health Record

• MACRA - Medicare Access and CHIP Reauthorization Act

• MIPS - Merit-Based Incentive Payments System

• MU – Meaningful Use

• PFS – Physician Fee Schedule

• PQRS - Physician Quality Reporting System

• QP - Qualifying APM Participant

• SGR – Sustainable Growth Rate

• VM - Value-Based Payment Modifier

A STROLL DOWN MEMORY LANE

• Late 1950’s 75% Americans had private insurance• AMA was against national health insurance

• 1965 Medicare Part A &B• Fear physicians would decline to see pt with this coverage

• Development of fee for service

• 1973 HMO• Fee for service, increase procedures and decrease preventative care

• 1997 Sustainable Growth Rate (SGR)• Restrict Medicare Part B

• April 16,2015 MACRA • CMS named the physician payment system created by MACRA the Quality Payment Program (QPP)

CMS’ Program History. Centers for Medicare and Medicaid Services. June 2018. https://www.cms.gov/About-CMS/Agency-Information/History/index.html

A STROLL DOWN MEMORY LANE

• 2015- The Medicare Access and CHIP Reauthorization Act terminated the Sustainable Growth

Rate (SGR) formula.

• If SGR would have continued it would have resulted in significant payment reductions for clinicians

participating in Medicare. CMS’ Program History. Centers for Medicare and Medicaid Services. June 2018. https://www.cms.gov/About-CMS/Agency-Information/History/index.html

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MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT (MACRA)

• The Department of Health & Human Services established a goal to convert from fee-for-

service Medicare payments to value-based payment models.

• A form of reimbursement that links payments for care to the quality of care provided.

• Incentivizes providers with rewards providers for both efficiency and effectiveness of care.

MACRA. Centers for Medicare and Medicaid Services. September 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

SO WHAT IS MACRA?

• Quality Payment Program that:

• repeals the SGF

• changes the way that Medicare rewards clinicians for value over volume

• streamlines multiple quality programs under the new MIPS

• gives bonus payments for participation in eligible APMs

MACRA. Centers for Medicare and Medicaid Services. September 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

MACRA’S GOAL

• CMS Center for Clinical Standards and Quality Director, Kate Goodrich, MD, stated MACRA’s goal:

“To have a single, unified program with flexibility. The new Merit-Based Incentive Payment System

(MIPS) will offer that flexibility and not be a one-size fits all program. The new rule will reimburse

physicians based on four factors.”

MACRA GOALS

• Improve patient outcomes and reduce overall costs the healthcare system.

• Expect in 2019 to:

• Reduce administrative costs by $87 million

• $843 million over the next 10 years

• Save 21 million clinician hours

CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-

what-you-need-know

MACRA REQUIRES CMS TO IMPLEMENT AN INCENTIVE PROGRAM

• MIPS

• a performance-based payment adjustment

through MIPS

• Most participate

• Reduce costs of care and/or support

high-value services

• Not typically covered under the Medicare

fee schedule (APMs)

• APMs

• earn a Medicare incentive payment for

sufficiently participating in an innovative

payment model

MACRA. Centers for Medicare and Medicaid Services. September 2018.

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

Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-

MIPS-and-APMs.html

WHO CAN PARTICIPATE IN QUALITY PAYMENT PROGRAMS

• Nurse Practitioners

• Some Physicians

• Physician Assistants

• Clinical Nurse Specialist

• Certified Registered Nurse Anesthetists

• Physical Therapist

• Occupational Therapist

• Speech Therapist

• Audiologist

• Clinical psychologist

• Registered dietitian or nutritional professionals

CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-

final-2019-mips-rules-are-here-what-you-need-know

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WHO IS IN

Bill more than $90,000 a year in allowed charges for covered professional services.

Provide care to 200 of fewer Medicare beneficiaries a year

Provide 200 or fewer covered professional services under the PFS

Low-volume threshold criteria. CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-

know

WHO IS OUT

• If you do not exceed all three you are excluded from MIPS. • You have the opportunity to “opt-in” if you meet or exceed one or two of the low-volume threshold

criteria.

or or

CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-know

Enrolled in Medicare for the first time in 2018

Participate in an APM and a QP

Participate in an APM and are a Partial QP

AM I IN OR OUT?

• To verify if you’re eligible to participate in MIPS, enter your 10-digit National Provider

Identifier in the status tool at:

https://qpp.cms.gov/participation-lookup

MIPS EHR incentive

Program

VM

PQRSMIPS

4 MIPS AREAS

• Quality (45%)

• Promoting Interoperability (25%)

• Cost (15%)

• Improvement activities (15%)

MACRA Basics Merit-based Incentive Payment System (MIPS). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/mips.html

MIPS PERFORMANCE MEASURES

• Quality• 6 measures to submit.

Example: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

• 12 months

• Promoting Interoperability• Example: Electronic prescribing, MU

• 90 days

• Cost• No submission required

• 12 month

• Clinical practice improvement activities • Example: Care coordination

• 90 days MACRA Basics Merit-based Incentive Payment System (MIPS). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-

management/payment/medicare-payment/mips.html

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QUALITY MEASURES

• Quality Payment Program website

https://qpp.cms.gov/mips/explore-measures/quality-measures

• Changes for 2019

• 8 new quality measures

• 26 measures removed

MIPS REPORTING

• January 1, 2019 to December 31, 2019

• Submit March 31, 2020

• Feedback July 2020

• Adjustment January 1, 2021

SCORE

0-----10-----20-----30-----40-----50-----60-----70-----80-----90-----100

78.72


HOW MUCH IS PAYMENT ADJUSTED

• 2019 +/- 4%

• 2020 +/- 5%

• 2021 +/- 7%

• 2022 +/- 9%


APM

• Another payment model to replace fee-for- services

• Larger organizations - have the infrastructure and resources to implement change

• To qualify as an eligible Advanced APM:

• Use of certified EHR technology

• Base payment must be based on quality measures (comparable to MIPS)

• There also needs to be financial risk

• or operate as a medical home (meeting CMS criteria)

MACRA Basics Advanced Alternative Payment Models (AAPMs). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/aapms.html

QUALIFYING APM PARTICIPANTS

• Clinicians meeting the criteria for this track are excluded from MIPS.

• Receive a lump sum bonus payment of 5% 2019-2024

• Receive a high fee schedule


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PARTIAL QUALIFYING APM PARTICIPANTS

• Meet a reduced threshold

• Participants can choose whether or not to participate in MIPS


WHO IS IN FOR APMS

• Organizations that are automatically qualified to APMs:

• Comprehensive ESRD Care Model

• Medicare Shared Savings Program -Track 2 and 3

• Next Generation ACO Model

• Comprehensive Primary Care Plus (CPC+):

• Oncology Care Model Two-Sided Risk Arrangement


SUMMING UP SO FAR

• MACRA

• MIPS vs APM

• More types of clinicians will need to report

• Opt-in and opt-out

• New measures

• Increase in penalties for clinicians who do not report or fail to meet minimum threshold (30 points)

• Increase payment adjustments

SO WHY?

WHAT IS NEXT

• New Value-Based Bundled Payment Model

• Announced in January 2018, and will be from October 1, 2018 through December 31, 2023.

• Participants can earn additional payments

• Bundled payments for additional clinical episodes

• outpatient episodes

• Preliminary target prices

• The amount CMS will pay for episodes of care under the model

• Participants assume risk for patients’ healthcare costs

• If ALL expenditures for a beneficiary’s episode of care are less than a spending target

• If the expenditures exceed the target price, the participant must repay money to Medicare

CMS Announces Participants in New Value-Based Bundled Payment Model. Centers for Medicare and Medicaid Services.

October 2018. https://www.cms.gov/newsroom/press-releases/cms-announces-participants-new-value-based-bundled-

payment-model

HOW DO I SUCCEED

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HOW CAN WE IMPROVE OUTCOMES

• Controlled High Blood pressure

• Proper assessment

• Logs

• Shorter follow up


• Hemoglobin A1C Control (<9%)

• Chart audit

• Shorter follow up

• Portal or telephone messages


• Colorectal Cancer Screening & Breast Cancer Screening

• Chart audit

• Cologuard and FIT

• Permanent deferral


• Influenza Immunization & Pneumonia Vaccination

• Chart audit

• Patient immunization cards in exam rooms

• Permanent deferral


• Diabetic Eye Exam

• Falls Screening

• BMI Screening and Follow Up

HOW MANY CLICKS ARE TOO MANY?

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DOES IT REALLY MATTER?

• Payment is there!

• Linked to NPI

REFERENCES

CMS’ Program History. Centers for Medicare and Medicaid Services. June 2018. https://www.cms.gov/About-CMS/Agency-Information/History/index.html

MACRA. Centers for Medicare and Medicaid Services. September 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-know

Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-know



CMS Announces Participants in New Value-Based Bundled Payment Model. Centers for Medicare and Medicaid Services. October 2018. https://www.cms.gov/newsroom/press-releases/cms-announces-participants-new-value-based-bundled-payment-model

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