macra in 2018 - greenwayhealth.com€¦ · • macra notice and comment closes early in the month...

1© Greenway Health, LLC. All rights reserved. Confidential and proprietary. Not for distribution except to authorized persons.

MACRA in 2018

David HellerIndustry & Government Affairs


Agenda

• Overview• Assistance for small practices• Reporting and scoring• Advancing Care Information• Quality & Clinical Practice Improvement Activities• Alternative Payment Models


Adjusted Medicare Part B payment to clinician

MIPS PAYMENT ADJUSTMENTS

2022+

±4% for 2017’s performance



±9% for 2020’s performance and future years

• The potential maximum adjustment % will increase each year from 2019 to 2022

Maximum Adjustments

• Composite Performance Score, clinicians will receive +/- or neutral adjustments up to the percentages shown here

Based on MIPS

2021

2020

2019


MACRA’s CY 2018 Top Takeaways: More Flexibility for Providers

More measures and

activities to choose from

New reporting options

The transition continues


Other notable impacts

21st Century Cures

Patients Over Paperwork

Meaningful Measures

Extreme and uncontrollable circumstances


OVERVIEW


The HouseThe Senate

Bottom line

92 yeas

2 nays

392 yeas

37 nays

2 abstained

MACRA, MIPS, APMs are not going away

MACRA, by the votes


Provider flexibility

Interoperability

Physician burden a serious concern

Looking possible

scaleback of MU, ACI

Support from both

sides of the aisle

Measures cost and quality

MACRA

8 I

It’s here to stay, with some tweaks possible


What is MACRA?

MAC

RAMIPS (standard)

MIPS (MIPS APMs)

Advanced APMs


Regulatory implementation

2019201820172016

• Final performance period for MU/PQRS/VBM

• Payment year for 2014 performance period

MACRA activities

• Payment year MU/PQRS/VBM (2015 performance)

• Final payment year for MU/PQRS/VBM (2016 performance)

• First MIPS performance period

• Report on either ACI Transition Year (Modified Stage 2) objectives or ACI (Stage 3) objectives

• 4 reporting options • Must begin

reporting by Oct. 2

• 2014 or 2015 CEHRT• Report on either ACI

Transition Year (Modified Stage 2) objectives or ACI (Stage 3) objectives

• May elect 90 day ACI/CPIA reporting period.

• Cost implemented

• Payment year for 2017 MIPS performance period

• 2015 CEHRT implemented

• Mean/median scoring

• Expansion of APM models

Sunsetactivities


A single MIPS composite performance score will factor in performance in four weighted categories on a scale of 0-100

What is MIPS?

QUALITY RESOURCE USE/COST

CLINICAL PRACTICE IMPROVEMENT

ACTIVITES

ADVANCING CARE INFORMATION

Replaces PQRS. Accounts for 60% of total performance score in year

one.

Replaces VBM. Accounts for 0%

of total performance score in year

one.

Accounts for 15% of total performance score in year

one.

Replaces Medicare MU. Accounts for 25% of total performance score in year

one.


Medicaid MU goes on separately

Medicaid meaningful use MIPS


Regulatory cycle: H1

Jan. Feb. March April May June

• NQF MAP convenes• Quality MUC

template published• Call for ACI measures• Call for IA measures• Call for quality

measures• Measures from prior

year’s process implemented

• MACRA notice and comment continues

• CMMI may issue new innovation models

• IA measures submission closes EOM

• MACRA proposed regulation issued, notice and comment begins

• Closure of call for new quality measures


• CMMI new innovation models may issue

• PTAC votes on physician designed APMs (quarterly meetings)


Regulatory cycle: H2

July Aug. Sep. Oct. Nov. Dec.

• MACRA notice and comment closes early in the month

• Proposed Physician Fee Schedule is issued, notice and comment opens

• CMMI may issue new innovation models may issue

• Proposed Physician Fee Schedule notice and comment continues

• PTAC meets on proposed APMs



• PTAC issues RFP for new APMs

• MACRA final regulation issued by Nov. 1, final list of new measures

• Physician fee schedule finalized (may be combined with MACRA regulation)

• PTAC votes on physician designed APMs (quarterly meetings)

• Proposed Physician Fee Schedule notice and comment closes early in the month



QualityMore outcomes based quality measures, special emphasis on care coordination, patient/caregiver experience, utilization, and performance gaps

Advancing Care InformationMore interoperability measures. Specifically, closing the referral loop. Also asking for ways to measure CEHRT workflow disruption for the purpose of health IT specifications.

Improvement ActivitiesMore IAs that line up with PCMH or other existing programs, importance on improving health outcomes, reducing care disparity, broadly applicable, easy to implement, and whether CMS can validate the activity.

APMsMore APMs and Advanced APMs, private payer models, small practice and rural setting APMs

Where’s MACRA going?Physician updates will be measured regularly, with a special emphasis on outcomes and interoperability


ASSISTANCE FOR SMALL PRACTICES


Virtual Group Reporting

Up to 10 ECs per Tax ID

Election by December 1

Allows small practices to scale reporting and performance

Assess quality and cost uniformly

Applications open in September

No limit on the number of TINs


Small practice bonus

2024

5 point bonus to

MIPS composite


Less than $90,000 in Medicare revenue excluded

Fewer than 200 Medicare unique

patients are excluded

ACI hardship exemption

More flexibility for small practices

Driving flexibility through exclusions and exemptions


REPORTING & SCORING


Performance thresholds, the MIPS composite score, & your bottom line

0 3 15 70 100

In the 2018 performance period, ECs who earn a composite score between 0-15 are subject

to a 0%-5% penalty in 2020. 15 is the performance threshold, increased from 3 in

2017. CMS estimates $173 million in penalties will be assessed.

ECs who earn a composite score between 15-70 are eligible for a 0%-5% incentive in 2020. CMS

estimates $173 million in incentives for this group.

ECs who exceed 70 are eligible for increased MIPS bonuses which will be paid out of a

pool of $500 million that is not subject to budget neutrality.


Who is eligible to participate in MIPS?

Years 1 and 2

Years 3+

Physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals

HHS Secretary may broaden EC groups to include others such as

Physicians (MD/DO and DMD/DDS), PAS, NPS, clinical nurse specialists, certified registered nurse anesthetists


MIPS does not apply to hospitals or facilities

Who is not eligible to participate in MIPS?

First year of Medicare

Part B participation

Below low patient volume

threshold

Certain participants in

Advanced APMs

Medicare billing charges ≤ $90,000 OR providers care for ≤ 200 patients in one year


Eligible clinicians can participate in MIPS as an individual or group

Eligible clinician reporting

GROUP

A group, as defined by taxpayer identification number (TIN), would be

assessed as a group practice across all four MIPS performance categories

INDIVIDUAL VIRTUAL

To be implemented in 2018 performance period, defined with a virtual group identifier,

TIN, and NPI combination


MIPS 2017 reporting options

Don’t participate, and receive a 4% negative adjustment rate1

Submit one quality measure, one improvement activity, or the required ACI measures for at least 90 days and avoid a negative adjustment

Submit at least more than one quality measure, more than one improvement activity, or more than the required ACI measures for at least 90 days, and get no adjustment or a small positive one

Submit data to MIPS for the full year, and get a positive adjustment

2

3

4


Sample reporting options in 2018

Don’t participate, and receive a 5% negative adjustment rate1

Report on the required ACI measures and one quality measure

Fully report on and participate in improvement activities

Submit six quality measures that meet data completeness criteria

2

3

4


Reporting timelines for 2018

90 days for Advancing Care Information1

90 days for Improvement Activities

Full year for Quality

Full year for Cost

2

3

4


60%15%

25%

0%

Advancing Care Information

Quality

Clinical Practice Improvement Activities

MIPS scoring in 2017


50%

15%

25%

10%Quality


Final Rule: MIPS scoring in 2018

Cost



30%

15%25%

30%

Quality


MIPS scoring in 2019

Cost



More points for complex patients

Bonus based on average

HCC scores


Improvement scoring

80%

45%

30%

Improvement scoring rewards clinicians for

improvement in the Quality and Cost

categories by comparing the current

performance period with the prior

performance period.

Quality improvement will be assessed at the

category level because different clinicians

may select very different measures that are

not comparable. Your improvement score is

added onto your Quality performance.

Cost improvement will be assessed at the

measure level because all clinicians are

generally measured on the same measures.

Your improvements score is added onto your

Cost performance.


Facility-based measurement coming in future years


COST


How is Cost measured?

• Medicare Spending per Beneficiary (MSPB) in 2018• Introducing episode-based measures in 2019


ADVANCING CARE INFORMATION


Scoring Advancing Care Information

Performance score, where the more you do the

more you earn (up to 50)

Bonus scores up to 25% for

miscellaneous Total (up to 100)

Base score to get any credit (50)


Which certified edition?

• 10% bonus to 2018 ACI score

• May use 2014 CEHRT

• May Use 2015 CEHRT

• May report on 2017 Transition Year ACI Objectives (derived from Stage 2)

• May report on ACI Objectives (derived from Stage 3)

Benefits of 2015 CEHRT

2017 Performance Period

2015 ONC

CEHRT

2017Performance

2018 Performance

• May use 2014 CEHRT

• May Use 2015 CEHRT

• May report on 2017 Transition Year ACI Objectives (derived from Stage 2)

• May report on ACI Objectives (derived from Stage 3)

2018 Performance Period


The return of exclusions

BUSINESS ECOSYSTEM

Protect Patient Health Information

(yes required)

Electronic Prescribing (numerator/

denominator)

Health Information Exchange

(numerator/denominator)

Coordination of Care Through Patient

Engagement (numerator/

denominator)

Public Health and Clinical Registry

Reporting

Patient Electronic Access (numerator/

denominator)

Advancing Care

Information


A shift in measuring public health reporting

Beyond the Performance Score

A 5% bonus score is available for submitting to another public health agency or clinical data regsitry

Performance ScoreConnecting to a public health registry gives you 10% to your ACI performance score.


Bonus score

2015 CEHRT

Registry reporting

Reporting improvement

activities through CEHRT

Bonus up to 25%


What’s next with ACI?

New call for measures

Use case: closing the

referral loop

Interoperability in non-office

settings


What about interoperability?

National Patient Identifier1

21st Century Cures, standards and penalties2

Interopereability and outcomes

3


Carequality & CommonWell Health Alliance Partnership


QUALITY & CLINICAL PRACTICE IMPROVEMENT ACTIVITIES


Data completeness threshold raised from 50% to 60%

Quality updates

Choice More CQMs available, focused on outcomes and other high priority measures

Reporting May not submit measures using multiple data submission mechanisms in 2018

Removing measures

Phase out process introduced for topped out measures

Floor Three point floor for each measure


More outcomes measures and more specialist measures

What’s coming with Quality

COMPANY47

1

May see continued focus on qualified registry reporting and QCDR reporting

Preference for outcomes measures over process measures

National Quality Forum’s Measure Applications Partnership: Call for measures

2

3

4


More improvement activities, expanding PCMH

50% of practices within a TIN need

PCMH recognition for full CPIA credit

PCMH definition

expanded to include CPC+

No change to scoring or

weight

More activities in general, and more activities that relate to

CEHRT


Expanded subcategories based on contribution to improvements in patient care, cost and quality

What’s coming with CPIA

1

More activities to come based on relevance to existing programs, importance towards improving health outcomes, alignment with PCMH and more

2


ALTERNATIVE PAYMENT MODELS


50%

20%

30%

0%


Quality


MIPS APM scoring in 2017


Advanced APM impact to providers

20242026+202020182016

5% Lump Sum

Bonus


Revenue-based risk definition extended for two years

Nominal risk

Revenue standard

8% of average estimated total

Medicare Parts A & B revenue

Benchmark-based standard

3% of expected expenditures the APM

is responsible for


The Medical Home Model – a more gradual ramp

Or

General definition

Quality incentive or PMPM at risk

2018: 2% 2019: 3%

2020: 4% 2021: 5%

RISK


Who’s in the APM track?

201720152024+20232022202120202019

Payments

25%

Patients

20%

Payments

50%

2019-2020• Medicare APMs only

2021+•Include private payers

Payments

75%

Patients Patients

35% 50%


More ways to qualify coming

1

2

3

All Payer Combination Option

Medicaid & CHIP

CMS Multi-Payer Models


Performance thresholds and Cost in the future

0 3 15 70 100

The performance threshold in 2019 will be set as the mean or median of prior MIPS composite scores unless

Congress amends MACRA.

30%

15%25%

30%

Cost

To change how CMS sets thresholds and Cost’s portion of the score for future years an act

of Congress is required.


1

2

3

Measure quality and costFirst, clinicians become accustomed to capturing metrics and measuring performance on quality and cost.

Implement technological and clinical processesAs MIPS ramps up, clinicians are incented to implement process changes that can quanitifiably move the needle on quality and cost.

Prepare for riskBy changing the way the clinicans deliver care over time, clinicans are equipped to take advantage of risk-bearing contracts that reward superior care over volume.

Congress’s vision: from MIPS to APMs


How to succeed with MACRA Don’t take the transition year off, instead prepare for success

Learn about the programLearn what it means for your bottom line, and what’s coming in the future. qpp.cms.gov and Greenway Health webinars

Compare your dataLook at your historical data and measures, and focus on what you’re good at, what’s relevant to your patient population, and where you can make the easiest improvements.

Design a planDesign a plan based on your data that accounts for 2017 and 2018. Use the transition year to test your plan, don’t slack this year or 2018 might catch you off-guard.

Design

Compare

Learn


Poll question

Are you interested in learning more? Let us know:a) I would like to preregister for your webinar on

December 21 at 12:00 p.m. ETb) I would like to speak with a Greenway Health

representative c) I'm not interested at this time


QUESTIONS


Acronyms Cheat

• ACI: Advancing Care Information• APM: Alternative Payment Model• CPIA: Clinical Practice Improvement Activities• EC: Eligible Clinician• HHS: The US Department of Health & Human Services• MACRA: Medicare Access & CHIP Reauthorization Act of

2015• MIPS: Merit-based Incentive Payment System• MU: Meaningful Use• NP: Nurse Practitioner• NPRM: Notice of Proposed Rulemaking• PA: Physician Assistant


Resources

• The Final Rule for 2018• Year 2 Overview fact sheet• 2017 Extreme and Uncontrollable Circumstances

Policy for MIPS fact sheet

https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf?utm_campaign=pi%20subscription%20mailing%20list&utm_source=federalregister.gov&utm_medium=email

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Interim-Final-Rule-with-Comment-fact-sheet.pdf

macra in 2018 - greenwayhealth.com€¦ · • macra notice and comment closes early in the month...

Documents