November 8, 2016

MACRA’s Final Rule: Updates to CMS’s Quality Payment Program and Its

Impact on Medicare Part B Reimbursement

Nina Marshall, MSW

Senior Director,

Policy and Practice

Improvement

Elizabeth Arend, MPH,

Quality Improvement

Advisor

• MACRA final rule overview – Eligibility

– Payment Adjustments & Timeline

• Merit-based Incentive Payment System (MIPS) – Quality

– Advancing Care Information

– Cost

– Improvement Activities

• MIPS Reporting

• How to Prepare

• Q&A

Outline

Medicare Access and CHIP

Reauthorization Act (MACRA) of

2015

• Repeals the Sustainable

Growth Rate formula

• Creates a new Quality

Payment Program by

streamlining existing programs

Review: What is MACRA?

• In the short-term, MACRA will

affect providers who participate in

Medicare Part B

• Long-term, MACRA will affect

everyone: as practices adapt to

value-based payment models,

MACRA will eventually drive

market shifts beyond Medicare

Part B

Who does MACRA Affect?

MACRA will affect:

• How health care data are shared, based on new standards for interoperability

• The measures used to assess performance, with a focus on outcomes, quality of care and patient experience

• The availability of federally-funded technical assistance for providers to successfully transition to value-based payment arrangements

The Big Picture

Clinicians can choose either:

• The Merit-Based Incentive

Payment System (MIPS), which

streamlines multiple quality

programs

• An Advanced Alternative

Payment Model (APM), which

provides bonus payments for

participation

Two Paths to Payment:

MACRA’s New Quality Payment Program

• Require participants to use certified EHR technology

• Require participants to bear “more than nominal financial risk”

…therefore not an option for 90%+ providers

In 2017, CMS anticipates that these will be Advanced APMs:

– Comprehensive ESRD Care (CEC) - Two-Sided Risk

– Comprehensive Primary Care Plus (CPC+)

– Next Generation ACO Model

– Shared Savings Program - Track 2

– Shared Savings Program - Track 3

– Oncology Care Model (OCM) - Two-Sided Risk

CMS will announce final list of Advanced APMs no later than January 1, 2017

Advanced APMs

• Combines and modifies three existing programs:

o Physician Quality Reporting System (PQRS)

o Electronic Health Records Incentive Program

(“Meaningful Use”)

o Value-based Payment Modifier (VM)

• Adds “Improvement Activities” category

Merit-based Incentive Payment

System (MIPS)

Clinicians who bill Medicare Part B using the physician fee schedule, including:

• Physicians (including psychiatrists)

• Physician assistants

• Nurse practitioners

• Clinical nurse specialists

• Certified registered nurse anesthetists

MIPS participation is voluntary for other health care providers in 2017, but they will not receive a payment adjustment

In 2017, MIPS applies to:

• Providers billing Medicaid

• Clinicians who are newly enrolled in Medicare

• Clinicians who are significantly participating in

an advanced APM

• Hospital-based and facility-based payment

programs

• Clinicians and groups who are NOT paid

under the Physician Fee Schedule (i.e.

FQHCs and partial hospitalization programs)

In 2017, MIPS does NOT apply to:

• Individual clinicians and groups that fall beneath the

“low volume threshold” who serve 100 or fewer

Medicare recipients OR bill Medicare $30,000 or less

per year

– Threshold will be applied at the individual clinician level

among those who choose to report to MIPS as individuals

– Threshold will be applied at the group level for all clinicians

who choose to report to MIPS as a group

• CMS will determine clinicians’ volume in advance

through claims analysis

In 2017, MIPS does NOT apply to:

MIPS Payment Adjustments

“Pick Your Pace” Reporting Options

in 2017 to Avoid 2019 Penalties

MIPS Scoring• CMS will factor in four weighted performance

categories to calculate a final score • Payment adjustments in 2019 may be negative,

neutral or positive based on CMS-established threshold

Quality Improvement

Activities

Advancing Care

Information Cost

Final Score

PQRS Value-based Modifier

Meaningful Use

• Requires providers to report six quality measures for a

minimum of 90 consecutive days

• Emphasis on outcome/high priority measures:

– Appropriate use

– Care coordination

– Patient experience

– Patient safety

• Option to use behavioral/mental health specialty

measure set

Quality

Quality Benchmark Comparisons

• Quality measure data will be compared to benchmarks in order to determine your Quality score

• Not all quality measures will have a benchmark. If there is no benchmark for a measure, clinicians / groups will receive three points

• CMS will publish benchmarks prior to the start of each performance year

• CMS plans to increase the number of required outcome measures through future rulemaking, as more outcome measures become available

• CMS also plans to increase emphasis on measures related to: – Appropriate use

– Patient experience

– Safety

– Care coordination

• CMS will update/add quality measures annually based on clinician input

Future Quality Measures

• Requires MIPS eligible clinicians to use certified EHR

technology (CEHRT)

• Two measure sets in 2017 for reporting based on EHR

edition:

1. Advancing Care Information Objectives and

Measures

2. Advancing Care Information Transition Objectives

and Measures (2017)

Advancing Care Information

Clinicians can use CEHRT certified to either the 2014 or

2015 Edition certification criteria

Reporting Options

EHR Certified to 2015 Edition:

Option 1: Advancing Care Information

Objectives and Measures

Option 2: Combination of the two

measure sets

EHR Certified to 2014 Edition:

Option 1: 2017 Advancing Care

Information Transition Objectives and Measures

Option 2: Combination of the two

measure sets

Clinicians must submit a numerator/ denominator

OR yes/no combination for each of the following

measures:

Protect patient health information

Electronic prescribing

Patient electronic access

Health Information Exchange: Send summary of care

Health Information Exchange: Request/accept

summary of care

Advancing Care Information:

Base Score

• Based on a MIPS eligible clinician’s

performance rate for each measure reported

• Nine measures

– Patient Electronic Access

– Coordination of Care through Patient Engagement

– Health Information Exchange

Advancing Care Information:

Performance Score

• Clinicians do NOT select cost measures

– CMS will apply measures to clinicians and determine

score based on Medicare Part B claims analysis

– No independent reporting required

• Cost analysis based on:

– Total per capita cost for all attributed beneficiaries

– Medicare spending per beneficiary (MSPB)

– 10 episode of care measures (not yet finalized)

Cost

• CMS will provide feedback based on 2017

performance, and will starting weighing cost

as part of final score in the 2018 performance

year

• Weight will gradually increase from 0 to 30

percent by 2019 performance year / 2021

payment year

Cost Performance Scoring

MIPS eligible clinicians can choose from a list of

90+ activities (updated annually) under nine sub-

categories:

Improvement Activities

Behavioral and Mental Health

• Depression screening

• Diabetes screening

• EHR Enhancements for Behavioral Health Data Capture

• Implementation of co-location of primary care and mental health services

• Implementation of integrated Primary Care Behavioral Health model

• Major depressive disorder prevention and treatment interventions

• Tobacco use

• Unhealthy alcohol use

Improvement Activities

Improvement Activity Scoring

• Activity weight for most clinicians:

Attest to completing up to four activities

for at least 90 days

• Activity weights for small/rural/HPSA

practices: Attest to completing up to

two activities for at least 90 days

• Full credit for clinicians in a patient-

centered medical home, Medical Home

Model or similar specialty practice

MIPS Individual vs. Group

Reporting

Individual Group

Defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN)

Defined as a set of 2+ clinicians, identified by their NPIs, who share a common TIN regardless of the specialty or practice site

Low volume threshold determined at individual level

Low volume threshold determined for entire group

Payment adjustment based on individual clinician’s performance

Groups are assessed as a group across all performance categories and receive one payment adjustment based on the group’s performance

Have the option to report via Medicare claims

Have the option to report via CMS Web Interface (groups 25+ only)

How to Prepare

Determine Quality Payment Program eligibility

Review CMS PQRS performance feedback / QRUR

Review applicable quality measures and improvement activities

Make sure your EHR is certified by the Office of the National Coordinator for Health Information Technology

Consider using a qualified clinical data registry or a registry to extract and submit your quality data

How to Prepare

Educate your entire team

“Pick your Pace” for 2017

Check out the National Council’s MACRA

resources and stay up-to-date by subscribing

to the Capitol Connector blog

Join a Transforming Clinical Practice Initiative

Practice Transformation Network (PTN)

How to Prepare

Quality Payment Program Service

Center

• 1-866-288-8912

• 1-877-715-6222

• Open Monday-Friday, 8am-8pm ET

CMS Resources

• Quality Payment Program Online Portal • Quality Innovation Networks (QINs) & Quality Improvement

Organizations (QIOs) • “Pick your Pace” blog post by CMS Acting Administrator

Andy Slavitt

Questions

Thank you!

Elizabeth Arend, MPH

Quality Improvement Advisor

National Council for Behavioral Health

ElizabethA@TheNationalCouncil.org