macra: payment reform...macra establishes two medicare paths for physicians • macra was designed...

© 2016 American Medical Association. All rights reserved.

Oklahoma State Medical Association

Cori H. Loomis, JD

Winter 2017

MACRA: Payment Reform


Some general observations

• MACRA is complex

– More than a “replacement for the SGR”

• Final Rule released in October 2016.

– Softens several parameters of the MACRA regime.

– Provides for 2017 to be a “transition year”.

– Weakens the thresholds by which providers may participate.

– Reduced the amount of measures required for reporting

– Softened the degree of risk providers must accept in Advanced APMs

2


Regulatory timeline

3

NPRM comments deadline

• June 27, 2016

Final MACRA rule issued

• Fall 2016 (Nov. 1?)

MIPS measurement and APM participation begins

• Jan 1, 2017

Second year of measurement

• 2018

MIPS and APM pay adjustments for 2017 performance occur

• Jan 1, 2019

• Implementation timeline

concerns:• Short lead-time for

physicians to learn the

rules

• Inadequate time to

make practice

adjustments

• Too few APMs are

available

Source: American Medical Association, 2016


MACRA – Statistics

4


Quality Payment Programs - Goals

• Support care improvement by focusing on better outcomes for patients,

decreased provider burden, and preservation of independent clinical

practice.

• Promote adoption of Alternative Payment Models that align incentives

across healthcare stakeholders.

• Advance existing efforts of delivery system reform, including ensuring a

smooth transition to a new system that promotes high-quality, efficient

care through unification of CMS legacy programs.

5

© 2016 American Medical Association. All rights reserved. 6

MACRA establishes two Medicare paths for physicians

• MACRA was designed to offer

physicians two payment model

pathways:

• A modified fee-for-service model

(MIPS)

• New payment models that reduce

costs of care and/or support high-value

services not typically covered under

the Medicare fee schedule (APMs)

• In the beginning, most are expected to

participate in MIPS

MIPS

APMs

Merit-based

Incentive Payment

System (MIPS)

7


Merit-Based Incentive Payment System

• A new program for certain Medicare-participating eligible clinicians that will make payment adjustments based on performance on quality, cost and other measures, and will consolidate components of 3 existing programs.

• MIPS will focus on:

– Quality – both a set of evidence-based, specialty-specific standards as well as practice-based improvement activities.

– Cost

– Use of certified-E.H.R. technology to advance interoperability

8


MIPS Participation

• Years 1 and 2 (others added in Year 3)

– Physicians

– Physician assistants

– Nurse Practitioners

– CRNAs

– Clinical Nurse Specialists

• 3 Groups who will NOT be subject to MIPS:

– First year of Medicare Part B Participation

– Below low patient volume threshold

– Certain participants in ADVANCED Alternative Payment Models

9


Transition Year – Final Rule

• Here is the Key:

You must do something in 2017 to

avoid penalty in 2019.

10


Timeline on payment adjustments

11

2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

on

Fee

Schedule

Updates

MIPS

QPs in

Adv.

APMs

0.5% annual baseline updates No annual baseline updates

4% 5% 7% 9%Max Adjustment(additional bonuses

possible)

0.25%

or

0.75%

9% 9% 9%

5% bonus



“Pick Your Path” - Four Reporting Options

• Option One: Test the Program

– Physicians required to report some data from after Jan. 1 to the Quality

Payment Program.

• Option Two: Partial-Year Reporting

– Physicians can choose to report Quality Payment Program information for a

reduced number of days.

• Option Three: Full-Year Reporting

– If ready, physicians can go ahead and report for the full calendar year 2017.

• Option Four: Advanced Alternative Payment Model (APM)

12


MIPS components

Quality Reporting (was

PQRS)

Resource Use or Cost (was Value-based Modifier)

Advancing Care Information (was

MU)

Clinical Practice Improvement

Activities

MIPS

13

MIPS aims:• Align 3 current independent programs

• Add 4th component to promote improvement and

innovation

• Provide more flexibility and choice of measures

• Retain a fee-for-service payment option

Clinicians exempt from MIPS (Final Rule

accepts AMA’s recommendation):• Increased low-volume threshold to $30K OR 100

patients

• About 600,000 clinicians are expected to

be affected by the law.

• 380,000 clinicians could be exempt

• $20 million will be dedicated for 5 years to

train and educate Medicare clinicians in

small practices of 15 clinicians or less in

underserved areas

Source with Modification: American Medical Association, 2016


MIPS Score

• A single MIPS composite performance score (CPS) will factor in

performance in 4 weighted performance categories on a 0-100 point

scale.

• Based on a MIPS Composite Performance Score , clinicians will receive

+/-or neutral adjustments.

14


MIPS component weights and scoring

15

Performance

Category

2017 2019 2020 2021

Quality 60% 50% 45% 30%

Resource

Use

0% 10% 15% 30%

ACI 25% 25% 25% 25%

CPIA 15% 15% 15% 15%


Clinical Quality

• Performance is calculated based on the submission of quality measures on an annual basis chosen by the clinician.

• 6 measures must be reported

• The measures available to clinicians will be updated annually through a call for quality measures process. CMS will publish a final list of quality measures in the Federal Register by November 1 of each year.

• Clinicians have the option of submitting general quality measures or specialty-specific quality measures.

16


Quality reporting vs. PQRS

PQRS

9 measures

Pass/fail approach

Measures must fall across specific quality domains

Quality in NPRM

6 measures

Partial credit allowed

Flexibility in choice of measures

Transition Year -Final Rule

1 out of at least 6 measures

Higher measure points may be awarded based

on achieving higher performance in the

measure.

17



Advancing Care Information

• Performance is calculated based on the submission of five E.H.R. use-

related measures (six fewer required measures than in the proposed rule).

• These measures include:

– Security risk analysis

– E-prescribing;

– Providing patient access;

– Sending summaries of care; and

– Requesting/accepting summaries of care.

• The Final Rule eliminates the all-or-nothing approach to reporting under the

proposed rule.

• CMS allows optional measures to be submitted for a higher score.

18


Advancing care information vs. meaningful use

19

MU

100% score required on all measures to avoid 5%

penalty

Included redundant measures and

problematic CPOE, CDS and clinical quality

measures

ACI in NPRM

Pass-fail program replaced with base and

performance scoring

11 Measures (reduction from MU)

Performance score thresholds eliminated

Public health registry reporting reduced

Final Rule

Measures reduced to 5

All other measures optional

Reporting on optional measures will allow provider

to earn higher score

Bonus available in transitional year for public

health reporting

Source with Modification: American Medical Association, 2016


Clinical Practice Improvement Activities

• Performance is calculated based on the clinician’s attestation to having

completed 4 clinical practice improvement activities.

• This is a reduction from the six activities under the proposed rule.

• Bonus scores are available for clinical improvement activities that use

certified electronic health record technology and for reporting to public

health and clinical data registries.

• Clinicians will be able to choose the activities that best fit their practice.

– 90+ proposed activities

• This is a new category and does not replace an existing program.

20


CPIA categories

Expanded Practice Access

Population Management

Care Coordination

Beneficiary Engagement

Patient Safety & Practice

Assessment

Achieving Health Equity

Emergency Response and Preparedness

Integrated Behavioral & Mental Health

21



Examples of Clinical Practice Improvement Activities

• Some examples of high-weighted activities (20 points) include:

– Beneficiary Engagement: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.

– Patient Safety and Practice Assessment: Consultation of Prescription Drug Monitoring Program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days.

• Examples of medium-weighted activities (10 points) include:

– Care Coordination: Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: participate in a Health Information Exchange, if available, and/or use structured referral notes.

– Population Management: Participation in research that identifies interventions, tools, or processes that can improve a targeted patient population.

22


CPIA Scoring

• Each activity is worth a certain number of points

• Activities categorized as “high” or “medium”, earning 20 or 10 points each, respectively.

• To get maximum credit, must achieve at least 60 points (can be achieved by selecting combination of high-and medium-weighted activities, all high-weighted, or all medium-weighted activities)

• Rules for non-patient facing, small practices (15 or fewer professionals, practices located in rural areas and geographic health professional shortage areas

– First activity gets 50% of the 60 points

– Second activity gets 100% of the 60 points

– Weight does not matter

• Full credit for patient-centered medical home, Medical Home, or comparable specialty practice.

• Eligible clinicians participating in an APM automatically receive a minimum half of highest potential score; but can increase by reporting additional activities

23


Cost or Resource Utilization

• Performance under this category (referred to in the proposed rule as

“resource utilization”) will be calculated based on cost measures

specified by CMS.

• Adaption of Value-based modifier payment program.

• Clinicians do not have to report data for this category—it is calculated

independently by CMS.

• To address public comments, this category will not be factored into the

performance scores for the first payment year 2019.

24


Calculating MIPS payment adjustments (2019)

25

Quality score

weighted 50%

Cost score

weighted 10%

ACI score

weighted 25%

CPIA score

weighted 15%

Composite

Performance

Score (CPS)

CPS at threshold (tied to

average performance) = 0%

CPS above threshold = 0% to 4%

CPS below threshold = 0% to -4%

Depending on CPS distribution, upward

adjustments only could increase up to 3x to

maintain budget neutrality

Physicians with CPS scores

< 25% of threshold receive

maximum reduction

Up to $500 million available

2019-2024 to provide 10%

extra bonus for exceptional

performance (> top 25% of

those above the threshold)

Maximum adjustment ranges increase to +/- 5% in 2020, +/- 7%

in 2021, +/- 9% in 2022 onward



How to report

• MIPS eligible clinicians must collect and report data for Quality, Advancing Care Information and CPIA performance categories.

• Clinicians may report as individuals or as part of a group.

• How you choose to report determines the reporting mechanisms available.

• Data submission is due for all reporting methods across all MIPS performance categories by March 31 following the performance year, which spans January 1-December 31.

26


MIPS Data Submission Options for Quality Performance

Category

• Individual Reporting

– Claims

– QCDR

– Qualified registry

– E.H.R.

– Administrative claims (if technically feasible, no submission required)

• Group Reporting

– QCDR


– E.H.R.

– CMS Web Interface (groups of 25 or more)

– CMS-approved survey vendor for Consumer Assessment of Healthcare Providers and Systems for MIPS

– Administrative claims (if technically feasible, no submission required)

27


MIPS Data Submission Options for Advancing Care

Information Performance Category


– Attestation

– QCDR


– E.H.R.

• Group Reporting

– Attestation

– QCDR


– E.H.R.

– CMS Web Interface (groups of

25 or more)

28


MIPS Data Submission Options for CPIA Performance

Category


– Attestation

– QCDR


– E.H.R.

– Administrative claims (if

technically feasible, no

submission required)

• Group Reporting

– Attestation

– QCDR


– E.H.R.

– CMS Web Interface (groups of

25 or more)

– Administrative claims (if

technically feasible, no

submission required)

29


Special Situations

• What if a clinician changed groups after the performance period?

Performance follows the NPI

If the NPI worked for 1 TIN in performance period, then eligible

clinician’s adjustment will be based on the old TIN/NPI CPS

If the NPI worked for more than 1 TIN, we would take the weighted

average of the TIN/NPI scores

If the NPI did not have a score (because they did not bill claims), then

the NPI is not in MIPS (Excluded due to low-volume in performance period

or being newly enrolled)

30

Alternative

Payment Models

(APMs)

31


APMs participation options as outlined by CMS

32

Advanced APMs

Qualified Medical Homes

MIPS APMs

• “Advanced” APMs--term

established by CMS; these

have greatest risks and offer

potential for greatest

rewards

• Qualified Medical Homes

have different risk structure

but otherwise treated as

Advanced APMs

• MIPS APMs receive

favorable MIPS scoring

• Physician-focused APMs

are under development

Physician-

focused

APMs TBD



MACRA incentives for Advanced APM participation

Model design

• APMs have shared savings, flexible payment bundles and other desirable features

Bonuses

• In 2019-2024, 5% bonus payments made to physicians participating in Advanced APMs

Higher updates

• Annual baseline payment updates will be higher (0.75%) for Advanced APM participants than for MIPS participants (0.25%) starting 2026

MIPS exemption

• Advanced APM participants do not have to participate in MIPS (models include their own EHR use and quality reporting requirements)

33Source: American Medical Association, 2016


CMS criteria for Advanced APMs

34

Advanced APMs

EHR use

Quality Reporting

Financial

Risk

• Participants must use certified EHR technology

• At least 50% of clinicians in first year, 75%

thereafter

• Payment based on quality measures

comparable to MIPS

• Bear “more than nominal risk” for monetary

losses (current proposal is 3% of total Medicare

expenditures)

• Expanded Medical Home models exempt from

risk

• Other Medical Home models have different

standards (2.5%-5% total Medicare revenues)

• Physicians may be Qualified Participants (QPs)

or Partially Qualified Participants (PQPs) based

on revenue and patient thresholds, with

differential rewards



Currently proposed Advanced APMs

Comprehensive ESRD Care Model

(currently 13 ESCOs)

2017

Comprehensive Primary Care Plus

(2017)

Medicare Shared Savings Track 2

(currently 6 ACOs, 1% of total)

2017

Medicare Shared Savings Track 3

(currently 16 ACOs, 4% of total)

2017

Next Generation ACO Model

(currently 18)

2017

Oncology Care Model, 2-Sided

Risk Arrangement

(coming in 2018)

35Source: American Medical Association, 2016

What Physicians

Can Do to Prepare

36


General Considerations

• Determine whether you have $30,000 or less in Medicare charges and 100 or fewer Medicare patients annually. If so, you are exempt from MIPS participation.

• If you are not already participating in a patient clinical data registry, contact your specialty society about participating in theirs—data registries can streamline reporting and assist with MIPS performance scoring.

• Physicians in a practice of more than one eligible clinician should decide whether to report individually or as a group.

• Determine whether your practice meets the requirements for small, rural or non-patient- facing physician accommodations.

37


MIPS: Quality Measurement and Reporting

• Check your Medicare Physician Quality Reporting System (PQRS) feedback reports. Make sure that you understand your current quality metrics reporting requirements and how you are scoring across both PQRS and private payers. Determine which quality measures you plan to report on; there are individual measures and specialty-specific measure sets.

• Access and review the 2014 annual PQRS feedback reports to see where improvements can be made. Authorized representatives of group and solo practitioners can view the reports on the CMS Enterprise Portal using an Enterprise Identity Data Management account with the correct role.

• Consider whether you plan to report through claims, electronic health record (EHR), clinical registry, qualified clinical data registry (QCDR) or group practice reporting option (GPRO) Web-interface. The GPRO Web-interface is only available for physicians in practices of 25 or more eligible clinicians.

• Seek out local support.

38

https://portal.cms.gov/


MIPS: Resource Use

• Check your Medicare quality and resource use reports (QRURs) to see

where improvement can potentially be made. (How to Obtain a QRUR.)

• Review CMS’s proposed list of episode groups.

• Identify your most costly patient population conditions and diagnoses.

Identify targeted care delivery plans for these conditions.

• Identify any internal workflow changes that can be made to support care

delivery plans.

• Identify potential partners outside of your practice to advance a

coordinated care plan (e.g., other specialists to whom you refer

patients).

39

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html


MIPS: Clinical Practice Improvement Activities

• Review the proposed rule's list of clinical practice improvement activities (CPIAs) to evaluate what activities your practice is already doing and what adjustments it should make to complete additional activities in 2017.

• The reporting period for CPIAs is 90 days. Consider which 90 days in 2017 would work best for your practice's selected CPIAs.

• If you participate in a nationally recognized, accredited patient-centered medical home (PCMH), a Medicaid medical home model, a medical home model, or are recognized by the National Committee for Quality Assurance as a patient-centered specialty model, ensure that your certifications and accreditations (as applicable) are current. Physicians participating in these medical homes earn full CPIA credit.

40

http://www.ama-assn.org/resources/doc/washington/list-of-proposed-cpias.pdf


MIPS: Advancing Care Information

• If you have an EHR, make sure it is certified EHR technology. Determine whether it is 2014- or 2015-edition certified health information technology; the version will determine the measures on which you report in 2017.

• Speak with your vendor about how their product supports new payment model adoption. For example: How does their product support Medicare quality reporting? Document these conversations.

• Consider how to ensure that you can report at least one unique patient (or answer "yes," as applicable) for each measure of the base score’s six objectives. Ideas include:

– Reach out to existing patients to encourage their use of patient portals to view, download and transmit their health information in 2017.

– Your EHR may allow you to send a secure message through the patient portal to all of your patients at once—if so, and doing so is appropriate for your practice, consider sending an appointment reminder to all of your patients in 2017.

• Conduct a careful security risk analysis in early 2017. Failure to properly do so will result in a score of zero for this category. Your risk analysis should comply with the HIPAA Security Rule requirements. The AMA website has resources to help with this step at ama-assn.org/go/hipaa.

• Determine whether there is an additional public health registry to which you can report to receive an additional point towards your total Advancing Care Information score.

41

http://www.ama-assn.org/go/hipaa


Alternative Payment Models

• Confirm whether you are a participant in any of the advanced APMs. If

not, contact your specialty society or state medical society to find out if

there are APM opportunities for your practice.

42


Take advantage of educational opportunities

43

www.stepsforward.org

Completion of select STEPSForward™ modules meets eligibility

criteria for CPIA credit


http://www.stepsforward.org/


Stay informed

44

www.ama-assn.org/go/medicarepayment

Leverage resources from the AMA and other Federation groups

• Contact your specialty or state

medical societies to find out if

there are APM opportunities for

your practice

• Seek out local support for your

quality improvement activities• Many local organizations such

as Practice Transformation

Networks provide resources

and technical support, often free

of charge, to help small

practices

New tools coming soon


http://www.ama-assn.org/go/medicarepayment

http://www.healthcarecommunities.org/CommunityNews/TCPI.aspx

macra: payment reform...macra establishes two medicare paths for physicians • macra was designed...

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