MIPS APMS/APM SCORING STANDARD OVERVIEW

APRIL 24, 2019

Topics

• Key Terms

• Overview of Alternative Payment Models (APMs)

• Overview of Advanced APMs

• Basics of MIPS APMs

• MIPS APMs Scoring Standard

• Participation Status for MIPS APMs

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TERMS TO KNOW

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Relevant Terms

• National Provider Identifier (NPI) – 10-digit numeric identifier for individual clinicians

• Tax Identification Number (TIN) – Number used by the Internal Revenue Service to identify an organization/entity, such as a group or medical practice.

• APM Name – The APM in which you participate as a part of your APM Entity.

• Subdivision Name (SD Name) – The specific APM in which you participate, including track (if applicable).

• APM Entity Name (APME) – The name of the organization in which you participate.

NPI APM Name Subdivision Name APME

1234567890 Comprehensive Primary Care Plus Model

CPC+ - Medical Home Sample Family Practice

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Additional Terms

• APM Entity - An entity that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation.

• Advanced APM – A payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.

• Affiliated Practitioner - An eligible clinician identified by a unique APM participant identifier on a CMS-maintained list who has a contractual relationship with the Advanced APM Entity for the purposes of supporting the Advanced APM Entity's quality or cost goals under the Advanced APM.

• Affiliated Practitioner List - The list of Affiliated Practitioners of an APM Entity that is compiled from a CMS-maintained list.

• MIPS APM – Most Advanced APMs are also MIPS APMs so that if an eligible clinician participating in the Advanced APM does not meet the threshold for sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard. The APM scoring standard is designed to account for activities already required by the APM.

• Participation List - The list of participants in an APM Entity that is compiled from a CMS-maintained list.

• Qualifying APM Participant (QP) - An eligible clinician determined by CMS to have met or exceeded the relevant QP payment amount or QP patient count threshold for a year based on participation in an Advanced APM Entity. 5

Relevant Financial Terms

• Full capitation risk exists where the APM Entity receives a per capita or an otherwise predetermined fixed payment for all items and services delivered to a population of beneficiaries, with no settlements done to reconcile or share losses incurred or savings earned by the APM Entity.

• The APM Entity bears the full risk, both downside and upside; therefore, capitation risk arrangements always require the APM Entity to bear the risk of more than nominal financial losses.

• Cash flow adjustments to later reconcile or adjust predetermined amounts based on actual experience may not be full risk arrangements.

• Total Risk: The maximum amount of losses possible under an Advanced APM must be at least 4 percent of the APM spending target.

• Marginal Risk: The percent of spending above the APM benchmark (or target price for bundles) for which the Advanced APM Entity is responsible (i.e., sharing rate) must be at least 30 percent.

• Minimum Loss Rate: The amount by which a clinician’s spending can exceed the APM benchmark (or target price for bundles) before the Advanced APM Entity bears responsibility for financial losses cannot exceed 4 percent.

• Financial Risk Standard: APM Entities must bear risk for monetary losses.

• Nominal Amount Standard: The risk APM Entities bear must be of a certain magnitude.

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ALTERNATIVE PAYMENT MODELS (APMS)

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What is an APM?

APMs are new approaches to paying for medical care through Medicare that incentivize quality and value. The CMS Innovation Center develops new payment and service delivery models. Additionally, Congress has defined—both through the Affordable Care Act and other legislation—a number of demonstrations that CMS conducts.

As defined by MACRA,

APMs include:

✓ CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)

✓MSSP (Medicare Shared Savings Program)

✓ Demonstration under the Health Care Quality Demonstration Program

✓ Demonstration required by federal law

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Alternative Payment Models (APMs)Overview

• A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care

• Can apply to a specific condition, care episode or population

• May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs

Advanced APMs are

a Subset of APMs

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Rewards for Participating in APMs

Potential financial rewards

Not in APM

MIPS adjustments

In APM

MIPS adjustments

+APM-specific

rewards

In MIPS APM

MIPS adjustments

APM Scoring Standard

toward

+APM-specific

rewards

In Advanced APM

APM-specific rewards

+If you are a

Qualifying APM

Participant (QP)

5% lumpsum bonus

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Illustrative Example of APMs

• Comprehensive list of APMs

• Includes the APM name, MIPS APM status, Advanced APM status, and

criteria for being considered an Advanced APM.

APM MIPS APMunder the

APM Scoring Standard

MedicalHome Model

Use of CEHRT

Criterion

QualityMeasures Criterion

Financial Risk

Criterion

Advanced APM

Comprehensive ESRD Care (CEC) Model (non-LDO arrangement one-sided risk arrangement)

YES No YES YES No No

Comprehensive Primary Care Plus (CPC+) Model YES YES YES YES YES YES

Frontier Community Health Integration Project Demonstration (FCHIP)

No No No No No No

Home Health Value-based Purchasing Model (HHVBP) No No No YES No No

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Where Can I Find Additional Information on the Models?

• If you’re interested in viewing the models that are currently enrolling, visit https://innovation.cms.gov/ and look for the following section on the main page:

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ADVANCED APMS

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Advanced APMs

Clinicians and practices can:

• Receive greater rewards for taking on some risk related to patient outcomes.

Advanced APMs

Advanced APM-specific rewards

+

5% lump sum incentive

“So what?” - It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

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Advanced APMsAdvanced APM Criteria

To be an Advanced APM, the following three requirements must be met.

The APM:

Requires participants to use certified EHR technology;

Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and

Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk.

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Advanced APMs

Current List of Advanced APMs for 2019

• Bundled Payments for Care Improvement (BPCI) Advanced Model

• Comprehensive Care for Joint Replacement Model

• Comprehensive ESRD Care Model (LDO Arrangement)

• Comprehensive ESRD Care Model (non-LDO Two-sided Risk Arrangement)

• Comprehensive Primary Care Plus (CPC+) Model

• Medicare Accountable Care Organization (ACO) Track 1+ Model

• Maryland Total Cost of Care Model (Care Redesign Program)

• Maryland Total Cost of Care Model (Maryland Primary Care Program)

• Next Generation ACO Model

• Shared Savings Program – Track 2

• Shared Savings Program – Track 3

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

• Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

To learn more about these Advanced APMs, visit the Advanced APMs webpage on qpp.cms.gov16

Benefits of Participating in an Advanced APM as a Qualifying APM Participant (QP)

QPs:

Are excluded from MIPS

Receive a 5% lump sum bonus

Receive a higher Physician Fee Schedule updatestarting in 2026

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Performance Year Thresholds to Become a Qualifying APM Participant

Requirements for Incentive Paymentsfor Significant Participation in Advanced APMs

(Clinicians must meet payment or patient requirements)

Performance Year 2019 2020 2021 2022 and later

Percentage of Payments through an Advanced APM

Percentage of Patients through an Advanced APM

✓The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result.

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What is the Performance Period for QPs?

• The QP Performance Period is the period during which CMS will assess eligible clinicians’ participation in Advanced APMs to determine if they will be QPs for the payment year.

• The QP Performance Period for each payment year will be from January 1—August 31st of the calendar year that is two years prior to the payment year.

Performance Period: QP status based on Advanced APM

participation

Incentive Determination:Add up payments for Part B

professional services furnished by QP

Payment:+5% lump sum payment made

(excluded from MIPS adjustment)

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MIPS APMS BASICS

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Relevant MIPS APM Terms

• Accountable Care Organizations (ACOs) – Accountable Care Organizations are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. ACO is used often in communication about the Shared Savings Program.

• APM Entity – An entity that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation.

• APM Scoring Standard – Defines the scoring weights per MIPS performance category for eligible clinician participation in an APM. The APM scoring standard is designed to account for activities already required by the APM. For example, the APM scoring standard eliminates the need for MIPS clinicians to duplicate submission of Quality and Improvement Activity performance category data and allows them to focus instead on the goals of the APM.

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What are MIPS APMs?

Goals

• Reduce eligible clinician reporting burden

• Maintain focus on the goals and objectives of APMs

How does it work?

• Streamlined MIPS reporting and scoring for eligible clinicians in certain APMs

• APM Entity level quality performance attributed down to MIPS Eligible Clinicians in that APM Entity

• All eligible clinicians in an APM Entity receive the same MIPS final score

• Uses APM-related performance to the extent practicable

MIPS APMs are a Subset of APMs

APMs

MIPS

APMs

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What are the Requirements to be Considered a MIPS APM?

The APM scoring standard applies to that meet these criteria:

✓APM Entities participate in the APM under an agreement with CMS

✓APM Entities include one or more MIPS eligible clinicians on a Participation List

✓APM bases payment incentives on performance (either at the APM Entity or eligible clinician level) on cost/utilization and quality

✓APM requires reporting on quality measures tied to performance on the first day of the MIPS performance period (January 1)

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MIPS APMs in 2019

• Bundled Payments for Care Improvement Advanced Model (BPCI Advanced)

• Comprehensive ESRD Care (CEC) Model (All Arrangements)

• Comprehensive Primary Care Plus (CPC+) Model

• Medicare Accountable Care Organization (ACO) Track 1+ Model

• Medicare Shared Savings Program Accountable Care Organizations - Tracks 1, 2, & 3

• Next Generation ACO Model

• Oncology Care Model (OCM – All Arrangements)

• Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

• Maryland Primary Care Program

• Independence at Home Demonstration

To learn more about these MIPS APMs, visit the MIPS APMs web page on qpp.cms.gov.

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APM SCORING STANDARD FOR MIPS APMS

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Advanced APMs (2019) FinalMIPS APMs – Criteria

Years 1 & 2 (2017 & 2018) Final

MIPS APM Criteria:

• Currently, one of the MIPS APM criteria is that an APM “bases payment on cost/utilization and quality measures”

• We did not intend to limit an APM’s ability to meet the cost/utilization part of this criterion solely by having a cost/utilization measure

Year 3 (2019) Final

MIPS APM Criteria:

• Reordered the wording of this criterion to state that the APM “bases payment on quality measures and cost/utilization”

• This would clarify that the cost/utilization part of the policy is broader than specifically requiring the use of a cost/utilization measure

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Advanced APMs (2019) FinalMIPS APMs – Aligning PI under the APM Scoring Standard

Years 1 & 2 (2017 & 2018) Final

MIPS APM Criteria:

• Under previously finalized policy for the APM scoring standard, Shared Savings Program ACOs are required to report Promoting Interoperability (PI) at the participant TIN level

• This differs from all other MIPS APMs, which allow MIPS eligible clinicians to report PI in any manner permissible under MIPS (i.e., at either the individual or group level)

Year 3 (2019) Final

MIPS APM Criteria:

• Align PI reporting requirements under the APM scoring standard so that MIPS eligible clinicians in any MIPS APMs, including the Shared Savings Program, can report PI in any manner permissible under MIPS (i.e., at either the individual or group level)

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APM Scoring Standard Snapshot Dates

The APM scoring standard offers a special, minimally-burdensome way of participating in MIPS for eligible clinicians in certain APMs.

To be considered part of the APM Entity for the APM scoring standard, an eligible clinician must be on an APM Participation List on at least one of the below three snapshot dates of the performance period. Otherwise, an eligible clinician must report to MIPS under the standard MIPS methods.

MAR

31JUN

30AUG

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*New – FULL TIN ONLY*

Dec

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*Note: The fourth snapshot date of December 31st is for full TIN APMs (Shared Savings Program) and allows participants who joined a full TIN APM between 9/1 and 12/31 to benefit from the APM scoring standard. We will not make QP determinations based on the fourth snapshot.

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APM Scoring Standard Low Volume Threshold

You Have Asked: “How does the low-volume threshold apply to MIPS eligible clinicians in

MIPS APMs?”

• Applies to MIPS eligible clinicians practicing as a part of an APM Entity in a MIPS APM.

• Will be calculated by CMS at the APM Entity level.

• If you are an individual or group that is below the low-volume threshold but part of an APM Entity (or ACO) that is above the low-volume threshold, you are subject to MIPS under the APM scoring standard.

Scenarios:

✓ The APM Entity is required to participate in MIPS if it exceeds the low-volume threshold.

• “So what?” - This means that groups and solo practitioners participating in the APM Entity will need to participate in MIPS for that TIN/NPI.

× The APM Entity is exempt from MIPS if it does not exceed the low-volume threshold.

• “So what?” - This means that groups and solo practitioners participating in the APM Entity will be exempt from MIPS for that TIN/NPI if the entire APM Entity does not exceed the low volume threshold.

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APM Scoring Standard MIPS Performance Category Weights

The performance category weights used to calculate the MIPS final score under the APM Scoring Standard for the 2019 performance period are as follows:

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APM Scoring Standard MIPS Performance Category Requirements

Quality:

• For MIPS APMs, the quality measures the APM requires are used to determine a MIPS Quality performance category score.

• ACOs will submit quality measures on behalf of their participants, according to APM requirements, via the CMS Web Interface.

• Quality measures are scored against the MIPS APMs' benchmarks for those measures. MIPS point values will be assigned according to the APM scoring standard

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APM Scoring Standard MIPS Performance Category Requirements

Cost:

• Clinicians in MIPS APMs will not be scored under the Cost performance category.

• No reporting is necessary.

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APM Scoring Standard MIPS Performance Category Requirements

Improvement Activities:

• Improvement Activity performance category scores for MIPS APMs are based on the Improvement Activities that are required by the APM.

• For 2019, all MIPS APMs will automatically receive the maximum points at the APM Entity level for the Improvement Activities performance category.

• No additional reporting is necessary.

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APM Scoring Standard MIPS Performance Category Requirements

Promoting Interoperability (PI):

• All MIPS eligible clinicians will report data for the PI performance category under the general MIPS requirements.

• PI can be reported via attestation, QCDR, Qualified Registry, CEHRT, or the CMS Web Interface.

• MIPS eligible clinicians in any MIPS APMs, including the Shared Savings Program, can report PI in any manner permissible under MIPS (i.e., at either the individual or group level).

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APM Scoring Standard MIPS Performance Category Requirements

PI for all MIPS APMs:

• MIPS eligible clinicians in the APM report the PI performance category through either a group TIN or individual reporting.

• CMS scores each MIPS eligible clinician in the APM using the highest score for the TIN/NPI combination for each MIPS eligible clinician – through either individual or group reporting.

• The score given to each MIPS eligible clinician will be averaged with the scores of the other clinicians in the APM Entity to produce one APM Entity score for the PI performance category.

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APM Scoring Standard MIPS Performance Category Requirements

You Have Asked: “What happens if a clinician participates in two or more MIPS APMs?”

• CMS will use the highest final score to calculate a MIPS payment adjustment for any clinician participating in two or more MIPS APM Entities.

• Exception:

- Clinicians who participate in both the Shared Savings Program and the Comprehensive Primary Care Plus Model.

- These clinicians will:

• Adhere to Shared Savings Program MIPS APM program requirements.

• Receive the Shared Savings Program ACO score, not the CPC+ APM Entity score.

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MIPS APMS PARTICIPATION STATUS

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APM Participation Status

You Have Asked: “Where can clinicians go to review their APM participation status?”

• Quality Payment Program Participation Status Look-up Tool on qpp.cms.gov.

• After entering a NPI, the clinician will see:

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APM Participation Status

• The look-up tool will then display the corresponding APM participation information:

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REFRESHER: The Four Layers of APMs

APMs

• Alternative Payment Models (APMs)

• Merit-based Incentive Payment System Alternative Payment Models (MIPS APMs)

• Advanced MIPS APMs (Combo)

• Advanced APMs

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WHERE CAN I GO TO LEARN MORE?

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Technical Assistance

CMS has free resources and organizations on the ground to provide help to eligible clinicians included in the Quality Payment Program:

To learn more, visit the QPP website: https://qpp.cms.gov/about/help-and-support#technical-assistance

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Q&A Session

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1-866-452-7887

If prompted, use passcode: 8678787

Press *1 to be added to the question queue.

You may also submit questions via the chat box.

Speakers will answer as many questions as time allows.

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