macra legislation and the quality payment program: what...
TRANSCRIPT
MACRA Legislation and the Quality Payment Program: What
You Need to Know!
November 9th, 2017
Learning Objectives
Agenda
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1. Understand how the 2017 & 2018 Performance
categories differ from one another
2. Identify which track participants are eligible for and
their options to participate in the following years
3. Understand the current and future program
requirements and learn the steps to take to be
successful amid payment adjustments
About HQI
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HQI is a non-profit healthcare quality consulting company which has
been leading the way in the healthcare since 1984.
Virginia & Maryland’s Quality Innovation Network-Quality
Improvement Organization (QIN-QIO) for CMS
Virginia’s Regional Extension Center (REC) for ONC
Southeast Practice Transformation Network (PTN) for CMS
Participant in AHRQ EvidenceNow Heart Health Collaborative
Quality Payment Program (QPP)
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The Quality Payment Program policy reforms
Medicare Part B payments and is a major step in
improving care across the entire health care
delivery system.
Quality Program Alignment
Healthcare Payment and Learning Action Network
Meaningful Measures
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• Group of public and private insurers, businesses and
others who have partnered together to commit to
payments tied towards quality and value and not fee for
service
• Changes in payment will trickle down from Medicare to
private insurers
Initiative
Meaningful Measures
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The Meaningful Measures initiative will “involve only
assessing those core issues that are most vital to providing
high-quality care and improving patient outcomes.”
CMS “aims to focus on outcome-based measures going
forward, as opposed to trying to micromanage processes.”
Outcome Measure
Meaningful Measures
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The health state of a patient resulting from health care. An
outcome measure can be used to assess quality of care to
the extent that health care services influence the
likelihood of desired health outcomes. Outcome-based
measures of quality reflect the cumulative impact of
multiple processes of care. Readmission (to the hospital)
and mortality (or death) rates are examples of outcome
measures.
Meaningful Measures
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CMS is “revising current quality measures across all
programs to ensure that measure sets are streamlined,
outcomes-based, and meaningful to doctors and patients”
and that Meaningful Measures “takes a new approach to
quality measures to reduce the burden of reporting on all
providers.”
a. Fee-for service, physicians paid on volume
b. Legacy Incentive programs phasing out
c. Transitioning to the Quality Payment
Program
Current Landscape
HHS Goals: Value Based Payment
Advanced Alternative Payment
Models (advanced APM)
• Qualifying participation
(QP) in an advanced APM
can earn clinicians a
Medicare incentive
payment for participating
in an innovative payment
model.
• Visit QPP.CMS.gov for a
full list of advanced APMs.
Merit-based Incentive Payment
System (MIPS)
Two QPP Tracks
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• Traditional Medicare
participation may earn a
performance-based
payment adjustment
through MIPS.
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Merit-based Incentive Payment System
(MIPS)
Starting in 2017
• Physicians
• Physician Assistants
• Nurse Practitioners
• Clinical Nurse Specialists
• Certified Registered Nurse
Anesthetists
Starting in 2019
MIPS Eligible Clinicians (EC)
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Secretary has the authority to add
other providers such as
• Physical or occupational therapists
• Speech-language pathologists
• Audiologists
• Nurse midwives
• Clinical social workers
• Clinical psychologists
• Dietitians / Nutritional professionals
Physician means doctor of medicine, doctor of
osteopathy (including osteopathic practitioner), doctor of
dental surgery, doctor of dental medicine, doctor of
podiatric medicine, or doctor of optometry, and, with
respect to certain specified treatment, a doctor of
chiropractic legally authorized to practice by a State in
which he/she performs this function.
MIPS Eligible Clinicians (EC)
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2017 & 2018 MIPS Exemptions
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• Clinicians who enroll in Medicare for the first time
during a performance period are exempt from
reporting on measures and activities for MIPS until the
following performance year.
• Clinicians significantly participating (QP) in Advanced
APMs
2017 & 2018 MIPS Exemptions
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Individual
• Individual NPI and TIN to
which their benefits are
reassigned
Group
2017 Individual vs. Group
MIPS Reporting
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• Two or more clinicians (NPIs)
who have reassigned their
billing rights to a single TIN OR
• As an APM Entity
If clinicians participate as a group they are assessed as a group across all four MIPS performance categories.
Individual
• Individual NPI and TIN to
which their benefits are
reassigned
Group
2018 Individual vs. Group
MIPS Reporting
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• Two or more clinicians (NPIs)
who have reassigned their
billing rights to a single TIN OR
• As an APM Entity
If clinicians participate as a group they are assessed as a group across all four MIPS performance categories.
&
Virtual Group
• Combination of 2 or more
Taxpayer Identification
Numbers (TINs) made up
of solo practitioners and
groups of 10 or fewer
eligible clinicians who
come together “virtually”
(no matter specialty or
location) to participate in
MIPS for a performance
period of a year.
Timeline from Performance
to Payment Adjustment
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2017 Transition Year
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Transitional policies in 2017 will focus the
program in its initial years on encouraging
participation and educating clinicians, all with
the primary goal of placing the patient at the
center of the healthcare system.
MIPS Performance Categories
vs. Previous Programs
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Replaces PQRSNew
Replaces Medicare EHR
Incentive Program
(Meaningful Use)
Replaces Value-based Modifier
MIPS Performance Categories
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Pick Your Pace Reporting Options
Pick Your Pace Reporting 2017
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Pick Your Pace Reporting 2017
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Submit 90-day minimum up to full calendar year of data
Pick Your Pace Reporting 2017
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More than 1 More than 1More than the
4-5 Required
Submit 90-day minimum up to full calendar year of data
Pick Your Pace Reporting 2017
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All required
measures
All required
measures
Base plus
Performance Data
Submit 90-day minimum up to full calendar year of data
AND AND
MIPS Final Score and Adjustments based on
2017 Performance Year
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Overview of Performance Categories
Quality Category Overview
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Quality Category = 60% of 2017 Final Score
• Submit 6 quality measures
• 1 of the measures must be an outcome measure
or a high priority measure
• Submit at least 90 days of data
Measures are posted online at
https://qpp.cms.gov/measures/quality
Quality Category Overview
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Quality Category Considerations
• Highest weighted MIPS performance category
• Some quality measures with historically high
performance rates are considered “topped out”
• Topped out measures have the potential to
earn fewer points
Easy Win Tip!
After selecting quality measures think about the
ACI measures or Improvement Activities you could
use to support high performance.
Advancing Care Information (ACI)
Category Overview
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ACI Category = 25% of 2017 Final Score
• Submit all required base measures
• Failure to report on the required base measures
will result in a score of 0 for the ACI category
• Submit performance measures to increase score
• Submit at least 90 days of data
Advancing Care Information (ACI)
Category Overview
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ACI Considerations
• Must use Certified EHR Technology (CEHRT) to
report
• In 2017, there are 2 measure sets for reporting
based on EHR edition:
Option 1: Advancing Care Information Objectives and
Measures
Option 2: 2017 Advancing Care Information Transition
Objectives and Measures
• ACI measures can be found online at
https://qpp.cms.gov/resources/education
Advancing Care Information (ACI)
Category Overview
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Easy Win Tip!
Review EHR workflows and address inefficiencies that
create obstacles. For example, do frequently used
documents take an unreasonable amount of time to
load? Are templates awkward or excessively time
consuming for the end user to navigate? Does staff
suffer from alert fatigue and skip recommendations
on how to handle specific patient populations?
Advancing Care Information (ACI)
Category Overview
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ACI Option 1 Measures
Eligible clinicians can use the ACI Option 1 Measures
• If you have technology certified to the 2015
Edition; or
• If you have a combination of technologies from
2014 and 2015 Editions that support these
measures.
Advancing Care Information (ACI)
Category Overview
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ACI Option 2 Measures
Eligible clinicians can use the ACI Option 2 Measures
• If you have technology certified to the 2015
Edition; or
• If you have technology certified to the 2014
Edition; or
• If you have a combination of technologies from
2014 and 2015 Editions.
Advancing Care Information (ACI)
Category Overview
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ACI Measure Exclusions
There will be exclusions for the Health Information
Exchange (HIE) measure, formerly Summary of Care, as
well as the e-Prescription (e-Rx) measure.
• HIE – Any MIPS eligible clinician who transfers a patient
to another setting or refers a patient <100 times during
the performance period.
• e-Rx – Any MIPS eligible clinician who writes fewer than
100 permissible prescriptions during the performance
period.
Improvement Activities Category Overview
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Improvement Activities = 15% of 2017 Final Score
• Choose 1 of the following combinations:
• 2 high-weighted activities OR
• 1 high-weighted activity + 2 medium-weighted
activities OR
• 4 medium-weighted activities
• Small practices*, rural practices*, Health
Professional Shortage Area* (HPSA) and non-
patient facing* eligible clinicians choose:
• 1 high-weighted activity OR
• 2 medium-weighted activities
*Refer to the MACRA Final Rule for definitions
Improvement Activities Category Overview
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Improvement Activity Considerations
• Participants in certified patient-centered medical
homes (PCMH), comparable specialty practices, or
an APM designated as a Medical Home Model will
automatically earn full Improvement Activity credit.
• Consult the Final Rule for Improvement Activity
credit given to APM participants.
• Improvement Activities can be found online at
https://qpp.cms.gov/measures/ia
Improvement Activities Category Overview
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Easy Win Tip!
Choose Improvement Activities after selecting
Quality Measures. Opt for Improvement Activities
that will support higher Quality Measures scores.
Cost Category Overview
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Cost Category = 0% of 2017 Final Score
• No reporting requirement – assessed on Medicare
claims data
• CMS will still provide Cost Category feedback for
the 2017 performance year, but it will not affect
2019 payments
Cost Category Overview
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Easy Win Tip!
In preparation for 2018 MIPS reporting,
use your QRUR to identify areas of high cost for your
population
Next Steps
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1) Determine whether MIPS reporting is necessary.
2) Follow HQI’s “Nine-Step Guide to Reporting in the
Merit-Based Incentive Payment System.”
3) Visit our FREE Resource Center
http://www.hqi.solutions/resource-center/
4) Ask for help!
Quality Payment Program Year 2
Final Rule for 2018
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1. Virtual Groups
2. Increasing the Low Volume Threshold
3. Multiple submission mechanisms
4. Rewards for quality improvement
5. Adding more Improvement Activities
6. Exclusions for HIE and e-prescribe
7. Add points for complex patients
8. Bonus points for small practices
Important Changes in 2018
Final Rule for 2018
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• Neutral payment adjustment score increases from 3pts to 15pts.
• Use of 2014 Edition and/or 2015 Certified Electronic Health
Record Technology (CEHRT) allowed. Bonus for 2015 CEHRT*.
• 5 point bonus for treatment of complex patients.
• Re-weighting the Quality, Advancing Care Information, and
Improvement Activities performance categories at 0% of the final
score for clinicians impacted by hurricanes Irma, Harvey and
Maria and other natural disasters.
Changes for small practices (15 or fewer clinicians)
Final Rule for 2018
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• Clinicians MIPS exempt with ≤ $90,000 in Part B
allowed charges OR ≤ 200 Part B beneficiaries
• Additional 5 point bonus to final score
• 3 points for Quality measures that don’t meet data
completeness requirements
• New hardship exception for the ACI performance
category
• Solo/Small practices have option to form or join
Virtual Group
Virtual Groups
Final Rule for 2018
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A Virtual Group is a combination of 2 or more Taxpayer
Identification Numbers (TINs) made up of solo
practitioners and groups of 10 or fewer eligible clinicians
who come together “virtually” (no matter specialty or
location) to participate in MIPS for a performance period
of a year.
The CMS Virtual Groups Toolkit with additional
information, including the election process, can be found
at https://www.cms.gov/Medicare/Quality-Payment-
Program/Resource-Library/Resource-library.html
Performance Score Weights
Final Rule 2018
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1. Quality = 50% in 2020 payment year. Must report a
full calendar year
2. Cost = 10 % in 2020 payment year
3. Improvement Activities = 15% in 2020 payment year
4. Advancing Care Information (ACI) = 25% in 2020
payment year
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Frequently Asked Questions
We are a specialty group and do not have a Medicare
Population: does MIPS apply to us?
FAQs
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1. Did you receive an eligibility determination letter? The eligibility
letters sent out by CMS indicated if clinicians were excluded from
MIPS due to charges or volume below the thresholds.
2. If you didn’t receive an eligibility letter, are you credentialed to
receive payment from Medicare? Have you checked your account
in PECOS?
3. You can check your eligibility status using the Look-Up Tool on
the CMS QPP website: https://qpp.cms.gov/
To avoid a payment adjustment, clinicians only need to
submit one measure at the minimum?
FAQs
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1. Yes, clinicians can submit at the minimum one
measure for a neutral payment adjustment.
2. HQI recommends submitting 90 days of data to
completely test report generation and data submission
and to potentially earn an incentive or positive
payment adjustment.
How do we meet the security risk assessment
requirement?
FAQs
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1. SRAs can be completed by an outside company or
consultant for a fee. Fees vary from company to company
and there is no set cost. HQI offers SRAs as a line of service.
2. There is a tool that can be used on the Health IT.gov
website. https://www.healthit.gov/providers-
professionals/security-risk-assessment-tool *Best practices
recommended that SRAs be completed by an outside
entity.
3. IT and EHR vendors offer assessments but they only
address your software and hardware, not your policies or
employees.
FAQs
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What is the low volume determination period?
A 24-month assessment period which includes a 2-segment
analysis of Medicare Part B claims data during an initial 12-
month period prior to the performance period followed by
another 12-month period during the performance period.
FAQs
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Are Medicare Advantage plans taken into
account in the low-volume determination?
Beneficiaries enrolled in Medicare Advantage plans that
receive their Part B services through their Medicare
Advantage plan will not be included in allowed charges billed
under Medicare Part B for determining the low-volume
threshold.
FAQs
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Are Rural Health Clinics (RHC) and Federally
Qualified Health Clinics (FQHC) exempt from
MIPS?
Items and services furnished by a MIPS eligible clinician that
are billed Medicare Part B charges by the MIPS eligible
clinician would be subject to the MIPS payment adjustment.
Some clinics do bill a small amount of Medicare Part B, while
others bill none. It is possible that a RHC or FQHC eligible
clinician with Medicare Part B claims would fall below the low
volume determination threshold.
FAQs
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What if a MIPS eligible clinician (such as a NP,
PA, etc.) bills under a supervising clinician’s
NPI? Does the rendering provider need to report
to MIPS?
The practice should report MIPS for any ECs listed under the
TIN in PECOS (Medicare credentialing).
Log into PECOS
(https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 ) to
see the NPIs listed under the TIN.
Where To Get Help
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Practice Size –
Eligible Clinicians
Email Phone
16 or more [email protected] 1-844-357-0589
15 or fewer [email protected] 1-866-333-4702
Practice
Transformation
Network
[email protected] 1-844-357-0589
@hqinnovators
hqinnovators
qin.hqi.solutions
Connect with us for up-to-date information
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Contact Information
Ward McGroarty, MHA
Physician Services Task Lead
804-287-6218
HQI Resource Center
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Free Resources on our Website!
HQI Resource Center
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http://www.hqi.solutions/resource-center/
QA&
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