flexibility & the macra final rule - greenway...

FLEXIBILITY & THE MACRA FINAL RULECompliance & Opportunity for Your Practice

MACRA

Overview ................................................................................................................................. 5What’s new ............................................................................................................................. 5

Advancing Care Information ..................................................................................................... 8Major changes ........................................................................................................................ 9Proposed rule vs. final rule snapshot .................................................................................. 9What’s coming in the future ................................................................................................ 10

Quality ....................................................................................................................................... 12Major changes ...................................................................................................................... 13Proposed rule vs. final rule snapshot ................................................................................ 14What’s coming in the future ................................................................................................ 14

Cost/Resource use .................................................................................................................. 16Major changes ...................................................................................................................... 17Proposed rule vs. final rule snapshot ................................................................................ 17What’s coming in the future ................................................................................................ 18

Clinical Practice Improvement Activities (CPIA) ................................................................... 20Major changes ...................................................................................................................... 21Proposed rule vs. final rule snapshot ................................................................................ 21What’s coming in the future ................................................................................................ 21

Reporting Methods and the 2017 Transition Year .................................................................. 22Major changes ...................................................................................................................... 23Proposed rule vs. final rule snapshot ................................................................................ 23What’s coming in the future ................................................................................................ 23Impact summary .................................................................................................................. 10

Advanced Alternative Payment Models and MIPS APMs ..................................................... 24Major changes ...................................................................................................................... 25Proposed rule vs. final rule snapshot ................................................................................ 25What’s coming in the future ................................................................................................ 26

Acronyms ................................................................................................................................. 28Useful charts and measures .................................................................................................. 30

Advancing Care Information: 2017 Transition Year ........................................................... 31Advancing Care Information: 2018...................................................................................... 31Episode-based measures ................................................................................................... 32Group Reporting Data Submission Mechanisms .............................................................. 33Data submission mechanisms for individual ECs ............................................................. 33

Additional resources ............................................................................................................... 32

CONTENTS

OVERVIEW

OVERVIEWOn Friday October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released the Final Rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The final rule defines the parameters of the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs), collectively referred to as the Quality Payment Program (QPP). The purpose of this overview is to help physicians and managers better understand the ways in which MACRA will change their practice. The largest final rule benefit for practices is increased flexibility.

Through MACRA’s scoring categories, Quality, Cost/Resource Use, Advancing Care Information (ACI), and Clinical Practice Improvement Activities (CPIA), practices are more responsible than ever for their financial health. But it doesn’t have to be a scary transition.

What's newThe changes from proposed to final rule of MACRA offer clients more flexibility for the first two years of participation. Overall, providers have more time to prepare, alter their workflows, and implement the technologies required under the program. CMS has released a series of provisions for 2017 in order to assist with this transition.

In addition to providing eligible clinicians (ECs) new reporting options and tracks, CMS has offered up multiple changes to each individual category. Each one is broken down below.

Small practice impact

A small practice is an organization with 15 or fewer ECs. The final rule provides small practices with increased support and flexibility. CMS is allocating $20 million per year over the next five years for technical assistance, resources, and learning opportunities. The Government Accountability Office (GAO) is also considering allowing small practices to pool financial risk with one another as groups. Finally, the final rule reduces some reporting requirements for small practices, notably in the CPIA category.

Understanding MACRA’s final rule presents significant opportunities for practices to organize compliance and drive profitability with new systems. Learning is the first step.

ADVANCING CARE INFORMATION

ADVANCING CARE INFORMATIONAdvancing Care Information (ACI) is the new form of Meaningful Use (MU), and measures the steps a practice takes to support improved patient engagement and connectivity through the use of health IT. It aims to reduce the reporting burden on practices by streamlining the old reporting guidelines under MU to now focus on interoperability and patient engagement, and reducing the number of required measures overall. ACI is made up of three different scoring elements: the base score, the performance score, and the bonus score.

Over 13,000 Greenway providers successfully attested for meaningful use, earning $23 million in incentives

The base score is worth 50 points, and requires that an EC simply report a 1 or Yes to the numerators of the required measures. You must pass the base score or you will receive a 0 for the base score. Some measures also have a performance score, and the more patients you impact, the higher that score will rise. Finally, you can receive a bonus score for connecting to different types of registries or by using health IT to deliver Clinical Practice Improvement Activities.

Major changesOverall, the changes to Advancing Care Information (ACI) are designed to give providers more flexibility in choosing what technologies and processes to use in order to be considered a “meaningful user of EHR.” CMS changed how the base score is calculated by reducing the number of required measures from 11 to 5, significantly changing the weight of public health reporting objectives. They have also added a bonus to your ACI score if you engage in CPIA activities supported by CEHRT.

Changes to the base score

There are now 5 required measures, compared to the 11 in the proposed rule. To get the base score, you only need to report a “1” as the numerator for Electronic Prescribing or a “Yes” for Security Risk Analysis. Security risk analysis and electronic prescribing were kept as required measures to promote the protection of health information and to fulfill legal requirements, respectively. Electronic prescribing is not being given a weight in the performance

score due to providers’ historical success in meeting the measure. This is similar to CMS’ reasoning for excluding CPOE and CDS under the proposed rule. The total number of required measures were also reduced for the initial 2017 performance period.

2017 REPORTING MEASURES 2018 REPORTING MEASURES

Security Risk Analysis Security Risk Analysis

Electronic Prescribing Electronic Prescribing

Provide Patient Access Provide Patient Access

Health Information Exchange Send Summary of Care

Request/Receive Summary of Care

Overall, CMS considers these measures to be the basic requirements for promoting patient engagement and interoperability. Due to the reduction in required measures and the elimination of minimum thresholds to meet the base score, CMS has largely done away with exclusions, particularly for the performance measures. This applies to measures that are used for both the base score and performance score, because a practice only needs to report a “1” in the numerator for those measures to reach the base score.

Interoperability changes

CMS has continued to promote interoperability, highlighted by the fact that sending and receiving summaries of care will be a required measure in 2018. Due to the difficulties many providers have faced when connecting to public health registries, CMS has made public health reporting optional.

Greenway Health connects to over 40 state immunization registries

Immunization registry connections are no longer part of the base score, and are now valued as a 10% performance score. Under the proposed rule, specialty registry connections and other public health reporting registry connections only gave providers a 1% bonus to their score. Due to the difficulty and time for connecting with these registries, CMS has decided to increase that bonus to 5% under the final rule.

Advancing Care Information

ACI and CPIA

If a client reports on Clinical Practice Improvement Activities (CPIA) that are supported by CEHRT functionality, they can receive up to a 10% bonus to their ACI score. CMS implemented this change to further promote the use of Health Information Technology (HIT), specifically around functionality that promotes patient engagement, access, and interoperability.

For example, to provide patients with 24/7 access, a practice may use a secure messaging portal to provide a patient with clinical advice. This would satisfy the requirement for being awarded the CPIA bonus to their ACI score. However, the documentation and thresholds required were not indicated in the final rule. CMS has stated that it will be possible to report on these activities manually through a calculation or report, due to the fact that many EHRs do not track the relationship between an activity and EHR usage. The purpose behind CMS’s requirement is to ensure providers have a documented record demonstrating that these activities reached a significant number of patients.

ACI Reporting

ACI did not significantly change its reporting methodologies from the proposed rule. For reference, providers may report by:

• Qualified registry

• EHR

• QCDR

• Attestation

• A CMS web interface

In 2017, providers may report using CEHRT 2014, CEHRT 2015, or a mix of the two.

If a provider uses 2014 CEHRT, they will report on objectives derived from Modified Stage 2. If a provider uses 2015 CEHRT they may report on ACI objectives derived from Stage 3, the Modified Stage 2 objectives, or a mix of the two.

What’s coming in the future

AACI will be subject to new evaluations over time. CMS will consider scoring, benchmarking, and the importance of the measures as they relate to promoting patient outcomes when offering up changes.

CMS is looking for guidance in developing new measures around interoperability. There will be a request for new kinds of interoperability measures within the next few months. They will also look at reporting on use cases, like using CEHRT to manage referrals and consultations to “close the referral loop.” They also want to see how they can measure interoperability for specialties in non-office settings.

In addition, CMS is looking for feedback on two items that impact health IT vendors. CMS is asking for suggestions on how workflow disruption using CEHRT can be measured for the purpose of health IT specifications and regulations. They will also soon be issuing sub-regulatory guidance to EHR vendors on how to technically submit data under the new program.

Proposed rule vs. final rule snapshotPROPOSED RULE FINAL RULE

Required measures 11 5

Immunization registries Required 10% performance score

Specialty registries (2017) 1% bonus 5% bonus

Other public health reporting 1% bonus 5% bonus

Performance bonus to ACI for using CEHRT to support CPIA activities 0% 10%


1,304

vendor systems

connected

21.8 million

messages per month

14,306

connections nationwide

Greenway Stats

QUALITY

QUALITYQuality replaces PQRS in 2017 and focuses on quality measure reporting.

Major changesQuality had two major changes under the final MACRA rule. Due to practice feedback, it eliminated the requirement that ECs select a “cross-cutting measure,” and it lowered the data completeness requirements for submitting on any particular Quality measure.

Cross-cutting measures no longer required

Under Quality, CMS sought to give specialists more flexibility by eliminating the cross-cutting measure requirement, due to many specialties claiming the proposed measures weren’t applicable to them. A cross-cutting measure was defined as a measure that was broadly applicable across different clinical settings. However, after 2017, full participation still means providers must select six Clinical Quality Measures Basics (CQMs) or one specialty-specific measure set. Additionally, providers must report on at least one outcomes measure, and if not available, another high priority measure. High priority measures include:

Data completeness

Practices may report CQM data through a number of options, including a Qualified Clinical Data Registry (QCDR) or through EHR reporting (such as a QRDA file). Originally, practices were required to have at least 90% data completeness in 2017. In other words, the practice had to have data on 90% of patients using any specific measure, including Medicare and non-Medicare patients.

For 2017, this requirement is reduced to 50% and will be adjusted to 60% in 2018. The reduced requirement is meant to decrease the administrative burden on ECs.

What's coming in the future

The most impactful change will be the continued addition of new quality measures to suit more varied clinical settings. CMS may reintroduce cross-cutting measures as more are added to the list of MIPS quality measures. CMS will also be asking for new specialty measure and measure set ideas going forward. In the immediate future, there will be a request through the National Quality Forum’s Measure Applications Partnership.

CMS has set out certain preferences for new quality measures, such as outcomes measures being preferred over process measures. In selecting new measures, CMS will prefer ones that:

• Do not fit under an existing measure

• Are beyond the concept phase and have started testing

• Have data submission mechanisms beyond just claims

• Identify appropriate use of diagnosis and therapeutics

• Address the domain for care coordination

• Address the domain for patient and caregiver experience

• Address the effectiveness, cost and utilization of healthcare resources

• Address a performance or measurement gap

The continued addition of quality measures offers providers new flexibility. Emphasis on broadening specialty measure sets presents a level of choice providers haven’t had before. This especially benefits specialties not involved with managing common chronic conditions.


Required measures 6, with a minimum of one outcomes measure and one cross-cutting measure. Another high priority measure if an outcomes measure is unavailable..

6, no requirement for a cross-cutting measure. Outcomes measure is still required, or another high priority measure if an outcomes measure is unavailable.

Data completeness 90% 50% in 2017, 60% in 2018

Quality

Outcomes Patient Experience

Patient Safety Care Coordination

Cost Appropriate Use

COST/RESOURCE USE

COST/RESOURCE USECost/Resource Use replaces the Value Based Modifier from previous reporting years, but will not impact MIPS reporting in 2017. There is no additional reporting necessary under Cost/Resource Use, as CMS will simply be looking at claims data.

Major changesCost experienced changes in its weight for 2017. In the proposed rule, the weight was 10%. For 2017, it is set at 0%. Many practices noted that some cost measures were too new to use them for payment adjustments. The final rule reflects this by giving providers more time to adjust to this scoring category, looking at 2017 as a sort of trial run.

Initially the proposed rule included over 40 episode-based measures. While these have all been tested for reliability, many of them had never been used for payment purposes. Practices noted that providers should have more time to see how performance on these measures would impact their reimbursement. In response, CMS decided to reduce the number of episode-based measures to 10, all of which had been reported on previously in QRUR reports.


CMS will continue to develop and refine cost measures in the future. Under the final rule, cost will increase to 10% for the 2018 performance period. In the 2019 performance period, it increases to 30%, which is required by the statute and only subject to change by Congressional action.

Traditionally, providers only receive QRUR reports twice a year, which does not present much insight into performance over the course of a given year, meaning this may be one of the harder categories in which to excel. Practices should find it easier to participate in the program in 2018 because of the current opportunity to observe how the measures impact them before being held accountable to those measures.


Scoreing weight in 2017 10% 0%

Number of episode-based measures Over 40 10

Cost/Resource Use

CLINICAL PRACTICE IMPROVEMENT ACTIVITIES (CPIA)

Getting Started | 15

Clinical Practice Improvement Activities is a new category for MIPS, and focuses on things such as achieving health equity, population management, care coordination, and expanded practice access. It’s designed around improving and expanding patient care. Rooted in the Patient-centered Medical Home’s history, it looks at processes and clinical changes at the practice level that can improve patient outcomes and control costs.

Major changesCPIA also went through significant changes in the Final Rule. CMS reduced the number of activities required to achieve the highest score and lowered that requirement even further for small practices. They will also provide a bonus score to ACI for using CEHRT to support CPIA activities and expand the definition of a Patient-Centered Medical Home for the purpose of PCMH scoring.

New CPIA scoring

In the proposed rule, an EC could receive up to 60 points for completing different activities. These points are made up of “high priority” activities that are worth 20 points, and “medium priority” activities that are worth 10 points. CMS reduced the number of points required to 40, while keeping the weights for activities the same. Now, a practice only needs to complete two high priority activities, four medium priority activities, or a mix of the two to reach the intended score. Additionally, small practices currently only need to earn 20 points to top out their CPIA score, but those requirements will be increased in the future.

The reduced number of measures gives the medical community time to adjust. Small practices, rural practices, and HSPAs received extra consideration because they are traditionally thinner on resources and staffing.

Expanding the meaning of PCMH for CPIA

The definition of a Patient-Centered Medical Home (PCMH) has expanded under CPIA, and they all automatically receive the maximum score. Originally, a PCMH designation was limited to certain private organizations, such as the National Committee for Quality Assurance (NCQA). Under the final rule, CMS has expanded this definition to include those receiving certification from not only national organizations, but also regional or state programs or other bodies that administer accreditation and have 500 or more participating entities.

Reweighted activities

CMS also reweighted several activities to further promote them. Participation in an RHC, HIS or FQHC is now designated as a high weighted activity. Similarly, participating in volunteer activities is also now weighted as high. These two activities were reweighted because of the time involved for each provider to complete them.

CLINICAL PRACTICE IMPROVEMENT ACTIVITIES (CPIA)

CPIA

2,000

Greenway Health providers participate in

PCMH

3

products with NCQA PCMH Recognition Auto-

credits

Greenway Stats

16 | Assessing and Selecting MU Measures CPIA


Maximum number of points, number of activities

60 points. Three high priority activities, six medium priority activities, or a mix of the two

40 points. Two high priority activities, four medium priority activities or a mix of the two

Maximum number of points, number of activities for small practices

60 points. Three high priority activities, six medium priority activities, or a mix of the two

20 points. One high priority activities or two medium priority activities

PCMH definition Limited to a certain list of accrediting organizations

Expanded to include any accrediting agency that has 500 or more participants, and meets the other requirements of a PCMH

Activity weights Participation in RHC, HIS, or FQHC medium priority

Participation in RHC, HIS, or FQHC high priority

Reporting can be done through EHR, qualified registry, a QCDR, the CMS web interface, or manual reporting. There are no thresholds associated with these activities. Instead, a practice needs only to report that a certain percentage of patients were impacted by the activity.

Reporting today can be done by EHR reporting, qualified registry, a QCDR, the CMS web interface or attesting manually. Sub-regulatory guidance will be issued soon on reporting mechanisms. There are no thresholds associated with these activities; rather, a practice needs to attest that a certain percentage of patients were impacted by the activity.


CMS is actively soliciting ideas for additional activities and subcategories for CPIA. They are conducting a study, for which providers can enroll in January, that intends to explore future activities that could be implemented. The study will consist of a diverse group so that CMS can receive feedback in different clinical settings. The participants will be:

Participants will be chosen based on their state coverage and the number of participants in the practice. For participating, practices receive a full score under the CPIA category.

10rural individual MIPS ECs or groups (less

than 3 ECs)

10non-rural ones

(less than 3 ECs)

3groups of 9-20

MIPS ECs

Three groups

of 21-100 MIPS ECs

Twospecialist groups

Future activities will be included based on several criteria. They include:

Relevance to existing programs

Importance in achieving improved health outcomes

Importance in reducing health care disparities

Alignment with PCMH

Representative of activities multiple ECs can perform

Ease of implementation, minimizing reporting burden

CMS can validate the activity

Evidence supporting that an activity has a high probability of improving health outcomes

CMS is also considering expanding the number of subcategories to give providers even more options. Whether CMS will approve a new subcategory depends on:

• The designated number of activities that meet the criteria for an improvement activity and cannot be classified under existing categories

• Whether newly identified subcategories would contribute to improvement in patient care practices or improvement in quality measures/cost categories

• Whether it would highlight improved health outcomes, patient engagement and safety based on evidence

The reduction in required CPIA activities gives practices more time to adjust to this scoring category. Practices familiar with PCMHs or other value-based programs like ACOs are well positioned to succeed.

REPORTING METHODS AND THE 2017 TRANSITION YEAR

Why Participate? | 19

REPORTING METHODS AND THE 2017 TRANSITION YEAR

Major changesCMS has provided ECs with more reporting options in the final rule. Under the proposed rule, full year reporting would have begun on January 1, 2017 and lasted throughout the year. Under the final rule, a practice need only report for 90 consecutive days at some point in 2017. Further, to minimize the reporting burden on ECs, CMS has created four reporting options and accounted for potential disruptions when upgrading electronic health records (EHRs) in 2018.

Reporting in 2017

In 2017, ECs are given four reporting options if they are subject to MIPS:

1. Do nothing, and receive a 4% penalty

2. Test your systems. Report for at least 90 days on at least one quality measure, one CPIA activity, or report the required ACI measures to avoid a negative adjustment.

3. Do more than the bare minimum. Report for at least 90 days on more than one quality measure, more than one CPIA activity, or more than the required ACI measures to avoid a negative adjustment and possibly receive a small positive adjustment.

4. Report for the full year and receive a positive adjustment.

CMS implemented these changes due to overwhelming comments from providers on the proposed rule. Many commenters noted that there wasn’t enough time between the final ruling and January 1 to learn about the new program and implement it. Additionally, small and rural practices cited resource constraints as reasons the timing was impractical.

Reporting in 2018

In 2018, an EC may report on ACI and CPIA for 90 days. CMS has granted this option for 2018 because they anticipate many practices will be upgrading their EHR systems to a 2015 Certified Electronic Health Record Technology (CEHRT) edition, and commenters noted that major EHR upgrades are disruptive to staff workflows and take time to implement.

Finally, CMS has decided not to allow virtual group reporting for 2017. They noted that the technology necessary for smaller practices to pool their reporting resources with one another has not been implemented or tested, but plan to make this option available in 2018.

Reporting methodologies

Certain reporting options receive scoring preferences. Providers receive bonus points in the Quality category for reporting using a QCDR, qualified registry, the CMS Web Interface, or CEHRT submission mechanism. Also, QCDR submission is emphasized for certain CPIA activities.

While several commenters noted that the number of reporting mechanisms was overly complex, CMS stated that the rules cannot simplify reporting to a single methodology until health IT is more broadly adopted. While the EHR market is vast, there are many other health IT services that continue to have low adoption rates, including networks like CommonWell, direct messaging, and population health analytics. This lack of universal adoption is a barrier to standards in development and interoperability.

Finally, CMS is finalizing its proposed methodology for identifying ECs. Each MIPS EC will receive a unique Taxpayer Identification Number (TIN) and National Provider Identifier (NPI) as the numbers used to assess the performance of individual MIPS ECs. MIPS

Reporting Methods

20 | Why Participate?

performance will be assessed separately for each TIN under which an EC bills.


CMS is looking at future changes to submission methods after 2017 and seeks to enable providers to submit using just one mechanism across all four categories.

Additionally, CMS is exploring standards for virtual group reporting in 2018. They are primarily looking at reporting requirements, and how those requirements can promote care coordination and quality care for virtual groups.

Impact summary

CMS estimates that over 90% of clinicians will receive neutral or positive adjustments based on the transition year’s reduced requirements. This significantly relieves practices of the pressure to test their systems, test new workflows, and implement health IT quickly. 2018 will continue to relieve this pressure by accounting for transitions to 2015 CEHRT.

Reporting Methods


Reporting options in 2017 Full year reporting beginning January 1, 2017.

1) Do nothing, and receive a 4% penalty

2) Test your systems. Report for at least 90 days on at least one quality measure, one CPIA activity or the report the required ACI measures to avoid a minimum adjustment.

3) Do more than the bare minimum. Report for at least 90 days on more than one quality measure, more than one CPIA activity, or more than the required ACI measures to avoid a negative adjustment and possible get a small positive adjustment.

4) Report for the full year and received a positive adjustment.

Reporting options in 2018 Full year reporting Full year reporting or 90 day reporting for ACI/CPIA if upgrading CEHRT edition.

Identifying ECs Use a unique combination of TIN/NPI numbers as an EC identifier

Same as proposed rule

Reporting methodologies Qualified registry, EHR reporting, QCDR, CMS Web Interface

Same, with preference to moving to using a single reporting methodology for each category.

ADVANCED ALTERNATIVE PAYMENT MODELS AND MIPS APMS

ADVANCED ALTERNATIVE PAYMENT MODELS AND MIPS APMS As an alternative to MIPS, practices can report using Advanced APMs or MIPS APMs. These tracks are not only incentive-based, but will change the way we pay for healthcare in the future. If a physician participates in an advanced alternative payment model, they will not only be exempt from MIPS reporting, but will also receive a 5% reimbursement on the previous year’s payments. To qualify to use an Advanced APM, a practice must use certified EHR technology, report quality measures comparable to those under MIPS, and most importantly, bear more than nominal financial risk.

Major ChangesThe primary changes to APMs focus on changing the definition of financial risk for standard Advanced APMs.

63 Greenway Health clients participating in CPC+

Initially, financial risk had a complex definition. It was based on marginal losses, the minimum loss rate, and total risk. Total risk was defined as the Advanced APM’s spending target, or the total cost of patient care. Many providers found this definition overly confusing. They also noted that in order to qualify under the definition of an Advanced APM, the total amount at risk had to be 4% of the spending target, which could amount to 20% of an organization’s Medicare revenue.

CMS wants to move providers towards Advanced APMs. To make them more attractive, they have relaxed and simplified the definition of an Advanced APM. Now, there is a “benchmark standard” and a “revenue standard” for total risk. Under the benchmark standard, Advanced APMs put 3% of their spending target at risk. Under the revenue standard, they put up to 8% of their average estimated total Medicare Parts A and B revenue.

The definition for Medical Home Advanced APMs, such as CPC+, remain largely the same. CMS adjusted it to have a higher focus on primary care and included OBGYN as a primary care group, because that specialty acts as the primary provider for many women. The definition of risk remains the same: The Medical Home must put its incentives and PMPM payments at risk, and those payments must represent a certain share of their Medicare revenue (2.5% in the 2017 performance period).

Moreover, CMS also removed the requirement that an Advanced APM must have a direct agreement with CMS. CMS expanded the definition to include organizations that have implicit, not necessarily contractual, agreements with CMS, such as ones driven by regulatory rulemaking or federal and state requirements.

Advanced Alternative Payment Models | 23

Nominal Risk

Revenue Standard

Benchmarkbased standard

8% of average estimated total Medi-care Parts A & B revenue

3% of expected expenditureres the APM is responsible for

24 | Getting Started

Previously, CMS intended to notify providers whether they were Advanced APM Qualifying Participants (QP) after the 2017 performance period. Providers noted that it was hard to plan for the program without knowing which track they would be participating in during the performance period. In response, CMS has accelerated the timeline on making QP determinations. They will notify providers as soon as possible, before the end of the 2017 performance period.

Medicare Shared Savings Program Track 1 is still excluded from APMs reporting because business risk is not considered “more than nominal.” To become a Track 1 ACO, a practice must make significant investments in IT, staffing, networks, and more, which ACOs argued constituted risk. CMS disagreed, saying those costs can’t be tied directly to patient care and are simply considered sunk costs. Sunk costs do not qualify as risk under MACRA.


The Advanced APM track is the preferred track, and CMS intends to incentivize providers to eventually move to it. MIPS is considered an “on-ramp.” Future changes are generally aimed at promoting the creation of new models.

In 2018, Other Payer Advanced APMs will become available. This opens up qualifying for Advanced APMs through arrangements with private payers, like commercial ACOs. The requirements are similar to a Medicare Advanced APM:

• The Advanced APM must use CEHRT.

• The arrangement provides payment for covered professional services based on quality measures comparable to MIPS.

• The Advanced APM bears more than nominal financial risk if total expenditures exceed expected expenditures, or is a Medicaid Home Model.

CMS is also considering how to measure total risk standards in designing Other Payer Advanced APMs. They are aiming to tailor risk to financial circumstances while still promoting coordinated care.

CMS is focusing on making more Medicare Advanced APMs available. It is also reopening applications to certain Advanced APMs, such as CPC+. They are adding a new Medicare Shared Savings Program, Track 1+, which will feature a lower degree of risk than Track 2. More Advanced APMs are on the horizon for small and rural practices, as well. CMS is seeking to tailor these to the challenges those organizations face and the levels of risk they are able to assume.

Advanced APMs are the preferred track under MACRA. As the years move on, more Advanced APMs will be released with requirements tailored to different practice circumstances. This will offer providers more flexibility in entering that track and allow them to escape mandatory MIPS reporting, while still taking advantage of the incentives available in those programs.

Further education on a quarterly basis will be important, given the level of activity around the call for new measures, objectives, and payment models.


General definition of nominal risk 4% Advanced APM spending target; 30% marginal risk; and, 4% minimum loss rate

Benchmarks standard: 3% of Advanced APM spending target; ORRevenue standard: 8% of Medicare Parts A and B revenue

Definition of Medical Home Advanced APM

Did not explicitly include OBGYN Focused on primary care, now explicitly includes OBGYN

Agreement with CMS Direct contract Agreement may be found through federal or state legislation and regulation

Timeline for notifying ECs that they are qualified participants in an Advanced APM

After the 2017 performance period Before the end of the 2017 performance period or as soon as possible

Advanced Alternative Payment Models

Getting Started | 25Advanced Alternative Payment Models

GLOSSARY OF ACRONYMS

GLOSSARY OF ACRONYMSACO: Accountable Care Organization

ACI: Advancing Care Information

APM: Advanced Payment Model

CEHRT: Certified electronic health record technology

CMS: Centers for Medicare & Medicaid Services

CPC+: Comprehensive Primary Care Plus

CPIA: Clinical Practice Improvement Activities

CQM: Clinical Quality Measure

EC: Eligible Clinician

eRx: Electronic prescribing

MACRA: Medicare Access & CHIP Reauthorization Act of 2015

MIPS: Merit-based Incentive Payment System

MSSP: Medicare Shared Savings Program

MU: Meaningful use

NCQA: National Committee for Quality Assurance

PCMH: Patient-centered Medical Home

QCDR: Qualified clinical data registry

QRDA: HL7 Quality Reporting Document Architecture

QRUR: Quality and Resource Use Report

Web Links | PB

USEFUL CHARTS AND MEASURES

Web Links | PB

Advancing Care Information: 2017 Transition YearOBJECTIVE MEASURE REQUIRED PERFORMANCE

Protect Patient Health Information Security Risk Analysis Y 0

Electronic Prescribing e-Prescribing Y 0

Patient Electronic Access Provide Patient Access

View, Download or Transmit (VDT)

Y N

Up to 20% Up to 10%

Patient-Specific Education Patient-Specific Education N Up to 10%

Secure Messaging Secure Messaging N Up to 10%

Health Information Exchange Health Information Exchange Y Up to 10%

Medication Reconciliation Medication Reconciliation N Up to 10%

Public Health and Clinical Data Registry Reporting

Immunization Registry Reporting

Syndromic Surveillance Reporting Specialized Registry Reporting

N N N

0 or 10% Up to 5% bonus permeasure, 15% maximum allowed

Advancing Care Information: 2018OBJECTIVE MEASURE REQUIRED PERFORMANCE

Protect Patient Health Information Security Risk Analysis Y 0

Electronic Prescribing e-Prescribing Y 0

Patient Electronic Access Provide Patient Access

Patient-Specific Education

Y N

Up to 10% Up to 10%

Coordination of Care Through Patient Engagement

View, Download or Transmit (VDT)

Secure Messaging

Patient-generated health data

N

N

N

Up to 10%

Up to 10%

Up to 10%

Health Information Exchange Send a Summary of Care

Request/Accept Summary of Care Clinical Information Reconciliation

Y Y Y

Up to 10%

Up to 10%

Up to 10%

Public Health and Clinical Data Registry Reporting

Immunization Registry Reporting Syndromic Surveillance Reporting Electronic Case Reporting Public Health Registry Reporting Clinical Data Registry Reporting

N N N

N

0 or 10% Up to 5% bonus permeasure, 15% maximum allowed

USEFUL CHARTS AND MEASURES

30 | Getting Started

Episode-based measuresMETHOD TYPE/ MEASURE NUMBER FROM TABLE 4 (METHOD A) AND TABLE 5 (METHOD B) FROM PROPOSED RULE*

EPISODE NAME AND DESCRIPTION

A/1 Mastectomy (formerly titled “Mastectomy for Breast Cancer”) Mastectomy is triggered by a patient’s claim with any of the interventions assigned as Mastectomy trigger codes. Mastectomy can triggered by either an ICD procedure code, or CPT codes in any setting (e.g. hospital, surgical center).

A/5 Aortic/Mitral Valve Surgery Open heart valve surgery (Valve) episode is triggered by a patient claim with any of Valve trigger codes.

A/8 Coronary Artery Bypass Graft (CABG) Coronary Artery Bypass Grafting (CABG) episode is triggered by an inpatient hospital claim with any of CABG trigger codes for coronary bypass. CABG generally is limited to facilities with a Cardiac Care Unit (CCU); hence there are no episodes or comparisons in other settings

A/24 Hip/Femur Fracture or Dislocation Treatment, Inpatient (IP)-Based Fracture/dislocation of hip/femur (HipFxTx) episode is triggered by a patient claim with any of the interventions assigned as HipFxTx trigger codes. HipFxTx can be triggered by either an ICD procedure code or CPT codes in any setting.

B/1 Cholecystectomy and Common Duct Exploration Episodes are triggered by the presence of a trigger CPT/HCPCS code on a claim when the code is the highest cost service for a patient on a given day. Medical condition episodes are triggered by IP stays with specified MS-DRGs.

B/2 Colonoscopy and Biopsy Episodes are triggered by the presence of a trigger CPT/HCPCS code on a claim when the code is the highest cost service for a patient on a given day. Medical condition episodes are triggered by IP stays with specified MS-DRGs

B/3 Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia For procedural episodes, treatment services are defined as the services attributable to the MIPS eligible clinician or group managing the patient’s care for the episode’s health condition.

B/5 Lens and Cataract Procedures Procedural episodes are triggered by the presence of a trigger CPT/HCPCS code on a claim when the code is the highest cost service for a patient on a given day.

B/6 Hip Replacement or Repair Procedural episodes are triggered by the presence of a trigger CPT/HCPCS code on a claim when the code is the highest cost service for a patient on a given day

B/7 Knee Arthroplasty (Replacement) Procedural episodes are triggered by the presence of a trigger CPT/HCPCS code on a claim when the code is the highest cost service for a patient on a given day

ADDITIONAL RESOURCESQuality Payment Program website

Executive Summary of the Final Rule

The Medicare Access and CHIP Reauthorization Act of 2015

Comprehensive list of APMs

Improvement Activities and APMs

https://qpp.cms.gov/

https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf

https://www.congress.gov/bill/114th-congress/house-bill/2/text

https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf

https://qpp.cms.gov/docs/QPP_APMs_and_Improvement_Activities.pdf






Group Reporting Data Submission Mechanisms

Quality QCDR

Qualified registry EHR

CMS Web Interface (groups of 25 or more)

CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with another data submission mechanism.)

Administrative claims (For all-cause hospital readmission measure -no submission required)

Cost Administrative claims (no submission required)


Attestation QCDR

Qualified registry

EHR

CMS Web Interface (groups of 25 or more)

Improvement Activities Attestation

QCDR

Qualified registry

EHR CMS Web Interface (groups of 25 or more)

Data submission mechanisms for individual ECs

Quality Claims

QCDR

Qualified registry

EHR

Cost Administrative claims (no submission required)


Attestation

QCDR

Qualified registry

EHR

Improvement Activities Attestation

QCDR

Qualified registry

EHR






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Documents