macra payment reform - parkview medical center … · • syndromic surveillance reporting •...

MACRA Payment ReformWhat practices need to know

about MIPS and APMs in 2017

MACRA payment reform

MIPS APMs

Choose your own adventure

Copyright 2017. Medical Group Management Association© (MGMA©). All rights reserved.

Merit-Based Incentive

Payment System


MIPS: Who’s in and who’s out in 2017

Included Medicare part B payments

Physicians, PAs, NPs, CNSs, and CRNAs

Groups that include the above clinicians

Excluded Medicare Part A (e.g., hospital payments)

Clinicians, groups that fall under the low-volume threshold

Providers billing Medicare for the first year

Groups with significant participation in APMs

About 45%

of clinicians

About 55%

of clinicians


Low volume threshold

$30k in Medicare Part B charges

OR

During one of the year-long determination periods:

• Sept. 1, 2015 - Aug. 31, 2016

• Sept. 1, 2016 - Aug. 31, 2017

includes a 60-day claims run-out

100 unique Part B patients


2016 2017 2018 2019 2020 2021 2022+

MIPS timeline

+7%

-7%

+5%

-5%

+4%

-4%

+9%

-9%

First

performanceyear for MIPS

First MIPS payment

year (based on

2017 performance)

Last

performanceyear for MU,

PQRS, VM

Last payment year for

MU, PQRS, VM


Quality

30%

Advancing

Care Info

(EHR Use)

25%

Cost

30%

MIPS performance category weights

2017

IA

15%

ACI

25%

Quality

60%

IA

15%

ACI

25%

Quality

50%

IA

15%

ACI

25%

Cost

30%

Quality

30%

Over time, the cost category will gradually become larger and the quality

category will become smaller

2018 2019


Quality

30%

Advancing

Care Info

(EHR Use)

25%

Cost

30%

MIPS category weights for MIPS APMs

MSSP Track 1 and

Next Gen ACOs

IA

20%

ACI

30%

Quality

50%

IA

25%

ACI

75%

Other MIPS APMs

* Does NOT include cost * Does NOT include cost or quality


Reporting mechanisms

QCDR Qualified

Registry

EHR Attest Web

Interface

(Groups

of 25+

only)

CAHPS

vendor

(groups

only)

Claims

(indiv.

only)

Quality

ACI

CPIA

• Report either as a group (TIN) or individual (NPI) across all 4 categories

• Choose 1 submission mechanism per performance category:


Report 6 measures, including an outcome measure (or high-

priority if none available) from choice of over 200 individual

measures or select from one of 30 specialty measure sets

• Tip: When a specialty measure set contains less than 6 measures,

you are only responsible for the measures within the set

Plus, for groups of 16 or more clinicians with at least 200

attributed cases, CMS will automatically calculate an all-cause

readmissions measure from administrative claims

Each measure is worth up to 10 points and is evaluated based

on performance relative to benchmarks

• Bonus points for reporting additional outcome or high-priority

measures and for end-to-end reporting

Quality


http://www.mgma.com/government-affairs/tools/table-a-finalized-individual-quality-measures-available-for-mips-reporting-in-2017

http://www.mgma.com/government-affairs/tools/table-e-2017-finalized-mips-specialty-measure-sets

Quality

Reporting

Mechanism

Reporting

Threshold

Performance

Period

Example

QCDR, Registry,

EHR

50% of all patients Any 90 consecutive

days

Diabetes: Foot

Exam

Claims 50% of Medicare

Part B patients

Any 90 consecutive

days

COPD: spirometry

testing

Web Interface Meet sampling

requirements

Up to a full year Falls: Screening for

future risk

CAHPS Meet sampling

requirements

Up to a full year Patient experience

questions

Reporting threshold and performance period vary by submission mechanism:


Improvement ActivitiesAttest to participating in activities that improve clinical

practice; select up to 4 from inventory of high- and medium-

weighted activities

• For 2017, report via a yes/no attestation; CMS to provide

forthcoming technical guidance on future year reporting

Preferential scoring for certain ECs and groups

• Half credit: non-patient facing ECs; small and rural practices

• Full credit: accredited medical homes; MIPS APMs

Tip: Only 1 EC in group needs to participate in an activity for

entire group to get credit


http://www.mgma.com/government-affairs/tools/table-h-finalized-improvement-activities-inventory

Improvement Activities

Activity Weight Points

Provide 24/7 access to clinicians for urgent

careHigh 20

Participate in an AHRQ-listed patient safety

organizationMedium 10

Regularly assess the patient experience of

care through surveys, advisory councils,

and/or other mechanisms.

Medium 10

Total score: 40 / 40


ACI

Base score: Mandatory- failing to report any measure

results in a total ACI score of 0

Performance score: Measures are scored up to 10 or 20

points relative to historic benchmarks

Bonus points: Available for reporting data to additional

registries (5 pts) and reporting certain IAs via EHR (10 pts)

Base Score

(50%)

Performance Score

(50%)

Bonus points

Total ACI

score

0-50 pts 0-90 pts Out of 100 pts0-15 pts


2017 ACI Measures

• Syndromic surveillance reporting

• Specialized registry reporting

• Report certain IAs using EHR

Ba

se 1. Protect patient health information

2. e-Prescribing

3. Health information exchange

4. Provide patient access

5. Patient-specific education

6. View, download, or transmit

7. Secure messaging

8. Medication reconciliation

9. Immunization registry reporting

Pe

rfo

rma

nce

Bonus

x2

x2


ACI: Exceptions• ACI automatically reweighted to zero for:

• Hospital-based ECs (75%+ of services at POS 21, 22, 23)

• Non-patient facing clinicians

• Non-physicians

• Other clinicians may apply for a hardship exception for one

or more for the following reasons:

• Insufficient Internet Connectivity

• Extreme and Uncontrollable Circumstances

• Lack of Control over the Availability of CEHRT

• CMS will no longer automatically exclude clinicians based

on specialty designation


Not counted toward MIPS score in 2017; may count in 2018

No separate reporting is required

• CMS will calculate score from administrative claims collected for a

full calendar year

Tip: CMS will provide feedback based on claims data in 2017; prepare

for 2018 and future years by assessing feedback reports

Measures include:

– Total per capita costs (Parts A and B) for all attributed beneficiaries;

– Medicare spending per beneficiary (MSPB); and

– Episode-based measures

Cost


http://www.mgma.com/government-affairs/tools/table-7-episode-based-measures-finalized-for-the-cy-2017-performance-period

Pick your pace options for 2017

Option Requirements 2019 Payment Outcome

Test the

program

Report:

-one quality measure or

-one improvement activity or

-the required ACI measures

Avoid penalty

Report

some data

Report for at least 90 days:

-more than one quality measure or

-more than one improvement activity or

-more than the required ACI measures

Avoid penalty and eligible

for partial positive

adjustment

All-in Report all MIPS data for at least 90

consecutive daysAvoid penalty and eligible

for full positive adjustment

and exceptional

performance bonus

Do nothing 4% penalty


4%

3%

2%

1%

0%

-1%

-2%

-3%

-4%

MIPS Performance

Threshold

Projected MIPS Adjustments for the 2017 Performance Year

MIP

S P

aym

en

t A

dju

stm

en

t Fa

cto

r

As a result of “pick your pace” combined with MIPS’ budget-

neutral design, the expected max incentive of < 1% is much

lower than the 4% allowed under statute.

Exceptional Performance

Threshold

3 70 100

MIPS

score


Alternative Payment ModelsAdvanced

AAPMs


Why should my practice consider

participating in an Advanced APM?


Qualifying participants get:

• Exemption from MIPS;

• 5% annual lump sum bonus payments through 2024; and

• A 0.5% higher fee schedule update from 2026 onward.

Partially qualifying participants get:

• The option to forego participating in MIPS.

• Favorable scoring in MIPS.


Does my APM meet the

requirements to be considered

an Advanced APM?


1. Requires participants to use CEHRT.

– Minimum of 50% of participating ECs in 2017

2. Provides payment based on quality measures

comparable to those used in MIPS.

3. Must satisfy financial risk requirements.

• Be a CMMI expanded medical home model*

• OR Meet financial and nominal risk standards.

Characteristics of an AAPM:

*To date, CMS has not issued any expanded medical

home models that would meet this definition.


AAPM Financial Risk Standard

If actual aggregate expenditures exceed expected

expenditures, the AAPM must:

• Withhold payments;

• Reduce payment rates; OR

• Owe payments to CMS.


AAPM Nominal Risk Standard:

Under the terms of the APM, the total annual

amount that the APM Entity would potentially owe or

forego to CMS is at least:

• 8% of average estimated total Medicare Parts A and B

revenues; OR

• 3% of expected expenditures for which the APM Entity is

responsible for under the APM.


Advanced APM Models in 2017 and 2018

2017

• MSSP ACO Tracks 2 & 3

• Next Gen ACOs

• Comprehensive ESRD Care Models

• CPC+

• Oncology Care Model (2-sided risk)

• CJR CEHRT Track

Anticipated for 2018

• Advancing Care Coordination

through Episode Payment

Models (Track 1)

• Cardiac Rehabilitation

Incentive Payment Model

• MSSP ACO Track 1+

CMS anticipates 25% of

clinicians will be considered

advanced APM qualified

participants in 2018 with

the additional models.

CMS anticipates 10% of

clinicians will be considered

advanced APM qualified

participants in 2017.


Does the APM Entity meet the

QP or partial QP threshold?


AAPMs must meet either the Medicare payment or patient

threshold during one of 3 following snapshots of time:

Jan-March, April-June, July-Aug

Participation Thresholds in 2017-2018

Patient

count

Payments

25%

20%10%

= QP

= partial QP

= non-QP

20%


How do I know if my practice will be

granted qualifying participant (QP)

status with the APM Entity?


• Depends on rules of particular AAPM

• CMS will look at relevant participant list on 3 specific dates

during the performance year (March 31, June 30, Aug. 31).

• A clinician or practice must appear on the list on at least 1 of

these dates to be considered (not necessarily all 3).

Determining QP Status


When will my practice get

the 5% lump sum bonus?


Advanced APM Timeline

2017 2018

2019 payment

year

2019 2020

2020 payment

year

2021 payment

year

2022 payment

year

QP status

determined based

on participation

thresholds

QP status

determined based

on participation

thresholds

QP status

determined based

on participation

thresholds

QP status

determined based

on participation

thresholds

Payments used

to determine 5%

lump sum bonus

Payments used

to determine 5%

lump sum bonus

Payments used

to determine 5%

lump sum bonus

APM bonus

distributed to

qualifying

participants

APM bonus

distributed to

qualifying

participants


• Do we want to be evaluated collectively at the APM Entity

level, or would my practice fare better at the TIN level

under MIPS?

• What are the benefits of participating in a particular APM

model outside of the lump sum bonus?

• What are the start-up and ongoing costs that go along with

participating in an APM?

• Should we participate in MIPS in 2017 and wait for

additional APMs in 2018 (or later)?

Questions your practice should consider

if it’s thinking about joining an AAPM:


What physician practices can do now:

Assess performance under current programs

Consider which pathway is best suited for your practice

Evaluate EHR and other vendor readiness and costs

Protect yourself against a MIPS penalty

Establish a game plan for participating/reporting

Engage in ongoing learning about MACRA

Keep an open mind, your strategy could change in 2018+.

For more, check out MGMA’s participation checklist >>


http://www.mgma.com/government-affairs/tools/participating-in-the-new-medicare-payment-system-a-checklist-for-medical-practice-leaders

MGMA Resources

Washington Connection (mgma.com/Washington)

Weekly enewsletter with breaking updates and everything

you need to know coming from our nation’s capital

MACRA/QPP Resource Center (mgma.com/MACRA)

Your one-stop shop for new MGMA resources and helpful

information

Dedicated MIPS/APMs e-group

Get your questions answered and engage in a robust

conversation with your MGMA peers about all things

MACRA


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