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Understanding MACRA & MIPS Trudi MatthewsUK’s Kentucky Regional Extension Center
The information contained in this presentation is for general information purposes only. The information is provided by UK HealthCare’s Kentucky Regional Extension Center and while we endeavor to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to content.
CMS’ Network of Support for MACRA & MIPS
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UK’s Kentucky REC & the Great Lakes Practice Transformation Network (GLPTN)
• Great Lakes PTN is one of 29 Practice Transformation Networks (PTNs)
• GLPTN works with 10 Support and Alignment Networks (SANs)
GLPTN State Level Leadership: • Indiana University (primary grant recipient)• University of Kentucky (Kentucky)• Purdue Healthcare Advisors (Indiana)• Northwestern University (Illinois)• Altarum Institute (Michigan)
CMS established the Transforming Clinical Practices Initiative (TCPI) to help clinicians achieve large-scale health transformations through collaborative and peer-based learning networks
Recent legislative, regulatory and marketplace developments suggest that the transition from volume to value-based payment is accelerating from a “testing” phase to a “scaling” phase.
Volume to Value Based Shift
Affordable Care Act Enacted
March 2010
January 2012
October 2012
Hospital Value Based Purchasing
Program
April 2013
Bundled Payments for Care Improvement
(BPCI)
CMS Announces Value-Based Payment Goals;
Value Modifier Program Begins
January 2015
Medicare Access and CHIP Reauthorization Act (MACRA) Enacted
April 2015
April 2016
MACRA NPRM, Medicaid
Managed Care Final Rule Released
July 2016
Cardiac & CJR Episode Payment NPRM Released
MACRA Final Rule Released
October 2016
Pioneer ACO Program Launched
Testing Phase Scaling Phase
Payers, Providers Differ in Value Based Care, Health IT OpinionsPayers see value based care as a fixture in US healthcare
June 07, 2017 - Payers see the move towards value-based care as a permanent fixture in the nation’s healthcare delivery system, with 82 percent of organizations responding to a Quest Diagnostics and Inovalon survey expecting it to continue despite any national healthcare regulation changes.This move from a fee-for-service based system to an integrated value-based delivery system is far from complete, the survey exposed a gap between the outlooks of health payer executives and providers on how well those VBC goals are being achieved.
Commercial Insurers Moving Forward with Value-based Payment in Spite of Provider Reluctance
Source: https://healthpayerintelligence.com/news/payers-providers-differ-in-value-based-care-health-it-opinions
MACRA Has Bipartisan Support MACRA was passed on April 14, 2015 by both houses of a Republican-controlled Congress,
had substantial Democratic support and was signed by a Democratic president. It is highly unlikely it will be repealed under the new administration.
MACRA Vote in Congress
Senate Vote: 92-8 House Vote: 392-37
MACRA Creates New Medicare Payment Program
APMMIPSMerit-based Incentive
Payment System Alternative Payment
Models
Experts anticipate
> 80% of practices will
participate in MIPS initially.
October 14, 2016: Release of Final Rule
Jan – Dec 2017: 1st Performance Period for MACRA
March 31, 2018: Reporting Deadline for First Year
Jan – Dec 2019: 1st Payment Year = +/- up to 4%
MACRA Timeline
• Physicians, PAs, NPs, CNS, CRNA• After 2020, CMS may expand to other clinicians in Medicare FFS: PT, OT,
NMW, CSW, Clinical Psychologists, Dieticians and Nutrition professionals
5 Types of Eligible Clinicians (ECs):
• Hospitals/Medicare Part A payments • FQHCs/RHCs and Medicaid Providers (that do not bill Medicare Phys. Fee
Schedule)
Not covered by MACRA:
• 1st year ECs• Low Volume: Less than $30K and/or 100 Medicare patients• Advanced APM Qualifying Provider
Exclusions:
• “Non-patient facing” clinicians• MIPS APMs
Different Scoring & Reporting Requirements:
MACRA Eligible Clinicians (ECs)
Who is eligible? See the QPP NPI Lookup Tool
Want to know who is eligible for MACRA/QPP? Go to http://qpp.cms.govand click on the “Check NPI ” button
But what if I am excluded from MACRA/QPP?
Why Should I Pay Attention to all of this?
Option 1: Test Submission
Option 2: Partial Submission
Option 3: Full Submission
Option 4: Advanced APM Participation
QPP
New 2017 Reporting Options
CMS intention states more and more of its $ will be spent in APMs over time
5% Annual Participation Bonus for Advanced APM participants from 2019-2025
Favorable scoring under MIPS for all APM participants
Annual update after 2025 is 0.75% for APM entities versus 0.25% for MIPS entities
What’s the big deal about Advanced APMs?
Advanced Alternative Payment Models
Next Generation ACO Model
Medicare Shared Savings Program – Tracks 2 & 3
Comprehensive Primary Care Plus (CPC+)
Comprehensive ESRD Care Model
Oncology Care Model Two-Sided Risk Arrangement (in 2018)
CJR Episode Model (in 2018)
In new MACRA
Final Rule, Advanced
APMsinclude:
Advanced APM participants are eligible for 5% bonus payment.But, only some APMs are risk-bearing Medicare payment models that qualify for this bonus payment.
MACRA does not change how any particular APM rewards value.APM participants who are not “Qualifying Providers” (QPs) will receive favorable scoring under MIPS.
All APMParticipantsClinicians in Advanced APMs will be deemed
Qualifying APM Participants (“QPs”) if they: 1. Report APM quality measures comparable to MIPS 2. Use of Certified EHR 3. Meet Advanced APM criteria (risk-bearing or medical
home model) 4. Must meet APM thresholds for payment and patient
volumes
Most physicians and practitioners who participate inAPMs will be subject to MIPS and will receive favorable scoring under MIPS.
Only QPs receive the 5% bonus from Medicare
Catch: Not every APM Participant will qualify for the 5% APM bonus
All APM Participants
Advanced APM
Participants
QPs
Merit-Based Incentive Payment Systems (MIPS)
Value-Based
Modifier
EHR Incentive Program
Physician Quality
Reporting System
MIPS: A Consolidation of 3 Programs
Maximum MIPS Payment Adjustments
Source: Leavitt Partners - MACRA: Quality Incentives, Provider Considerations, and the Path Forward
Notes: Losers fund winners
Top performers: - Up to 3X more with scaling factor
- Additional bonus up to 10% from $500 M funded separately Non-participation
Only
MIPS Performance Measurement
Providers will receive a MIPS final score based on 4 weightedperformance categories:
Quality Cost
CY19 60% 0% 15% 25%
CY20 50% 10% 15% 25%
CY21 30% 30% 15% 25%
ImprovementActivities
Advancing CareInformation
Year 1 Thresholds Already Set
0 Points =Full 4% Penalty
3 Points Minimum Threshold =No Penalty, No Reward
Between 4-69 Points = Some Bonus Possible
70+ = Exceptional Performance
Split $500M Pool
Individual vs. Group Reporting
Individual
Under a NPI number and TIN where they
reassign benefits
Group
2 or more clinicians (NPIs)
who have reassigned their billing rights to a
single TIN*
As an APM Entity
Options
Improvement Activities:• Annual Registration in the Prescription Drug Monitoring Program• Completion of training and receipt of approved waiver for provision opioid medication-assisted
treatments (buprenorphine) Medium)• Consultation of the prescription drug monitoring program (high)• Implementation of medication management practice improvements (medium)• Practice improvement for bilateral exchange of patient information (medium)
Quality Measures:• Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use• Documentation of Signed Opioid Treatment Agreement• Opioid Therapy Follow-up Evaluation• Pain Assessment and Follow-Up• Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
MACRA Intersection with Opioid Treatment
Highlights of the 2018 Year 2 MACRA/QPP Proposed Rule
Review 2017 QPP NPRM for Year 2 • Performance Threshold • Performance Category Weights• Key Performance Category changes• Low Volume Thresholds• Bonus opportunities:
• Small Practice • Complex Patient
• Non-patient facing & Facility Based • Virtual Groups
QPP NPRM Y2: Objectives
NOTE: Most of the changes proposed for PY18 are oriented toward clinicians in small practices and in rural and underserved areas.
QPP NPRM Y2: Threshold
0 Points =Full 5% Penalty
15 Points Minimum Threshold =No Penalty, No Reward
Between 16-69 Points =
Some Bonus Possible
70+ = Exceptional Performance
Split $500M Pool
QPP NPRM Y2: MIPS Performance Measurement
Providers will receive a MIPS final score based on 4 weightedperformance categories:
Quality Cost
CY19 60% 0% 15% 25%CY20 60% 0% 15% 25%CY21 30% 30% 15% 25%
ImprovementActivities
Advancing CareInformation
For Year 2:
QPP NPRM Y2: MIPS Reporting Timeframe
Quality
Full Year
Cost
No reporting required
Advancing Care Information
90 days
Improvement activities
90 days
Reporting Deadline:
March 31st
Expanded measures to quality for ACI bonus
Additional measures available
% Final Score: Measures: Requirements: Method:
Makes up 15% of your final score
PCMH/PCSP requires 50% NPI’s in TIN
Reweight for Non patient facing
40 pts needed, 2-4 Activities:
Re-weighting for: Non-patient
facingSmall practicesHRSA
locations
Multiple submissions methods allowed
QPP NPRM Y2: Proposed Changes to IA
Increased from:
30,000 in Medicare Part B or
100 Medicare Patients
To:
90,000 in Medicare Part Bor
200 Medicare Patients
QPP NPRM Y2: Low Volume Threshold
2017 PY Eligibility: 2018 PY Eligibility:
Preparing for MACRA & QPP
1. Team
2. Assessment
3. Action Plan
To Start With
Get to Know your Quality & Resource Use Report (QRUR)
Playbook for the Value Journey
Culture of Continuous Quality Improvement & Team Based Care
Patient Attribution & Population Health
Performance Measurement, Data Analysis and Identification of Gaps in Care
Identification of Higher Risk, High Cost Patients & Targeted Care Management
Care Coordination across the Medical Neighborhood
Patient Engagement & Experience of Care
Determine Eligibility & Track
Determine if Group or Individual Reporting
Pick your Pace
Determine Submission Method(s)
Choose Measures to
Monitor/ReportReport before
March 31st 2018
Next Steps for MACRA/QPP Participation
CMS MIPS Benchmark Results 2017
Measure_NameCMS Quality Measure ID
CMS eMeasure ID
NQF Measure
IDSubmission
MethodMeasure
TypeDecile
3Decile
4Decile
5Decile
6Decile
7Decile
8Decile
9Decile
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Controlling High Blood Pressure 236 CMS165v5 0018 EHR Process
50.00 -55.39
55.40 -59.72
59.73 -63.59
63.60 -67.38
67.39 -71.00
71.01 -75.33
75.34 -80.89
>= 80.90
Controlling High Blood Pressure 236 CMS165v5 0018
Registry/ QCDR Process
51.00 -58.20
58.21 -63.56
63.57 -68.27
68.28 -72.40
72.41 -76.69
76.70 -82.75
82.76 -91.06
>= 91.07
Example of QPP Quality Measure Scoring
To be eligible for bonuses under MACRA, entities must score in the highest deciles for every measure.
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THANK YOU!