8/6/2018

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The Quality Payment Program:

Sarah Leake, MBA, CPHIMS

Deb Anderson, CPHIMS

August 8, 2018

Year 2 (2018) Overview

Disclaimer

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This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently, so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

Important Note: This presentation was developed under contract with Centers for Medicare & Medicaid Services (CMS). Slides are courtesy of CMS from various CMS webinars and presentations about the Quality Payment Program.

Learning Topics

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1) Examine the Quality Payment Program and how it

applies to clinics and clinicians

2) Identify steps and prepare for QPP-MIPS in 2018

3) Understand the capabilities of a Certified Electronic

Health Record Technology (CEHRT) in relationship to

MIPS

4) Review reporting and submission for MIPS and

Medicaid

5) Identify resources, tools and technical assistance

available for support in the MIPS program

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Quality Payment Program Overview

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Medicare Access and CHIP

Reauthorization Act (MACRA) of 2015

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Bipartisan legislation. MACRA intended to:

1. Repeal the Sustainable Growth Rate (SGR)

2. Improve care for Medicare beneficiaries

3. Reauthorize the Children’s Insurance Program (CHIP)

4. Change the physician payment system from focus on

quantity of services to quality of care

Origin of Quality Payment

Program (QPP)

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• Increases focus on quality of care and value of

care delivered

• Moving toward patient-centric health care

system

– Delivers better care

– Smarter spending

– Healthier People

• Offers two tracks of participation

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MACRA =

Quality Payment Program

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MACRA is being implemented as the Quality

Payment Program (QPP)

The QPP encompasses two pathways:

MIPSThe Merit-based Incentive

Payment System

If you decide to participate in MIPS,

you will earn a performance-based

payment adjustment through MIPS

orAPMs

Advanced Alternative

Payment Models

If you decide to participate in an

Advanced APM, you may earn a

Medicare incentive payment for

sufficiently participating in an

innovative payment model

What is an Alternative Payment Model (APM)?

APMs are new approaches to

paying for medical care through

Medicare that incentivize quality

and value.

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What is an Alternative

Payment Model (APM)?

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APMs are new approaches to paying for medical care

through Medicare that incentivize quality and value.

Per MACRA, APMs include:

• CMS Innovation Center model (under

section 115A, other than Health Care

Innovation Award)

• Medicare Shared Savings Program (MSSP)

• Demonstration under Health Care Quality

Demonstration Program

• Demonstration required by federal law

MACRA does not change how any APM rewards value. APM

participants who are not “QPs” will receive favorable scoring under

MIPS. Only some of these APMs will be Advanced APMs.

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

Advanced APMs must meet

certain criteria

Requires

participants to use

certified EHR

technology

Provides payment

for covered

professional

services based on

quality measures

comparable to

those used in MIPS

quality performance

category

Either:

1) Is a Medical

Home Model

expanded under

CMS Innovation

Center OR

2) Requires

participants to

bear a more than

nominal amount

of financial risk

1 2 3

The MIPS Reporting Option

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What is MIPS?

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Prior to 2017 there were multiple quality and value

reporting programs for Medicare clinicians.

MACRA/QPP streamlines (combines) legacy programs

into a single, improved reporting program: MIPS

MIPS

Physician Quality Reporting Program

(PQRS)

Value-based Payment Modifier

(VM)

Medicare EHR Incentive Program

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Which clinicians does the

Quality Payment Program affect?

Will it affect me?

Short answer:

Quality Payment Program affects clinicians who

participate in Medicare Part B.

Clinician Impact

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?

QPP MIPS Program Eligibility

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No change in the types of clinicians eligible to participate

in 2018. For 2017 and 2018, the types of clinicians are as

follows:• Physicians

Doctors of

Medicine

Doctors of

Osteopathy

• Dentists

• Optometrists

• Chiropractors

• Podiatrists

• Physician assistants

• Nurse practitioners

• Clinical nurse

specialists

• Certified registered

nurse anesthetists

Who is included in MIPS for

2018?

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Change to the Low-Volume Threshold for 2018.

• Includes MIPS-eligible clinicians billing more than

$90,000 a year in Medicare Part B allowed charges

AND providing care for more than 200 Medicare

patients a year.

– In 2017: MIPS-eligible clinicians billing more than $30,000 a

year in Medicare Part B allowed charges AND providing care

for more than 100 Medicare patients a year.

• Voluntary reporting remains an option for those

clinicians who are exempt from MIPS.

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Who Is Exempt? MIPS Year 2 (2018)

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No change from 2017 in basic-exemption criteria

for those newly enrolled in Medicare criteria:

• Enrolled in Medicare for the first time during the

performance period = exempt until following

performance year

Below the low-volume threshold:

• Medicare Part B allowed charges less than or equal to

$90,000 a year OR those who see 200 or fewer

Medicare Part B patients a year

Significantly participating in Advanced APMs:

• Receive 25 percent of their Medicare payments OR

see 20 percent of Medicare patients through an

Advanced APM

How is Special Status

Determined for QPP

• CMS retrieves and analyzes Medicare Part B claims

data

• Special rules under QPP will affect the number of total

measures, activities or entire categories that an

individual clinician or group must report

SPECIAL STATUS providers have reduced requirements

for MIPS reporting:

• Small practices

• Rural

• Health Professional Shortage Area (HPSA)

• Non-Patient Facing

• Hospital based

2018 Special Status

for Clinician

https://qpp.cms.gov/participation-lookup/about

Adjustments

Improvement Activity and Quality

Promoting Interoperability

Improvement Activity

Promoting Interoperability

Promoting Interoperability

Improvement Activity

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How do clinicians

participate in MIPS?

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Individual: Under National Provider Identifier (NPI) number

and Taxpayer Identification Number (TIN) where they reassign

benefits

Group:

a) Two or more clinicians identified by their National

Provider Identifier (NPIs) who have reassigned their

billing rights to single Tax Identification Number (TIN)*

b) As an APM Entity

Virtual Group: Made up of solo practitioners and groups of 10

or fewer eligible clinicians who come together “virtually” (no

matter what specialty or location) to participate in MIPS for a

performance period for a year

* If clinicians participate as a group, they are assessed as group across all

four MIPS performance categories

Strategy for TINs with more

than one eligible clinician

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TIN can decide to report as

individuals or a group

If the group decides to report

as a group, provider data

from ALL providers is

aggregated in entire group

performance

If group gets positive payment

adjustment, all included and

exempt group members

receive adjustment

When reporting as a group,

ALL eligible clinicians

(included and exempt) are

incorporated

Determining Your Eligibility and Special Status

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QPP Webpage

Check Eligibility

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MIPS Eligibility Lookup Tool

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Individual and Group Details

Example

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Special Status Example Screen

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Exercise 1:

Determine your MIPS Status

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Go to qpp.cms.gov

website

Type in your individual NPI(s) in

lookup tool

Determine answers to

these questions:

• Are you eligible?

• Are you included?

• Are you included as an

individual? Are you

included as a group?

• Do you have a special

status?

A Closer Look into MIPS Categories

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MIPS Category: Cost

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10 percent of Final Score in 2018

No reporting requirement

CMS will assesses clinicians on Medicare

adjudicated claims data for two measures

1. Medicare Spending per Beneficiary (MSPB)

2. Total per capital cost measures

Expect proposed new cost measures in the future

Cost Category – Improvement

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Two Cost Measures

1. Total per Capita:

Measures of all Medicare Part A and Part B cost during performance period

2. Medicare Spending per Beneficiary (MSPB):

Determines what Medicare pays for services performed by individual clinician during MSPB episode: the period immediately before, during and after patient’s hospital stay

Analyze How to

Lower Costs

• Transitional care

management

• Chronic care

management

• Keep patients out of

hospitals

• Confirm visits to provider/

specialists outside your

facility

MIPS Category: Quality

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50 percent of Final Score in 2018

More than 270 measures available• Most participants: Report up to six quality measures,

including an outcome measure, for a 12-month period.

Report eCQMs through EHR (if available for 2018 reporting)

Other options:

• Data extracted through EHR and registry submission

• Claims coding to include Quality G-Code (individual only)

Quality Measure Selection tool: https://qpp.cms.gov/measures/quality

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MIPS Category:

Improvement Activities

15 percent of Final Score in 2018

Attest to participation in activities that improve

clinical practice▪ Examples: Shared decision-making, patient safety,

coordinating care, increasing access

Minimum 90-day period

Choose two high weight or four medium weight

activities

Expanded Practice Access Population Management Care Coordination

Beneficiary EngagementPatient Safety & Practice

AssessmentParticipation in an APM

Achieving Health EquityIntegrating Behavioral and Mental

Health

Emergency Preparedness &

Response

MIPS Category:

Improvement Activities Cont.

Groups with 15 or fewer participants, non-patient

facing clinicians or those in a rural or health

professional shortage area: ▪ Have less requirements - attest to completing ONE high

weight or TWO medium weight activity for a minimum of

90 days.

112 activities over nine subcategories:

For a full list of activities, please visit QPP.CMS.gov

Medicare EHR Incentive Program Is

NOW Promoting Interoperability

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Overall goal of Meaningful Use incentive

program is to strengthen sharing of health care

data between providers

• Make the program more flexible and less

burdensome

• Emphasize measures that require the exchange of

health information between providers and patients

• Incentivize providers to make it easier for patients to

obtain their medical records electronically

Use of Technology for Continuity of Care

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-

Interoperability-Fact-Sheet.pdf

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MIPS Category:

Promoting Interoperability (PI)

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25 percent of Final Score in 2018

Promotes patient engagement and the electronic

exchange of information using certified EHR technology

In 2018, there are two measure sets for reporting:• PI for those using 2015 edition CEHRT

• PI 2017 transition for 2014 edition CEHRT

5 percent bonus score for submitting to additional public

health agency or clinical data registry not reported under

performance score

Some Improvement Activities are eligible for 10 percent

PI bonus if CEHRT is used to complete Improvement

Activity

2018 PI Transition Measures

and Scoring (2014 CEHRT)

35https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-Interoperability-Fact-Sheet.pdf

Bonus Score

(up to 25%)

Performance

Score

(up to 90%)

Required

Base Score

(50%)

2018 PI Measures and Scoring

(2015 CEHRT)

36https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-Interoperability-Fact-Sheet.pdf

Required

Base Score

(50%)

Bonus Score

(up to 25%)

Performance

Score

(up to 90%)

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Submission Methods for MIPS

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Category Individual Group

Quality

• Qualified Clinical Data

Registry (QCDR)

• Qualified Registry

• EHR

• Claims

• QCDR

• Qualified Registry

• EHR

• Administrative Claims

• CMS Web Interface

• CAHPS for MIPS Survey

Improvement

Activities

• QCDR

• Qualified Registry

• EHR

• Attestation

• QCDR

• Qualified Registry

• EHR

• CMS Web Interface

• Attestation

Advancing

Care

Information

• QCDR

• Qualified Registry

• EHR

• Attestation

• QCDR

• Qualified Registry

• EHR

• CMS Web Interface

• Attestation

Cost• No submission required

• CMS will use claims data

• No submission required

• CMS will use claims data

MIPS: CMS Web Interface

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MIPS participation via CMS Web Interface is only available to

groups with 25 or more eligible clinicians.

Registration period is April 1 through June 30, 2018.

If your group registered for CMS Web Interface in 2017 to

report for MIPS, CMS automatically registered your group to

use CMS Web Interface in 2018.

If your group would like to participate through another data

submission option, you should cancel your election in the

registration system between April 1 and June 30, 2018.

Must register to administer Consumer Assessment of

Healthcare Providers and Systems (CAHPS) for MIPS survey.

Source: https://qpp.cms.gov/mips/individual-or-group-participation/about-group-registration

A Look into MIPS Performance Scoring for 2018

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MIPS Performance Categories

for Year 2 (2018)

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Comprised of four performance categories in 2018

MIPS Year 2 (2018) Performance PeriodChange: Increase to Performance Period

2017 Pick Your Pace Year

Performance

Category

Minimum

Performance

Period

Quality

90-days minimum;

full year (12 months)

was an option

Cost

Not included.

12 months for

feedback only.

Improvement

Activities90 days

Promoting

Interoperability90 days

2018 Transition Year

Performance

Category

Minimum

Performance

Period

Quality 12 months

Cost 12 months

Improvement

Activities90 days

Promoting

Interoperability90 days

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MIPS Year 2 (2018) MIPS: Performance

Threshold & Payment Adjustment

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How can I achieve 15 points?• Report all required Improvement Activities

• Meet the Advancing Care Information base score and submit one quality

measure that meets data completeness

• Meet the Advancing Care Information base score by reporting the five

base measures and submit one medium-weighted Improvement Activity

• Submit six quality measures that meet data completeness criteria

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2017 and 2018

Score Comparison

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>70

points

• Positive adjustment

• Eligible for exceptional

performance bonus –

minimum of additional 0.5%

4-69

points

• Positive adjustment

• Not eligible for exceptional

performance bonus

3

points• Neutral payment adjustment

0

points

• Negative adjustment of -4%

• 0 points = does not

participate

>70

points

• Positive adjustment greater than 0%

• Eligible for exceptional performance

bonus – minimum of additional 0.5%

15.01-

69.99

points

• Positive adjustment greater than 0%

• Not eligible for exceptional

performance bonus

15

points• Neutral payment adjustment

3.76-

14.99

points

• Negative payment adjustment

between -5% and 0%

0-3.75

points• Negative adjustment of -5%

Payment Adjustment Increase

Transition Year 1 (2017) Final Year 2 (2018) Final

MIPS Estimator Tool

44https://www.mipsestimator.org/

MIPS Year 2 (2018)Extreme and Uncontrollable Circumstances (2)

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The Final Rule with Comment Period for Year 2

extends Transition Year hardship exception

reweighting policy for Promoting Interoperability

performance category to now include Quality,

Cost and Improvement Activities.

The hardship exception application deadline is

December 31, 2018.

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Exercise 2: Decide Your Reporting Goal & Plan

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Answer worksheet questions #5, #6, #7• Do you plan to report MIPS?

• If you use an EHR, have you participated in MIPS or

Meaningful Use in the past?

• If you participated in MIPS in 2017, how did you

participate?

• How might you participate in the four MIPS Categories?– Quality

– Promoting Interoperability

– Improvement Activity

– Cost (CMS calculated, but how might you improve this score?):

How much can MIPS adjust

payments?

Based on a MIPS Composite Performance Score, clinicians will receive +/-or

neutral adjustments up to the percentages noted.

What to Expect from your EHR?

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Using EHR for MIPS Activity

Category EHR Functionality

Cost and

CQM reporting for Medicaid

• Extract data and reports on high risk patients for care

coordination

• Sharing of patient information for referrals or ER/Hospital

visits

Quality • CQM reporting in QRDA I or III format

• Submission capability by practice or vendor

• Report and extract data for CQM improvement projects

Improvement Activity • Special bonus in PI for use of EHR in IA activities

• Capabilities of data and reporting for IA – Telehealth,

Behavior Health, etc.

Promoting Interoperability

and Medicaid

• Direct messaging

• PHR availability

• Health information exchange

• Reporting for registries

Promoting Interoperability

Overall of Meaningful Use incentive program to

strengthen sharing of health care data between

providers

• Make the program more flexible and less

burdensome,

• Emphasize measures that require the exchange of

health information between providers and patients,

and

• Incentivize providers to make it easier for patients to

obtain their medical records electronically

50https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-

Interoperability-Fact-Sheet.pdf

Use of Technology for Continuity of Care

Reporting for Medicaid

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Meaningful Use in Medicaid(now Promoting Interoperability)

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http://ehrincentives.guam.gov/Attachments/Guam_EHR_Incentive_Outreach_Presentation.pdf

Merit-based

Incentive

Payment System

(MIPS) applies to

services under

Medicare Part B.

MIPS does NOT

replace

Medicaid’s EHR

Incentive

Program, which

continues

through program

year 2021.

Clinicians eligible

for Medicaid EHR

Incentive

Program will

continue to attest

to state Medicaid

agencies to

receive incentive

payments.

If those clinicians

serve patients in

Medicare Part B,

they may also

participate in

MIPS.

Medicaid Promoting

Interoperability

Medicaid is STILL available for participation through 2021.

Requirements for Providers:

• Meet or exceed the PI measure thresholds

• Report 30 percent Medicaid volume in required time period

• Has submitted to a Medicaid EHR program prior to 2017

Hospitals earn no incentive but will receive Penalty if they

do not Report Meaningful use in the Medicare Program

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.

Promoting Interoperability(MU)

Measures Modified Stage 2

• Protect Patient Health Information

• Clinical Decision Support

• CPOE

• Electronic Prescribing (eRx)

• Health Information Exchange >10%

• Patient Specific Education

• Medication Reconciliation

• Patient Electronic Access >5%

• Secure Messaging (EPs only) >5%

• Public Health and Clinical Data Registry Reporting

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https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medicaid_Modif

iedStage2_2018.pdf

Same measures as 2017.

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Promoting Interoperability(MU)

Measures Stage 3

• Objective 3 Patient Electronic Access

– Provide Patient Access - 80%

– Patient Education - 35%

• Objective 4 Coordination of Care (must attest on all three measures but

meet at least two measure thresholds)

– VDT- 5% (2018) and 10% (2019

– Secure Messaging- 5% (2018) and 25% (2019)

– Patient Generated Health Data - 5%

• Objective 5 Health Information Exchange (must attest on all three

measures but meet at least two measure thresholds)

– Send a Summary of Care - 50%

– Request/Accept Summary of Care - 40%

– Clinical Information Reconciliation - 80%

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https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medica

id_Stage3_2018.pdf

Wyoming Medicaid

• EHR Incentive Website

http://wyomingincentive.wyo.gov/

• State Level Registry

https://wyslr.com/

• Provider Stage 3 Objectiveshttps://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContent

s_EP_Medicaid_Stage3_2018.pdf

Resources and Strategy

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Quality Payment Program

Resources

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Utilize Quality Payment Program Resources:

Centers for Medicare & Medicaid Services

(CMS): https://qpp.cms.gov• Help and Support:

https://qpp.cms.gov/about/help-and-support

• QPP Resource Library:

https://www.cms.gov/Medicare/Quality-Payment-

Program/Resource-Library/Resource-library.html

This is your FRIEND!

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QPP Landing Page

Where to Find Resources

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Sign into QPP with Enterprise Identity

Management (EIDM) Credentials

61EIDM Training Video – Submitting a Role Request and completing RIDP https://www.youtube.com/watch?v=OmL4JOOQ7Rc

MIPS Strategic Alignment

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When choosing MIPS category activity:

Review current quality

program requirements,

align project for biggest

ROI or alignment across

programs (MIPS,

department of health

programs, CCM, CPC+,

PCMH, payer, etc.)

If possible, choose a

measure or activity that

benefits more than one

MIPS category, including

IA and Cost

Clinic Quality Crosswalk (Example for Wyoming)

Healthcare TopicsMedicaid

MU MIPS

WDH

CDP 1305 QIN/QIO

Million

Hearts

GPRA for

IHS

PCMH

NCQA

Care Delivery Topics

Care Coordination x x x x

Behavior Health Integration x x x

Beneficiary Engagement x x x x x

Chronic Care Management x x x x x x

Use of CEHRT/Data x x x x x

Chronic Conditions

Cardiovasular x x x x x x x

Diabetes x x x x x x

Quality Measures

Diabetes A1c Poor Control x x x x x x x

Controlling High Blood Pressure x x x x x x x

Closing the Referral Loop x x x x

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Quality Reporting Efficiency

CCM/TCM - Example

• Report clinical quality measure CMS 50/ID 374

(closing the referral loop) for one of your quality

measures (it is a high priority measure)

• Can attest to IA – medium activity (care

coordination IA_CC_1 )

• Qualifies for a 10 percent PI category bonus

• Improve on Cost Category due to TCM focus

*check for current benchmark/submission methods

IMPROVEMENT ACTIVITY QUALITY COST

PROMOTING INTEROPERABILITY

Questions?

Developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization

(QIN-QIO) for Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the

Northern Mariana Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health

and Human Services. Contents presented do not necessarily reflect CMS policy. 11SOW-MPQHF-WY-D1-18-18

Additional Resources

66

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Learning Opportunities

CMS has created several learning modules aimed

at helping you understand and succeed in the QPP

program. You can find those modules here:

https://learner.mlnlms.com/Default.aspx

Check out our Quality Health Blogs

MIPS and MU (now Promoting Interoperability)http://mpqhf.org/blog

Tools and Assessment

Get customized support for your practice by filling

out a short assessment – Mountain-Pacific:

http://mpqhf.com/QIO/qpp-enroll/

MIPS Estimator: https://www.mipsestimator.org/

Provider eligibility look up tool: http://qpp.cms.gov/

For more information, contact a QPP expert:

Mountain-Pacific Quality Health

Please contact us for assistance!

Visit us online at

www.mpqhf.org

Deb Anderson

danderson@mpqhf.org

(307) 772-1096

Sarah Leake

sleake@mpqhf.org

(406) 461-4504