macra - robert hall

MACRAQuality Payment Programs

Sustainable Growth Rate2002-2015

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MACRA Timeline

• MACRA enacted: April 16, 2015• Request For Information: October 2015• Proposed Rule released: April 27, 2016

– 60-day comment period• Final Rule released: October 14, 2016

*Medicare physician fee schedule published separately

Materials herein reflect public law 114-10 dated April 16, 2015

MACRA Timeline2017 2018 2019 2020 2021 2022-2024 2025 2026

Medicare Part B Baseline Payment Updates

+0.5% +0.5% +0.5% 0% 0% 0%+0.25%*

+0.75%**

*Non-qualifying APM Conversion Factor**Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)PQRS, Value-based

Modifier, & Meaningful Use Quality, Cost, Advancing Care Information, & Improvement Activities

-9% -9%? 0 or +/-4%*“Pick Your Pace” +/-5% +/-7%

Qualifying APM Participant5% Incentive payment

Excluded from MIPS

+0%

+/-9%

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Medicare Physician Payments 2017 to 2020

2015 Performance Year – PQRS, VBM, MU

• 2017 Payment Year [-9%]

2016 Performance Year – PQRS, VBM, MU

• 2018 Payment Year [-9%]

2017 Performance Year – MACRA Pick Your Pace

• 2019 Payment Year [0 to +4%]

2018 Performance Year – MACRA QPP

• 2020 Payment Year [+/- 5%]

MACRA Quality Payment Program Payment Pathways

Merit-Based Incentive Payment System (MIPS)

Advanced Alternative Payment Models (AAPM)

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Who May/Must Participate

Physicians (MD/DO)

Physician Assistant

Nurse Practitioner

Clinical Nurse

Specialist

Certified Registered

Nurse Anesthetist

MACRA defines eligible clinicians as:

*You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as established by the law.

Merit-Based Incentive Payment System

(MIPS)

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Consolidates Quality & Value Programs

• Physician Quality Reporting System

• Value Based Payment Modifier

• Meaningful Use MIPS

MU

VBPMPQRS

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Establish Final Score

Quality Cost Improvement Activities

Advancing Care

Information

Weighting by Category - 2017

Quality; 60%Improvement Activi-

ties1, 15%

Advancing Care In-formation; 25%

1 - “Certified” PCMH receives the full 15 points for CPIA; APM Participants receive half credit

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MACRA Timeline2017 2018 2019 2020 2021 2022-2024 2025 2026

Medicare Part B Baseline Payment Updates

+0.5% +0.5% +0.5% 0% 0% 0%+0.25%*

+0.75%**

*Non-qualifying APM Conversion Factor**Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)PQRS, Value-based

Modifier, & Meaningful Use Quality, Cost, Advancing Care Information, & Improvement Activities

-9% -9%? 0 or +/-4%*“Pick Your Pace” +/-5% +/-7%

Qualifying APM Participant5% Incentive payment

Excluded from MIPS

+0%

+/-9%

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‘Pick your Pace’ Options for 2017Test

• Submit some data to QPP

• No adjustment

Partial Participation• Report part

of the year• Small

positive adjustment

Full Participation• Report full

year• Modest

positive adjustment

Advanced APM

• Qualifying Program & Eligible Clinician

• 5% incentive payment

NO NEGATIVE PAYMENT ADJUSTMENTS

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Data Submission

• Physicians participating in the MIPS pathway must submit quality, advancing care, and clinical practice improvement activity data to CMS by March 31, 2018. Physicians participating in an Advanced Alternative Payment Model also must submit data by March 31, 2018.

• If you do not submit 2017 data by the March 31, 2018 deadline, you will receive a negative 4% payment adjustment in 2019.– Report as an individual – if you submit MIPS data as an individual, your payment

adjustment will be based on your performance. An individual is defined as a single NPI tied to a single TIN.

– Report as a group – if you submit MIPS data as a group, then the group will get one payment adjustment based on the group’s performance. A group is defined as a set of physicians and other clinicians, identified by their NPIs, sharing a common Tax Identification Number or TIN.

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Exemptions

• Year 1 Medicare• Eligible Advanced Alternative Payment Model with Bonus• Below low volume threshold

– Less than or equal to $30,000 Medicare payments; or less than or equal to 100 Medicare beneficiaries

Alternative Payment Models

(APMs)

DefinitionsQualifying APM• Based on existing payment models

Advanced APM• Based on criteria of the payment model

Qualifying APM Participant• Based on individual physician payment or patient

volume

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Advanced APMs• Shared Savings Program (Tracks 2 & 3)• Next Generation ACO Model• Comprehensive Primary Care Plus (CPC+)• Comprehensive ESRD Care (CEC) (large dialysis

organization arrangement)• Oncology Care Model (OCM)• All other APMs that meet criteria for the APM scoring

standard

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Additional Rewards for Qualifying Participants

• Not subject to MIPS• 5% bonus 2019-2024• Higher fee schedule update 2026

QPAdvanced APM

Medical Home

Materials herein reflect public law 114-10 dated April 16, 2015

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Medical Home Criteria

• A Medical Home Model as an APM entity is required to have the following elements: • A primary care focus consisting of primary care or

multispecialty practices with primary care physicians and practitioners that offer primary care services.

• Empanelment of each patient to a primary clinician.

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Medical Home Criteria

• A Medical Home Model also must have at least four of the following additional elements:

• Planned coordination of chronic and preventive care• Patient access and continuity of care• Risk-stratified care management• Coordination of care across the medical neighborhood• Patient and caregiver engagement• Shared decision-making• Payment arrangements, in addition to, or substituting for fee-for-service

payments (for example, shared savings, population-based payments) 

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Medical Home Recognition

• Recognized certification organizations expanded to include state-based, regional or state programs, private payers, or entities that administer patient-centered medical home accreditation to at least 500 practices.

• If one practice under the TIN has PCMH recognition, then the entire TIN will qualify for full points within the improvement activities category.

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Impact on Solo/Small Practices

• CMS estimates that at least 80% of physicians  in small and solo practices with one to nine physicians  will receive a positive or neutral MIPS payment adjustment in 2019.

What Can I Do Right Now?

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Test•Report something

Partial Participation

•Report 90 days

Full Participation

•Report Full Year

Advanced APM

• MSSP (Tracks 2 & 3)

• Next Gen ACO

• CPC+

‘Pick Your Pace’

There is Help Available

• Find a PTN– Go to aafp.org/tcpi

– Click “Find a PTN” to find a practice transformation network in your area

– Email tcpi@aafp.org with any questions.

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