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©2015 American Academy of Neurology
MACRA and the Axon Registry: What
You Need to Know
Lyell K. Jones Jr. MD, FAAN
Vice Chair, AAN Registry Committee
Associate Professor of Neurology, Mayo Clinic
September 8, 2016
©2015 American Academy of Neurology
Goals• By the end of this session, we want you to be able
to explain to a colleague:
The essential aspects of MACRA and its effect on CMS
payment systems
Differences between the two major components of
MACRA: the Merit-Based Incentive Payment System
(MIPS) and Alternative Payment Models (APM)
Interactions between the MACRA and the Axon Registry
Slide 2
©2015 American Academy of Neurology
Background: Health Care Costs
Slide 3Source: Kaiser Family Foundation
Projections of National Health Care Expenditures and Share of GDP, 2013-2023
©2015 American Academy of Neurology
Background: Health Care Costs
Slide 4CMS, 2015: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html Accessed 2/5/15
©2015 American Academy of Neurology
Background: Current CMS Programs
• Physician Quality Reporting System (PQRS)
Providers who report approved quality measures avoid
penalties (up to -2% in 2017)
CMS will be moving to performance based adjustment
• Value-Based Payment Modifier (VBPM)
Providers are scored on PQRS performance and resource use
(cost) to receive bonuses or penalties (-4% to +4%)
• Meaningful Use (MU), or EHR Incentive Payment Program
Has transitioned from bonuses for attestation to penalties for
failing to attest (-4% in 2017)
Slide 5
©2015 American Academy of Neurology
What is MACRA?•The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
•Passed with wide bipartisan and bicameral support
House vote: 392-37
Senate vote: 92-8
• Signed into law April 16, 2015
•Proposed rule released April 2016
Slide 6
©2015 American Academy of Neurology
Medicare Payment Modernization• Permanent repeal of the SGR
• MACRA implements a completely new payment
structure
• Rulemaking will be critical to implementation
Slide 7
Volume Value
©2015 American Academy of Neurology
MIPS Exclusions
First year of Medicare Part B
Participation
Below low volume threshold for
patients seen/ Medicare
allowable charges
Qualifying participant in an
approved advanced
Alternative Payment Model
(APM)
Slide 9
©2015 American Academy of Neurology
MIPS Performance Categories• Quality
• Resource Use
• Advancing Care Information
• Clinical Practice Improvement Activities
Slide 10
©2015 American Academy of Neurology
MIPS Performance Categories
Quality (50%)
Resource Use (10%)
Advancing Care Information(25%)
Clinical Practice ImprovementActivities (15%)
Slide 11
©2015 American Academy of Neurology
MIPS Performance Categories• Quality (50%)
Will closely resemble PQRS
Measures will be selected from multiple domains:
–Clinical care
–Safety
–Care coordination
–Patient and caregiver experience
–Population health and prevention
Slide 12
©2015 American Academy of Neurology
MIPS Performance Categories• Quality (50%)
Certain measure types will be given priority for
inclusion:
–Outcomes
–Patient experience (such as patient reported
outcomes or PROs)
–Care coordination
–Appropriate resource use
Slide 13
©2015 American Academy of Neurology
MIPS Performance Categories• Resource Use (10%)
This will be similar to the Value-based Payment Modifier
(VBPM)
New “classification codes” will be used:
–Care episode groups: likely will be used to identify
episodes in episode-based payment models
–Patient condition groups: likely will be used for group
assignments with condition-based payment
–Patient relationship categories: likely will be used to
define provider attribution of patient outcomes
Slide 14
©2015 American Academy of Neurology
MIPS Performance Categories• Advancing Care Information (ACI, formerly
Meaningful Use or MU) (25%)
Will generally align with existing MU requirements
Inconsistencies between current programs (e.g., PQRS
and MU) will be eliminated
Approved measures (in the Quality category) will
automatically satisfy the MU quality measure reporting
requirements
Slide 15
©2015 American Academy of Neurology
MIPS Performance Categories• Clinical Practice Improvement Activities (CPIAs) (15%)
This is new for CMS, but will feel similar to practice improvement activities in other parts of our practice
Approved CPIAs will likely include:
–Expanded practice access
–Population health management
–Care coordination
–Beneficiary engagement
–Patient safety and practice assessment
–Participation in an APM
QCDR (registry) participation will positively impact score
Slide 16
©2015 American Academy of Neurology
MIPS Risk Corridor
-15.00%
-10.00%
-5.00%
0.00%
5.00%
10.00%
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
Annual Update Max. Penalty Bonus Potential
Slide 17
Combined PQRS, MU,
VBPM penalties
©2015 American Academy of Neurology
Alternative Payment Models• Providers that receive significant revenue from
qualifying APMs are exempt from MIPS
• Eligible for 5% bonus 2019-2024
• Qualifying APMs:
Use certified EMR technology
Employ quality measures similar to MIPS
Must be risk-bearing
• Model criteria to be further defined by CMS
Slide 18
©2015 American Academy of Neurology
Alternative Payment Models• Current examples of APMs:
Accountable care organizations (ACOs)
Patient-centered medical homes (PCMHs)
“Bundled” payments/episode-based payments
• Advanced APMs described in proposed rule are very
narrowly defined
Flexibility and specialty-relevant models will be
important to encourage neurologist participation
The AAN is actively developing neurology-relevant APMs
Slide 19
©2015 American Academy of Neurology
Alternative Payment Models• A Technical Advisory Committee (PTAC) has been
formed to advise CMS on development of new APMs
11 members, 7 physicians
• New APMs may be submitted on an ongoing basis
• CMS is tasked with developing APMs targeted to:
Specialty practices
Smaller practices
Risk-based models
Slide 20
©2015 American Academy of Neurology
Overall Payment Updates2015-2018 2019 2020 2021 2022-
2024
2025 2026+
Conversion
Factor
Update
0.5% 0.5% 0% 0% 0% 0% MIPS: 0.25%
APM: 0.75%
MIPS
Adjustment
Factor
PQRS, MU,
and VBPM
penalties in
effect (-
4.5% to -
10%+)
-4% to
+4%*
-5% to
+5%*
-7% to
+7%*
-9% to
+9%*
-9% to
+9%
-9% to
+9%
APM Bonus 5% 5% 5% 5%
% Medicare
Revenue
from APM
25% 25% 50% 50-75% 75% 75%
Slide 21*additional bonus for top performers NOT
included
©2015 American Academy of Neurology
MACRA: Specialities and Subspecialties
•While the proposed rule reduced the number of
reported quality measures from 9 to 6, there may
be few relevant options in a subspecialty practice
• Advanced APMs are narrowly defined, with
unresolved barriers for specialty practices
• Risk adjustment in the proposed rule does not take
into account subspecialty patient populations
©2015 American Academy of Neurology
How is AAN preparing for MACRA?• The AAN has been very active in the regulatory
advocacy phase, urging CMS to consider neurologists and their patients in the rulemaking process
• AAN staff and volunteers are actively working to develop new payment models that better serve neurologists
• Using numerous channels (trained speakers, AAN.com, online videos, the Annual Meeting, etc), the AAN is working to educate neurologists on the urgency of approaching payment changes
©2015 American Academy of Neurology
Axon RegistryTM Participation •Will seamlessly report Quality data and ACI
attestation in MIPS
•Will positively impact score on CPIA component of
MIPS
•Will give practices access practice trend data and
identify potential areas for improvement
• Go to www.aan.com/practice/axon-registry for
more information
Slide 24
©2015 American Academy of Neurology
MACRA and the Axon Registry• The rule proposes QCDRs act as intermediaries on
behalf of clinicians and submit data for the Quality,
CPIA, and ACI categories:
Quality - Means for quality reporting component
Clinical practice improvement activities – Component of
several CPIAs and as a means to attest to participation
Advancing care Information- Means for attestation in
ACI component
• In the future, align MIPS/Axon measures and
further clarify CPIAs
©2015 American Academy of Neurology
MACRA and the Axon Registry• Concerns with the proposed rule:
Little detail in proposed rule on requirements for QCDRs
No guidance for vendors or QCDRs
As CMS further clarifies, AAN will assess AAN’s potential
financial impact of providing service and vendor
capability to develop the technology
©2015 American Academy of Neurology
What do you need to do now?• If you haven’t reported on meaningful use (MU),
start now
• If you haven’t reported PQRS measures, start now
• If you have done PQRS, become familiar with your
QRUR reports to identify areas for improvement
©2015 American Academy of Neurology
MACRA: Take Away Points• MACRA signals the transition to value-based payment
systems
• Many details have yet to be clarified in the final
MACRA rulemaking
• The ideal MACRA participation pathway for any one
practice will depend on a number of factors
• Axon will be an important tool for neurologists in
the MACRA era
Slide 28