oklahoma state medical association jack beller, md 2016 mac… · oklahoma state medical...

Oklahoma State Medical Association

Jack Beller, MD

2016

MACRA: Fundamentally Changing Physician Practices?

Rev. 10/17/16

© 2016 American Medical Association. All rights reserved.

MACRA

• Repeals the Sustainable Growth Rate (SGR) Formula and sets up 2 payment programs: MIPS and APMs

• Streamlines multiple quality programs (Meaningful Use, PQRS, Value-based Modifier) under MIPs

• APM: Bonus payments for participation in eligible models.

• MIPS: Additional payment for exceptional performance possible

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Some general observations

• MACRA is complex

– More than a “replacement for the SGR”

– Regulations can add complications and have

• Many of the new requirements are simply revisions of current requirements

• One goal of MACRA was to simplify administrative processes for physicians

– Compared to recent past/ current framework, the proposed regulations include some improvements but there is more to be done.

– More improvements are needed— to make this less of a burden on doctors’ offices.

• The proposed rule issued in April is a draft attempt to implement a complex law.

– Lengthy and detailed recommendations have been submitted for improvements.

• Final rules were released mid October and are being evaluated at this point.

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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 (estimated to be about 80%) are expected to participate in MIPS

• There is a third option – do nothing and be guaranteed the maximum penalty for the first year.

MIPS

APMs

Merit-based Incentive Payment System (MIPS)

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MIPS components

Quality Reporting (was

PQRS)

Resource Use or Cost (was Value-based Modifier)

Advancing Care Information (was

MU)

Clinical Practice Improvement

Activities

MIPS

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MIPS aims: • Retain a fee-for-service payment option • Align 3 current independent programs • Add 4th component to promote improvement and

innovation • Provide more flexibility and choice of measures Clinicians exempt from MIPS: • First year of Part B participation • Medicare claims < $30K OR < 100 patients • Advanced APM participants • Would exempt 29% of physicians (vs. 10%) while

covering 93% of Medicare spending • Mean Medicare revenue per physician is about

$109K


2019 (first year) penalty risks compared MIPS factors 2019 scoring

Quality measurement 50% of score

Advancing Care Info. 25% of score

Resource use 10% of score

Clinical improvement activities 15% of score

Total penalty risk Max of -4%

Bonus potential Max of 4%, plus potential 10% for high performers

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Timeline on payment adjustments

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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


Quality Reporting

Quality

6 measures

Partial credit allowed

Flexibility in choice of measures

AMA recommendations

Maintain scoring thresholds at 50% (vs. proposed 80-90%)

Further reduce the number of required quality measures to 4

Simplify the scoring methodology

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Resource Use

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Resource Use

Focuses solely on cost/ resource-use; no duplicative quality reporting

41 episode-based measures proposed

Plans to improve attribution methods in 2018 (for 2020 payments)

AMA recommendations

Cost measures flawed, episode groups need testing/ improvement

Improve attribution methods for episodes

Develop pilot rather than using flawed measures

Do not incorporate Part D or B drug costs


Advancing Care Information

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ACI

Pass-fail program replaced with base and performance scoring

Measures reduced

Performance score thresholds eliminated

Public health registry reporting reduced

AMA recommendations

50 point base score threshold still 100%; grant credit for measures reported

Maintain existing measure exclusions

Permit proposals for more relevant measures

Establish a 90-day reporting period


CPIA basics • 15% of total MIPS score • 90-day reporting period MIPS weight

• 8 activity categories • 90+ activities • Do not need activities in each category

CPIA categories

• 60 points = 100% CPIA score • 7 of 8 categories have both high (20 points) and medium (10 points) weighted

activities Scoring

• Certified PCMH (60 points); other APM (30 points) • Non-patient facing specialties & small rural practices need fewer points (one

activity for partial credit, 2 activities for full credit) Exceptions

• High weight activities should be expanded, required activities reduced • Credit for APM participation should be increased • Practices should be able to maintain CPIA activities over time

Concerns

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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

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MIPS component weights and scoring in 2019

50%

25%

15%

10%

Component Weights

Quality

ACI

CPIA

Resource Use

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Four Reporting Options for MIPS • Option One: Test the Program

– Physicians required to report some data from after Jan. 1 to the Quality Payment Program. No penalty – no bonus.

• Option Two: Partial-Year Reporting – Physicians can choose to report Quality Payment Program information for a

reduced number of days. No penalty – eligible for partial bonus.

• Option Three: Full-Year Reporting – If ready, physicians can go ahead and report for the full calendar year 2017.

– No penalty – eligible for full bonus.

• Option Four: Advanced Alternative Payment Model (APM) – No penalty – eligible for full bonus – eligible for exceptional bonus.

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Some observations about MIPS

Positives: • Overlapping quality measurement

across separate programs eliminated

• Overall reduction in measures, many thresholds eliminated

• More flexibility in measure choice

• Pass/ fail approach (largely) eliminated

• Financial risk from penalties significantly reduced

Issues to address: • Aggregate administrative burden

for practices is still too high

• MU measures largely retained in ACI

• Full-year reporting for most components

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Small practice accommodations

Provisions

• Low-volume MIPS exemption

• Fewer quality measures, CPIA reporting requirements

• Reporting category exemptions if insufficient measures applicable

• Cost score not calculated if volume insufficient for measures

AMA Recommendations

• Peer-to-peer comparisons on performance

• Further reduce reporting requirements

• Consistent definition of small practice

• Implement virtual group provision

• Maintain EHR exemption for lack of high speed Internet, physicians who do not refer patients

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MACRA

• CMS has estimated that up to 80% of physicians will take the MIPS option or do nothing for the first year. The reason for this is primarily because not enough APMs have been designed yet.

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Alternative Payment Models (APMs)

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APMs participation options as outlined by CMS

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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)

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CMS criteria for Advanced APMs

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Advanced APMs

EHR use

Quality Reporting

Financial Risk

• Participants must use certified EHR technology

• Payment based on quality measures comparable to MIPS

• Bear “more than nominal risk” for monetary losses


Currently proposed Advanced APMs

Comprehensive ESRD Care Model

(currently 13)

Comprehensive Primary Care Plus (coming in Fall 2016 –

Oklahoma has one)

Medicare Shared Savings Track 2

(currently 6 ACOs, 1% of total)

Medicare Shared Savings Track 3 (currently 16 ACOs,

4% of total)

Next Generation ACO Model (currently 18)

Oncology Care Model, 2-Sided

Risk Arrangement (coming in 2018)

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MIPS APMs

Criteria • Do not meet qualifications for Advanced APM—most likely financial risk • Examples includes Track 1 ACOs, certified medical homes, bundled payment programs, any upside

risk-only models

Advanced APM benefits do not apply • Must participate in MIPS to receive any favorable payment adjustments • Do not qualify for 5% APM bonus payments 2019-2024 • Not eligible for higher baseline annual updates beginning 2026

Other benefits • Certified medical home participants get full CPIA score (60 points); others get half (30 points) • APM-specific rewards (e.g., shared savings) • Eligible for annual MIPS bonuses, which continue indefinitely (vs. 6 years for 5% APM bonuses)

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Requirements and payments for APM participants

Qualified Participant in Advanced APM

Partially Qualified Participant in Advanced APM

MIPS APM participant

Patient and revenue thresholds required

>25% revenues or >20% patients in 2019, rising to 75% or 50%, respectively by 2023

>20% revenues or >10% patients in 2019, rising to 50% and 35%, respectively, by 2023

None

Eligible for APM bonus, higher updates

Yes No No

Must participate in MIPS No Optional (but no performance adjustments without MIPS)

Yes

MIPS scoring and adjustments

N/A Favorable weighting and scoring

Favorable weighting and scoring

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APMs and MIPS reporting at a glance

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In an APM?

Yes No

In first year in Medicare or below the volume threshold?

Yes No

In an Advanced APM?

Yes No

Enough payments or patients to meet the threshold?

Yes No

Qualifying APM Participant. Eligible for: • 5% lump sum bonus payment 2019-2024 • Higher fee schedule updates 2026 and beyond • APM-specific rewards • Exclusion from MIPS reporting

Not subject to MIPS

Subject to MIPS

Partially qualified or MIPS APM participant: • Favorable CPIA scoring • APM-specific rewards


Some observations about APM pathway

• Performance judged on group basis

• Too few qualified APMs will be available in 2017

• Timeline for developing new models is long

• Risk requirements are unrealistic (e.g., risk for costs vs. revenues, no credit for investment)

• Risk requirements too complicated

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Moving Forward

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Timeline on payment adjustments

29

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


Four Reporting Options for MIPS

• Option One: Test the Program – Physicians required to report some data from after Jan. 1 to the Quality Payment

Program. No penalty – no bonus.

• Option Two: Partial-Year Reporting – Physicians can choose to report Quality Payment Program information for a

reduced number of days. No penalty – eligible for partial bonus.

• Option Three: Full-Year Reporting – If ready, physicians can go ahead and report for the full calendar year 2017. – No penalty – eligible for full bonus.

• Option Four: Advanced Alternative Payment Model (APM) – No penalty – eligible for full bonus – eligible for exceptional bonus.

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Regulatory timeline

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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

What Physicians Can Do to Prepare

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General Considerations

• Determine whether you have $30,000 or less in Medicare charges OR 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.

• Go to www.AMA-ASSN.org/go/Medicarepayment • Go to www.GPP.CMS.gov

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

http://www.gpp.cms.gov/


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 support from your EHR vendor.

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https://portal.cms.gov/


MIPS: Resource Use

• Check your Medicare quality and resource use reports (QRURs) to see where improvement can potentially be made.

• 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).

• Go to www.CMS.gov. Search Medicare, then search CPIA, MIPS, Advancing care information, etc.

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

http://www.cms.gov/


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.

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

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.

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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.

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Actions to Take

• If you have an EHR, make sure it is certified EHR technology (CEHRT)

– Using a certified EHR is essential for both APM participation and MIPS reporting

• Speak with your EHR vendor about how their product supports the requirements of MACRA

• Join the OSMA in establishing a members only virtual ACO.

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AMA Tools to help prepare for MACRA

• AMA Payment Model Evaluator

– Provides guidance as to which payment model is best for your practice

• AMA STEPS Forward

– Provides educational modules on different topics

• Inside Medicare’s New Payment System

– Guidance on implementing MACRA and how to avoid pitfalls

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Take advantage of educational opportunities

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www.stepsforward.org

Completion of select STEPSForward™ modules meets eligibility criteria for CPIA credit

http://www.stepsforward.org/


Stay informed

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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

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

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