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MACRA APPLICATIONS & IMPLICATIONS PART 2: THE FINAL RULE

Zach RemmichManaging Consultantzremmich@bkd.com

Mark Blessing, CPAPartner, BKD Physician Services

mblessing@bkd.com

January 17, 2017

• Participate in entire webinar• Answer polls when they are provided• If you are viewing this webinar in a group

Complete group attendance form with• Title & date of live webinar• Your company name• Your printed name, signature & email address

All group attendance sheets must be submitted to training@bkd.com within 24 hours of live webinar Answer polls when they are provided

• If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar

TO RECEIVE CPE CREDIT

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• Value-Based Reimbursement Evolution • Recap of MACRA Program Overview• What’s New Under the Final Rule• Strategic Implications• Questions

AGENDA

Value-Based Reimbursement Evolution

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PART B GRADUAL SHIFT TOWARD VALUE

1965Medicare is

born

1984Medicare Economic

Index (MEI) introduced

1989Resource-Based Relative

Value Scale (RBRVS) & Volume Performance

Standard (VPS) introduced

1997Sustainable

Growth Rate (SGR) replaced

VPS

2006Physician Quality Reporting System (PQRS) initiated

2010ACA requires value-based

payment modifier

2009HITECH Act

enacts meaningful use &

incentive payments

2015MACRA: MIPS &

APMs, SGR eliminated

??? 2017 & beyond???

CMS SHIFT TO VALUE – FFS PAYMENTS LINKED QUALITY

Hospitals• Hospital Acquired Conditions Reduction Program• Readmission Reduction Program• Hospital Value-Based Purchasing Program• Meaningful UsePhysicians• Physician Quality Reporting System• Value-Based Modifier Program• Meaningful UsePAC & Other• End Stage-Renal Disease QIP• SNF Value-Based Modifier• Home Health Value-Based Modifier

%06

50%

All Medicare FFS

2018

All Medicare FFS (Categories 1–4)FFS Linked to quality (Categories 2–4)

Alternative payment models (Categories 3–4)

Current CMS Programs

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CMS SHIFT TO VALUE – FFS PAYMENTS LINKED ALTERNATIVE PAYMENT MODELS

%06

50%

All Medicare FFS

2018

All Medicare FFS (Categories 1–4)FFS Linked to quality (Categories 2–4)

Alternative payment models (Categories 3–4)

Current CMS APM Programs

• Accountable Care Organizations• Medical Homes• Bundled Payments • Comprehensive Primary Care Initiative• Comprehensive End-Stage Renal Disease• Medicare-Medicaid Financial Alignment Initiative

Fee-For-Service Model• Pioneer Accountable Care Organizations

• Moves away from transactional fee-for-service & shifts toward quality & cost management of beneficiaries

• Emphasis on data analytics, provider documentation & patient panel management

VALUE-BASED REIMBURSEMENT SHIFT

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• Care coordination & population health management are more the focus

• Commercial carriers rapidly following in CMS’s footsteps • Publication of outcomes data proliferating—increased financial

responsibility by patients for their care

VALUE-BASED REIMBURSEMENT SHIFT

Recap of MACRA Program Overview

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MACRA ACRONYMS• ACI: Advancing Care Information• APM: Alternative Payment Model• CMS: Centers for Medicare & Medicaid Services• FFS: Fee-for-Service• EC: Eligible Clinicians (provider subject to MACRA)• CPIA: Clinical Improvement Activities (also known as IA or Improvement Activities)• MACRA: Medicare Access and CHIP Reauthorization Act of 2015• MIPS: Merit-Based Incentive Payment System• MIPS APM: Qualify for preferential MIPS Scoring but not considered Advanced APMs• MU: Meaningful Use• PQP: Partial Qualifying APM Participant• PMPM: Per Member Per Month• QP: Qualifying APM Participant• VBPM: Value-Based Payment Modifier• NPI: National Provider Identifier• CAHPS: Consumer Assessment of Healthcare Providers and Systems• PQRS: Physician Quality Reporting System• QRURs: Quality and Resource Use Reports• QIO: Quality Improvement Organization

• Repeals Sustainable Growth Rate (SGR) & ends “doc fix”• Phases out Medicare payment adjustments under current

physician reporting programs Physician Quality Reporting System (PQRS) Physician Value-Based Modifier Program (VBM) Medicare Physician Meaningful Use (MU)

WHY MACRA IS IMPORTANT

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• Requires CMS to develop & implement a complex system for measuring, reporting & scoring the value & quality of care via two separate clinician participation tracks

• Very small percentage of eligible clinicians exempted from system• Performance period started January 1 & impacts payment in 2019• Enacted with bipartisan support

WHY MACRA IS IMPORTANT

NEW PHYSICIAN QUALITY REPORTING PROGRAM (QPP)

Advanced Alternative Payment Models (APMs)

Merit-based Incentive Payment System (MIPS)

• Payments for cost & quality performance built on FFS structure

• 5% bonus in 2019 to 2024• Exempt from MIPS reporting• Payment & patient thresholds• Requires downside risk, quality & CEHRT• 70,000–120,000 clinicians will qualify in

year 1(1)

OR• Fee-for-service with performance-based

adjustment applied to future Medicare Part B payments

• Consolidates physician reporting programs • Performance measured against peers• Stakes rise over time – 4% 2019; 9% 2022• Most clinicians will participate in year 1

500,000 – 645,000(1)

• Excluded: 1st year Medicare or low volthreshold

Most eligible clinicians should assume they fall in the MIPS track which looks & feels similar to current Medicare physician reporting programs in terms of reporting & impact on future reimbursement

(1) Per CMS estimates of eligible APM and MIPS clinicians found in MACRA final rule

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MIPS OVERVIEW REFRESHER

Quality(60%)

Resource Use(0%)

Advancing Care

Information(15%)

Improvement Activities

(25%)

• Replaces PQRS• Most participants report

six measures, including one outcome

• Can receive partial credit• Bonus points available• Group Web Interface –

report 15 measures• MIPS APMs report

quality through APM

• Replaces VBPM cost component

• Included in 2018 performance year

• Based on claims data• 10 disease groups• Refining attribution

methodology

• Replaces MU• Moves away from “all

or nothing”• Base score attestation• Performance score• Reduced number of

measures• Bonus points available• Certain exemptions• Can report as a group

• New category• >90 activities to choose

from• Report High or Medium

weighted activities• 90 consecutive days• Preferential scoring

PCMH full credit Half credit for MIPS

APMS

Year 12017

Composite Performance Score (CPS)

*See Appendix 1, 2 & 3 for preferential scoring & small practice accommodations

HOW TO SEND MIPS DATA TO CMS Group Reporting

• Group that consists of a single TIN with ≥ two ECs (at least one MIPS EC) who have reassigned their billing rights to the TIN

• Group evaluated on all measures reported regardless of applicability to individual ECs

• Payment adjustments based on group performance

• All TIN measure data included, regardless of MIPS eligibility

• May report through CMS Web Interface CEHRT Registry QCDR

Individual Reporting

• Single MIPS eligible clinician• Payment adjustments based on individual

performance• May report through

CEHRT Registry QCDR Or may submit quality data through Medicare

claims process

(1) Must report across all performance categories as an individual or a group(2) Do not have to declare group reporting to CMS unless reporting through

Web Interface (June 30, 2017)

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• Individual reporting – CMS will use your Tax Identification Number (TIN) & National Provider Identifier (NPI) – must use TIN/NPI for all categories

• MIPS group reporting – the group’s TIN is used as identifier Exception for CMS Web Interface or CAHPS for MIPS Survey

• APM entity group reporting – each individual identified by a unique APM participant identifier

• Payment adjustments (+/-) & APM bonus – applied at TIN/NPI level for groups, individuals & APM group

HOW CMS WILL IDENTIFY YOU

2017• Jan 1 – First performance measurement year for MIPS• Jun 30 – CMS Web Interface election deadline• Oct 1 – Last day to start 90-day reporting period• Nov 1 – 2018 performance thresholds announced• March/June/August – APM QP determinations2018• Jan 1 – 2nd performance measurement year for MIPS – likely first year of broader participation for all providers • Jan to Mar – 2017 performance data submission period• Nov 1 – 2019 performance threshold announced• March/June/August – APM QP determinations• Dec 31 – MU, PQRS & VBM payment adjustments sunset for Medicare providers• Likely additional APMs added as qualifying Advanced APMs2019• Possible expansion of eligible clinician list• First MIPS payment adjustments applied• First APM performance assess• Likely inclusion of an all-payor APM model

MACRA TIMELINE

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• Assess clinician eligibility Begin to assess eligibility of MIPS eligible clinicians under Final Rule requirements by reviewing

historical Medicare Part B payments & volumes• Assess current quality reporting performance

Become familiar with quality reporting requirements Begin to identify potential reporting metrics based on historical performance or area of specialty

• Access Medicare Quality & Resource Use Reports (QRURs) to identify improvement areas• Identify reporting strategy

Analyze various reporting strategies based on specialty, quality outcome performance & MIPS status

Identify various reporting strategies to improve performance under MIPS• Identify future reporting strategy

Evaluate current infrastructure with regards to reporting under MIPS & identify what MACRA track is feasible for the organization/clinician in the future

Evaluate whether future reporting strategy aligns with organizations that will help improve quality & drive down costs

• Stay informed

PREPARING FOR TRANSITION YEAR & BEYOND

What’s New?

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• Revised low-volume threshold for MIPS exclusion Patients & Part B charge went from “both” to “either/or”

• Part B charges ≤ $10k to $30k• Eliminated cost component weighting in 2017• Reduced some of reporting burden Quality – reduced percent of applicable patients CPIA – number of activities to report went from six to four; two for small & rural practices ACI – reduced reporting from 11 to five measures; non-physicians may elect not to report

• Established minimum reporting requirements (“Pick Your Pace”) to avoid penalties in first year

• Reopening application process for CPC+ & developing a new MSSP Track 1 program with downside risk (Track 1+)

KEY CHANGES IN FINAL RULE

2017 MIPS TRANSITION YEAR MIPS “Pick Your Pace”

“Report Nothing” “Testing” “Partial Reporting” “Full MIPS Reporting”

4% penalty No negative adjustment or

bonus

Small positiveadjustment

+Potential bonus

Max potential adjustment

+ Potential bonus

+Potential

exceptional bonus

CMS is estimating 90% of eligible clinicians will receive a positive or neutral MIPS adjustment for 2017 transition year

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• Requirement: Submit a minimum amount of 2017 data to Medicare—for example• One quality measure, one time, one patient• One improvement activity or• Report core ACI measures

No minimum reporting period• Application: Clinicians & groups with limited experience reporting to CMS programs

or lack technology & infrastructure necessary to collect & report data• Consider reporting multiple quality metrics & improvement activities – practice MIPS

reporting in low risk environment in Year 1• Use 2017 to get organized & develop a strategy for 2018 (e.g., what metrics do you

want to collect & report; research multiple vendor registries)

“TESTING” – AVOID NEGATIVE ADJUSTMENT

• Requirement: Report more than the following for 90 consecutive days One quality measure One improvement activity More than base ACI measures

• Application: Clinicians with necessary technology & infrastructure but not ready for full participation

• Consider reporting quality measures for more than 90 days to maximize performance & establish solid baselines for 2018

• Strategize when to conduct 90 day performance period based on measures selected & practice bandwidth (Oct 1, 2017, last day to start 90 days) – do not need to conduct performance categories at same time

• Previous considerations apply as well

“PARTIAL” REPORTING – SMALL POSITIVE ADJUSTMENT

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• Requirement: Meet reporting requirements across all categories for 90 days or more

• Application: Clinicians not ready to commit to participation in an APM but have necessary processes, infrastructure & technology to capture the upside incentive

• Consider reporting as much data as you can to improve chances of a higher score & bonus points– CMS selects your top performing metrics >70 points makes you eligible for additional performance bonus

• Work with EHR or registry vendor on end-to-end electronic reporting for quality bonus points & ACI bonus for submitting improvement activities

• Previous considerations apply as well

“FULL MIPS” – POSITIVE ADJUSTMENT & BONUSES

Strategic Implications

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• “Pick Your Pace” is CMS’s answer to demands to slow down, or delay, implementation of MACRA

• “Pick Your Pace” changes encourage at least partial reporting compliance in year 1

• The second year, & beyond, is not affected by “Pick Your Pace”, so implementation has not been delayed Report at least partially in the first year

STRATEGIC IMPLICATIONS – WHAT’S NEW

• Continue to keep your eye on the ball – “Pick Your Pace” does not slow down MACRA implementation

• Full management of MACRA requires development of “Integrated Delivery System” (IDS) infrastructure ROI for development of IDS infrastructure tied to extent of future value-based reimbursement penetration; MACRA not enough

• CMS value-based initiatives continue to focus on key elements Financial risk or reward to providers based on cost of beneficiaries to MC (hospital in CJR, physician in MACRA, etc.)

Associated or direct financial risk or reward to providers for care outcomes

Associated requirements for providers to coordinate care & manage care episodes

Requirements to share medical data across providers

• Elements of MACRA scoring could be improved through shorter-term attention to specific MIPS parameter elements

• Recommended approach Short-term: MACRA FFS Maximization

Long-term: Integration Infrastructure Development

STRATEGIC RECOMMENDATIONS

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The information contained in these slides is presented by professionals for your information only and is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.

BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.nasbaregistry.org.

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• CPE credit may be awarded upon verification of participant attendance

• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at training@bkd.com

CPE CREDIT

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• Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record

• Anticoagulant management improvements • Glycemic management services • Chronic care & preventative care management for empaneled

patients • Implementation of methodologies for improvements in longitudinal

care management for high-risk patients • Implementation of episodic care management practice

improvements • Implementation of medication management practice improvements • Implementation or use of specialist reports back to referring

clinician or group • Implementation or documentation improvements for

practice/process • Implementation of practices/processes for developing regular

individual care plans

MIPS CPIA ELIGIBLE FOR ACI BONUS

• Practice improvements for bilateral exchange of patient information

• Use of certified EHR to capture patient reported outcomes • Engagement of patients through implementation of

improvements • Engagement of patients, family & caregivers in developing a

plan of care • Use decision support & standardized treatment protocols to

manage workflow in the team to meet patient needs • Leveraging a QCDR [qualified clinical data registry] to

standardize processes for screening • Implementation of integrated PCBH [patient-centered

behavioral health] model • Electronic Health Record Enhancements for BH [behavioral

health] data capture

Appendix 1

• Low volume threshold• “Pick Your Pace” transition for 2017 CMS estimates 90% of eligible clinicians will get zero or positive adjustments CMS estimates 80% of those will be in groups < 10

• Eased requirements for improvement activities component• $100 million in grants for technical assistance to small practices via

QIOs, regional health cooperatives, etc.• Participation in rural health clinics sufficient for full improvement

activities score for rural & small practices• Future rulemaking to address virtual groups, pooled financial risk

arrangements

SMALL PRACTICE ACCOMMODATIONS & IMPACTS

Appendix 2

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Practice Type Definition Exclusions & Preferential Scoring

Low volume clinicians & groups

MIPS eligible clinicians or groups that1. Have total Medicare Part B allowed charges less than or equal to

$30,0002. Provide care to 100 or fewer Part B-enrolled Medicare

beneficiaries

Exempt from MIPS: May voluntarily report data but not eligible for payment adjustments under MACRA

Small practices Practices consisting of 15 or fewer clinicians Will have weight of any selected improvement activity doubled (high worth 40 & medium worth 20)

Rural practices Practices located in zip codes that are included in the most recent set of Health Professional Shortage Areas (HPSAs)

May apply for a hardship exemption & have their ACI category score reweighted to zero Will have the weight of any selected improvement activity doubled (high worth 40 & medium worth 20)

Non-patient facing MIPS eligible clinicians & groups

Individual MIPS ECs – bills 100 or fewer patient-facing encounters during 12 month periodGroups – 75%, or more, of groups is made up of clinicians who meet the definition of non-patient facing MIPS eligible clinicians

Not required to report Advancing Care Information. Category is re-weighted to zero Will have the weight of any selected improvement activity doubled (high worth 40 & medium worth 20)

Hospital-based MIPS eligible clinicians

MIPS ECs who furnish at least 75% of their services in sites of services identified by Place of Service (POS) codes 21, 22 or 23

Not required to report Advancing Care Information. Category is re-weighted to zero

Non-physician MIPS eligibleclinicians

NPs, Pas, CNSs & CRNAs Not required to report Advancing Care Information. Category is re-weighted to zero

MACRA EXCLUSIONS & PREFERENTIAL SCORINGAppendix 3

MACRA EXCLUSIONS & PREFERENTIAL SCORINGPractice Type Definition Exclusions & Preferential Scoring

MIPS Eligible Clinicians new to Medicare

MIPS ECs that have not previously submitted Medicare claims in the past performance year

Exempt from MIPS: may voluntarily report data but not eligible for payment adjustments under MACRA

Patient Centered Medical Home

One of the following1. Accredited by a nationally recognized accreditation association

including the Accreditation Association for Ambulatory Health Care, National Committee for Quality Assurance, Joint Commission or Utilization Review Accreditation Commission

2. Participates in a Medicaid Medical Home Model or Medical Home Model

3. Received the NCQA Patient-Centered Specialty Recognition4. Accredited by another certifying body that has certified at least 500

medical organizations & meets national accreditation guidelines

Automatically receive full credit toward the improvement activities performance category

MIPS APM APMs that fall below the QP thresholds or groups in the MSSP Track 1, Oncology Care Model (1 sided risk arrangement) or Comprehensive ESRD Care (1 sided risk arrangement).

Automatically receive full credit toward the improvement activities performance category

Advanced APM Meet applicable QP determination thresholds by having a certain percentage of payments or patients attributed to the Advanced APM

Exempt from MIPS: may voluntarily report data but not eligible for payment adjustments under MACRA

Appendix 3

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• CMS aggregates all scores for MIPS ECs identified in APM

• Final score applied to all MIPS eligible clinicians identified on APM entity’s participation list

• APM scoring will NOT apply to MIPS eligible clinicians who are not on a participation list

MIPS APM SCORING

Performance Category Weights

MIPS Performance Category

MSSP ACOMIPS APM

Next Generation MIPS APM

All other MIPS APMs

Quality50% 50% 0%

Cost0% 0% 0%

AdvancingCare Information

20% 20% 25%

ImprovementActivities 30% 30% 75%

*2017 MIPS APMs receive full Improvement Activities credit

Appendix 4

• Certified Electronic Health Record Technology https://chpl.healthit.gov/#/search

• Quality Improvement Organizations http://qioprogram.org/contact-zones?map=qinTPCI

• Transforming Clinical Practice Initiative https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/ http://www.healthcarecommunities.org/

• Quality Payment Program https://qpp.cms.gov/measures/performance

• Electronic Health Record Hardship (Advancing Care Information Hardship) https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/paymentadj_hardship.html

• Physician Compare https://data.medicare.gov/data/physician-compare

• Medicare Claims https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-

Charge-Data/Physician-and-Other-Supplier2014.html

RESOURCES

Appendix 5