MACRA MIPS QPP and APMs

Program Updates

Dale W Bratzler DO MPH MACOI FIDSAEdith Kinney Gaylord Presidential Professor

Professor Colleges of Medicine and Public HealthChief Quality Officer ndash OU Physicians

Medical Director ndash Clinical Skills Education and Testing Center

April 28 2018

Speaker Disclosure

I have no relevant financial relationships or affiliations to disclose

Dale W Bratzler DO MPH

dale-bratzlerouhscedu

Speaker Disclosure

bull Current appointment as a ldquoQuality Payment Program Clinical Championrdquo for the Centers for Medicare amp Medicaid Services

bull Recently appointed member of the Technical Expert Panel (TEP) for the project entitled ldquoDevelopment of Inpatient Outcome Measures for the Merit-based Incentive Payment Systemrdquo

bull Rural Quality Advisory Panel for the Rural Quality Improvement Technical Assistance (RQITA) Program (funded by the Federal Office of Rural Health Policy)

bull Co-Chair National Quality Forum Technical Advisory Panel ndashPrimary Care and Chronic Illness Safety Standing Committee

All are volunteer positions

Objectives

bull Explain the drivers promoting change in payment methods

bull Review the background of the Quality Payment Program

bull Review statutory updates to MIPS and the QPP

Payment reform in healthcare is inevitable

httpswwwnprorgsectionsthetwo-way20180130581804474amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

Health care costs are a hungry tapeworm on the American

economy Berkshire Hathaway Chairman and CEO Warren Buffett says and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their US

employees at a lower cost

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Speaker Disclosure

I have no relevant financial relationships or affiliations to disclose

Dale W Bratzler DO MPH

dale-bratzlerouhscedu

Speaker Disclosure

bull Current appointment as a ldquoQuality Payment Program Clinical Championrdquo for the Centers for Medicare amp Medicaid Services

bull Recently appointed member of the Technical Expert Panel (TEP) for the project entitled ldquoDevelopment of Inpatient Outcome Measures for the Merit-based Incentive Payment Systemrdquo

bull Rural Quality Advisory Panel for the Rural Quality Improvement Technical Assistance (RQITA) Program (funded by the Federal Office of Rural Health Policy)

bull Co-Chair National Quality Forum Technical Advisory Panel ndashPrimary Care and Chronic Illness Safety Standing Committee

All are volunteer positions

Objectives

bull Explain the drivers promoting change in payment methods

bull Review the background of the Quality Payment Program

bull Review statutory updates to MIPS and the QPP

Payment reform in healthcare is inevitable

httpswwwnprorgsectionsthetwo-way20180130581804474amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

Health care costs are a hungry tapeworm on the American

economy Berkshire Hathaway Chairman and CEO Warren Buffett says and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their US

employees at a lower cost

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Speaker Disclosure

bull Current appointment as a ldquoQuality Payment Program Clinical Championrdquo for the Centers for Medicare amp Medicaid Services

bull Recently appointed member of the Technical Expert Panel (TEP) for the project entitled ldquoDevelopment of Inpatient Outcome Measures for the Merit-based Incentive Payment Systemrdquo

bull Rural Quality Advisory Panel for the Rural Quality Improvement Technical Assistance (RQITA) Program (funded by the Federal Office of Rural Health Policy)

bull Co-Chair National Quality Forum Technical Advisory Panel ndashPrimary Care and Chronic Illness Safety Standing Committee

All are volunteer positions

Objectives

bull Explain the drivers promoting change in payment methods

bull Review the background of the Quality Payment Program

bull Review statutory updates to MIPS and the QPP

Payment reform in healthcare is inevitable

httpswwwnprorgsectionsthetwo-way20180130581804474amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

Health care costs are a hungry tapeworm on the American

economy Berkshire Hathaway Chairman and CEO Warren Buffett says and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their US

employees at a lower cost

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Objectives

bull Explain the drivers promoting change in payment methods

bull Review the background of the Quality Payment Program

bull Review statutory updates to MIPS and the QPP

Payment reform in healthcare is inevitable

httpswwwnprorgsectionsthetwo-way20180130581804474amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

Health care costs are a hungry tapeworm on the American

economy Berkshire Hathaway Chairman and CEO Warren Buffett says and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their US

employees at a lower cost

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Payment reform in healthcare is inevitable

httpswwwnprorgsectionsthetwo-way20180130581804474amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

Health care costs are a hungry tapeworm on the American

economy Berkshire Hathaway Chairman and CEO Warren Buffett says and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their US

employees at a lower cost

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpswwwnprorgsectionsthetwo-way20180130581804474amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

Health care costs are a hungry tapeworm on the American

economy Berkshire Hathaway Chairman and CEO Warren Buffett says and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their US

employees at a lower cost

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Health care costs are a hungry tapeworm on the American

economy Berkshire Hathaway Chairman and CEO Warren Buffett says and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their US

employees at a lower cost

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpwwwmodernhealthcarecomarticle20180131NEWS180139978utm_source=modernhealthcareamputm_medium=emailamputm_content=20180131-NEWS-180139978amputm_campaign=am

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpbusinessroundtableorgmedianews-releasesstudy-shows-uncompetitive-tax-code-contributes-increased-foreign-acquisition-us

Fixing the tax code will make American businesses more competitive globallyhellip

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpswwwcfrorgbackgrounderhealthcare-costs-and-us-competitiveness

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpwwwcommonwealthfundorgPublicationsFund-Reports2017JulMirror-Mirror-International-Comparisons-2017

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

0

2

4

6

8

10

12

14

16

18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

United States (166)

Switzerland (114)

Sweden (112)

France (111)

Germany (110)

Netherlands (109)

Canada (100)

United Kingdom (99)

New Zealand (94)

Norway (93)

Australia (90)

Percent of GDP

E C Schneider D O Sarnak D Squires A Shah and M M Doty Mirror Mirror 2017 International Comparison Reflects Flaws and Opportunities for Better US Health Care The Commonwealth Fund July 2017 Available at

httpwwwcommonwealthfundorgpublicationsfund-reports2017julmirror-mirror-international-comparisons-2017

Corporate healthcare costs ndash A competitive disadvantage in the global market

GM says healthcare costs add between $1500 and $2000 to the sticker price of every automobile it makes

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

CMS projected that healthcare spending will on average rise 55 percent annually from 2017 to 2026 and will comprise 197 percent of the US economy in 2026 up from 179 percent in 2016 By 2026 health spending is projected to reach $57 trillion

httpswwwreuterscomarticleus-usa-healthcare-spendingu-s-healthcare-spending-to-climb-5-3-percent-in-2018-agency-idUSKCN1FY2ZD

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpswwwpgpforgbudget-basicsbudget-explainer-medicare

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Despite the amount of money the US spends on health carehellip

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Per capita health expenditures and life expectancy

1970-2014

httpeconomistsviewtypepadcomeconomistsview2

01703life-expectancy-and-health-

expenditurehtml

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpswwwhealthsystemtrackerorgbriefincreases-in-cost-sharing-payments-have-far-outpaced-wage-growth_sf_s=Payments+for+cost+sharing+item-start

More out-of-pocket spending for healthcare

Widening gap between

wages and out-of-pocket

costs

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Payment Reform seems Inevitable

bull We have a payment system that has rewarded more care (including redundancy) regardless of the value (or quality) of that care Fee-for-service payment is inflationary

bull Payment models have not promoted coordination of care across settings

bull Poor outcomes and disparities of care persist

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Remember when we had the SGR

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpwwwgpogovfdsyspkgBILLS-114hr2enrpdfBILLS-114hr2enrpdf

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Republican controlled Senate and House

bull Senate vote 92 yea 8 nay

bull House vote 392 yea 37 nay

House sponsor Michael C Burgess MD [R - Texas]

Repealed the SGR

Very bipartisan

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

MACRA moves Medicare Part B clinicians to a performance-based

payment system

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

What is the Merit-based Incentive Payment System

Combines legacy programs into single improved reporting program

PQRS

VM

EHR

Legacy Program Phase Out

2016 2018

Last Performance Period PQRS Payment End

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

TITLE ImdashSGR Repeal and Medicare Provider Payment Modernization ndash What happened in 2017

Eligible Professional

Advanced Alternate Payment Mechanisms (APM)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models 5 bonus each year from 2019-

2024 075 increase per year beginning

in 2026

Merit-based Incentive Payment System (MIPS)dagger

bull Providers receive a score of 0-100bull Each year CMS will establish a

threshold score based on the median or mean composite performance scores of all providers Providers scoring above the threshold will

receive bonus payments (up to three times the annual penalty cap)

daggerPerformance scores will be posted to Physician Compare website

Quality Payment Program (QPP)

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

What Is MIPS Performance Categories

bull Reporting standards align with Alternative Payment Models when possible

bull Many measures align with those being used by private insurers

Quality CostImprovement

ActivitiesAdvancing Care

Information

MIPS

FINAL SCORE

(0 ndash 100)

Clinicians will be reimbursed under Medicare Part B based on this Performance Score

Cost was not considered in the score for 2017

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

MIPS Scoring for Quality

Select 6 of the approximately 300 available quality measures (minimum of 90 days)bull Or a specialty setbull Or CMS Web Interface measuresbull Readmission measure is included for group reporting with groups with

at least 16 clinicians and sufficient cases

Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

Failure to submit performance data for a measure = 0 points

Bonus points are

available

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

wwwqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

wwwqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpsqppcmsgovresourceseducation

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Costs

bull CMS will calculate from claims episode-specific measures to account for differences among specialties

ndash For cost measures clinicians that deliver more efficient care achieve better performance and score the highest points (the most efficient resource use)

ldquoEpisodes of carerdquo roll up all costs of inpatient and outpatient care (including imaging laboratory drugs rehabilitation etc)

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

MIPS Performance Category

Improvement Activities ndash 15 of Score

bull Attest to participation in activities that improve clinical practice

ndash Examples Shared decision making patient safety coordinating care increasing access

bull Clinicians choose from 90+ activities under 9 subcategories

4 Beneficiary Engagement

2 Population Management

5 Patient Safety and Practice Assessment

1 Expanded Practice Access 3 Care Coordination

6 Participation in an APM

7 Achieving Health Equity8 Integrating Behavioral

and Mental Health9 Emergency Preparedness

and Response

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpsqppcmsgovmeasuresia

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

MIPS Scoring for Improvement Activities(15 of Final Score in Transition Year)

Total points = 40

Activity Weights

- Medium = 10 points

- High = 20 points

Alternate Activity Weights

- Medium = 20 points

- High = 40 points

For clinicians in small rural and underserved practices or with non-patient facing clinicians or groups

Full credit for clinicians in a

patient-centered medical home Medical Home

Model or similar specialty practice

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Option 1 Option 2 Option 1 Option 2

MIPS Performance Category

Advancing Care Informationbull Clinicians must use certified EHR technology to report

For those using EHR Certified

to the 2015 Edition

For those using

2014 Certified EHR Technology

Advancing Care

Information Objectives and

Measures

Combination of the two

measure sets

2017 Advancing

Care Information Transition

Objectives and Measures

Combination of the two

measure sets

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

MIPS Scoring - Advancing Care Information(25 of Final Score) Base Score

Clinicians must submit a numeratordenominator or YesNo response for each of the following required measures

Advancing Care Information Measures

2017 Advancing Care Information Transition

Measures - Security Risk Analysis- e-Prescribing - Provide Patient Access- Send a Summary of Care- RequestAccept a

Summary of Care

- Security Risk Analysis- e-Prescribing - Provide Patient Access- Health Information

Exchange

Base score (worth 50 )

Failure to meet reporting requirements will result in base score of zero and an advancing care information performance score of zero

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

MIPS Scoring - Advancing Care Information(25 of Final Score) Performance Score

Advancing Care Information Measures

Measure Performance

Score

Provide Patient Access Up to 10

Patient-Specific EducationUp to 10

View Download and Transmit (VDT)Up to 10

Secure Messaging Up to 10

Patient-Generated Health DataUp to 10

Send a Summary of CareUp to 10

RequestAccept a Summary of CareUp to 10

Clinical Information ReconciliationUp to 10

Immunization Registry Reporting 0 or 10

Advancing Care Information Transitional Measures

Measure Performance

Score

Provide Patient Access Up to 20

Health Information Exchange Up to 20

View Download or TransmitUp to 10

Patient-Specific Education Up to 10

Secure Messaging Up to 10

Medication Reconciliation Up to 10

Immunization Registry Reporting 0 or 10

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Scoring under MIPS

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

Sliding scale negative adjustment

70

Except for the ldquotop performancerdquo incentives the program must be budget neutral There

have to be losers to have incentive payments

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Alternate Payment Models (APMs)

bull ldquoSubstantial portionrdquo of revenues from ldquoapprovedrdquo alternate payment models

ndash For now very few ldquoapprovedrdquo APMs

ndash Not subject to MIPS

bull Receive 5 lump sum bonus payments for years 2019-2024

bull Receive a higher fee schedule update from 2026 onward

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Alternate Payment Models

bull Advanced APMs defined as those that meet criteria for linking payments to quality measures using EHRs and nominal risk Only participants in Advanced APMs at MACRA thresholds qualify for 5 lump sum payments

bull Current models that meet Advanced APM criteria are Track 2 amp 3 ACOs Next Generation ACOs Comprehensive Primary Care Plus (CPC+) some Comprehensive ESRD Care organizations (ESCOs)ndash 6 (1) MSSP ACOs are in Track 2 and 16 (4) are in Track 3

ndash There are 13 ESCOs and 18 Next Gen ACOs

ndash CPC+ just announced three weeks ago

The practice must bear more than nominal financial risk

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Qualifying Advanced APMs

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

Advanced APM ndash to avoid MIPS

httpsqppcmsgov

httpsqppcmsgov

48

49

50

51

52

Scoring for MIPS - 2018

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

70

15

54

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

49

50

51

52

Scoring for MIPS - 2018

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

70

15

54

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

50

51

52

Scoring for MIPS - 2018

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

70

15

54

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

51

52

Scoring for MIPS - 2018

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

70

15

54

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

52

Scoring for MIPS - 2018

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

70

15

54

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

Scoring for MIPS - 2018

Threshold (No Payment Adjustment)

Maximum Penalty

Top performance -Additional ldquoBonusrdquo

Incentive

100

0

Po

ints

4 in 2018 5 in 2019 7 in 2020 and 9 in 2021 to 2023

Sliding scale positive adjustment

70

15

54

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

54

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

bull Link to the legislation itself

bull httpswwwcongressgovbill115th-congresshouse-bill1892textq=7B22search223A5B22bipartisan+budget+act+of+2018225D7Dampr=1

bull More information from CMS on these details in the coming months

55

Additional Flexibility for the MIPS Transition

in theBipartisan Budget Act 2018

In closinghellip

bull In my opinion healthcare payment reform is inevitable

bull There is strong and bipartisan support to move away from fee-for-service payment

bull Physicians will increasingly have to participate in programs that promote value-based payment models

dale-bratzlerouhscedu

dale-bratzlerouhscedu