CMS Slides on MACRA Quality Payment Program Proposed Rule

8/17/2019 CMS Slides on MACRA Quality Payment Program Proposed Rule

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The Medicare Access & Chip Reauthorization Act of 2015

QUALITYPAYMENT

PROGRAM


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This presentation was current at the time it was published oruploaded onto the web. Medicare policy changes frequently solinks to the source documents have been provided within thedocument for your reference.

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

2

Disclaimer


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KEY TOPICS:

1) The Quality Payment Program and HHS Secretary’s Goals

2) What is the Quality Payment Program?

3) How do I submit comments on the proposed rule?

4) The Merit-based Incentive Payment System (MIPS)

5) Incentives for participation in Advanced Alternative PaymentModels (Advanced APMs)

6) What are the next steps?


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In January 2015, the Department of Health and Human Services announcednew goals for value-based payments and APMs in Medicare

4

The Quality Payment Program is part of a broaderpush towards value and quality


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Medicare Payment Prior to MACRA

The Sustainable Growth Rate (SGR )

• Established in 1997 to control the cost of Medicare paymentsto physicians

Fee-for-service (FFS) payment system, where clinicians are paid based onvolume of services, not value.

5

TargetMedicare

expenditures

Overallphysician

costs

>IF Physician paymentscut across the board

Each year, Congress passed temporary “doc fixes” to avert cuts

(no fix in 2015 would have meant a 21% cut in Medicare paymentsto clinicians)


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INTRODUCING THE QUALITY

PAYMENT PROGRAM

6


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First step to a fresh start

We’re listening and help is available

A better, smarter Medicare for healthier people

Pay for what works to create a Medicare that is enduring

Health information needs to be open, flexible, and user-centric

Quality Payment Program

The Merit-basedIncentive

Payment System(MIPS)

AdvancedAlternative

Payment Models(APMs)

or

Repeals the Sustainable Growth Rate (SGR) Formula Streamlines multiple quality reporting programs into

the new Merit-based Incentive Payment System (MIPS) Provides incentive payments for participation in

Advanced Alternative Payment Models (APMs)


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When and where do I submit comments?

• The proposed rule includes proposed changes not reviewed in thispresentation. We will not consider feedback during the call as formalcomments on the rule. See the proposed rule for information onsubmitting these comments by the close of the 60-day comment period

on June 27, 2016. When commenting refer to file code CMS-5517-P.

• Instructions for submitting comments can be found in the proposed rule;FAX transmissions will not be accepted. You must officially submit yourcomments in one of the following ways: electronically through

• Regulations.gov• by regular mail• by express or overnight mail• by hand or courier

• For additional information, please go to:http:// go.cms.gov/QualityPaymentProgram

8

http://go.cms.gov/QualityPaymentProgramhttp://go.cms.gov/QualityPaymentProgramhttp://go.cms.gov/QualityPaymentProgram


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MIPS: First Step to a Fresh Start

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MIPS is a new program

• Streamlines 3 currently independent programs to work as one and toease clinician burden.

• Adds a fourth component to promote ongoing improvement andinnovation to clinical activities.

MIPS provides clinicians the flexibility to choose the activities andmeasures that are most meaningful to their practice to demonstrateperformance.

Quality Resource use

:

Clinical practiceimprovement

activities

Advancing care

information


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Currently there are multiple quality and value reporting programs for Medicare clinicians:

10

Medicare Reporting Prior to MACRA

Physician QualityReporting Program

(PQRS)

Value-Based PaymentModifier (VM)

Medicare ElectronicHealth Records (EHR)

Incentive Program


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PROPOSED RULE

MIPS: Major Provisions

11

Eligibility (participants and non-participants)

Performance categories & scoring

Data submission

Performance period & payment adjustments


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Years 1 and 2 Years 3+

Physicians (MD/DO and DMD/DDS),PAs, NPs, Clinical nurse specialists,

Certified registered nurseanesthetists

Physical or occupational therapists,Speech-language pathologists,Audiologists, Nurse midwives,Clinical social workers, Clinical

psychologists, Dietitians /Nutritional professionals

Affected clinicians are called “MIPS eligible clinicians” and will participate in MIPS. The types of Medicare Part B eligibleclinicians affected by MIPS may expand in future years.

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Who Will Participate in MIPS?

Secretary maybroaden Eligible

Clinicians group toinclude others

such as


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There are 3 groups of clinicians who will NOT be subject to MIPS:

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Who will NOT Participate in MIPS?

1FIRST year of Medicare

Part B participationCertain participants inADVANCED Alternative

Payment Models

Below low patientvolume threshold

Note: MIPS does not apply to hospitals or facilities

Medicare billing charges less than or equal to$10,000 and provides care for 100 or fewer Medicare

patients in one year


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Note: Most clinicians will be subject to MIPS.

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Not in APMIn non-Advanced

APMQP in Advanced

APM

Note: Figure not to scale .

Some people may be in

Advanced APMs butnot have enough

payments or patientsthrough the Advanced

APM to be a QP.

In Advanced APM, but

not a QP


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Eligible Clinicians can participate in MIPS as an:

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PROPOSED RULE

MIPS: Eligible Clinicians

Or

Note: “Virtual groups” will not be implemented in Year 1 of MIPS.

A group, as defined by taxpayer

identification number (TIN),would be assessed as a grouppractice across all four MIPS

performance categories.

GroupIndividual


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PROPOSED RULE

MIPS: PERFORMANCECATEGORIES & SCORING

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QualityResource

use

:

Clinicalpractice

improvementactivities

Advancingcare

information

A single MIPS composite performance score will factor in performance in 4 weighted performance categories on a 0-100 pointscale:

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MIPS Performance Categories

MIPSComposite

PerformanceScore (CPS)


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Year 1 Performance Category Weights for MIPS

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QUALITY50%

ADVANCING CAREINFORMATION

25%

CLINICAL PRACTICEIMPROVEMENT

ACTIVITIES15%

COST10%


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QualityResource

use

:

Clinicalpractice


Advancingcare

information

*Proposed qualitymeasures are available in

the NPRM

*clinicians will be able tochoose the measures onwhich they’ll be evaluated

The MIPS composite performance score will factor in performance in4 weighted performance categories on a 0-100 point scale :

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What will determine my MIPS score?

MIPSComposite



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Summary:

Selection of 6 measures

1 cross-cutting measure and 1 outcome measure, or another highpriority measure if outcome is unavailable

Select from individual measures or a specialty measure set

Population measures automatically calculated

Key Changes from Current Program (PQRS):

• Reduced from 9 measures to 6 measures with no domain

requirement

• Emphasis on outcome measurement

• Year 1 Weight: 50%

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PROPOSED RULE

MIPS: Quality Performance Category


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QualityResource

use

:

Clinicalpractice


Advancingcare

information

*Will compare resources used totreat similar care episodes and

clinical condition groups acrosspractices

*Can berisk-adjusted toreflect external

factors

The MIPS composite performance score will factor in performancein 4 weighted performance categories on a 0-100 point scale :

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MIPSComposite



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Summary:

Assessment under all available resource use measures, as applicableto the clinician

CMS calculates based on claims so there are no reporting

requirements for clinicians Key Changes from Current Program (Value Modifier):

• Adding 40+ episode specific measures to address specialtyconcerns


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PROPOSED RULE

MIPS: Resource Use Performance Category


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QualityResource

use

:

Clinicalpractice


Advancingcare

information

*Examples include care coordination,

shared decision-making, safety

checklists, expanding practice access


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MIPSComposite



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Summary:

Minimum selection of one CPIA activity (from 90+ proposedactivities) with additional credit for more activities

Full credit for patient-centered medical home

Minimum of half credit for APM participation

Key Changes from Current Program:

• Not applicable (new category)


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PROPOSED RULE

MIPS: Clinical Practice Improvement ActivityPerformance Category


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QualityResource

use

:

Clinicalpractice


Advancingcare

information

* % weight of this

may decrease as moreusers adopt EHR


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MIPSComposite



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Who can participate?

PROPOSED RULEMIPS: Advancing Care Information

Performance Category

Those Not EligibleInclude: NPs, PAs,Hospitals, Facilities &Medicaid

Individual

Group

Participatingas an..

or

All MIPS EligibleClinicians


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The overall Advancing Care Information scorewould be made up of a base score and a

performance score for a maximum score of 100

points




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Base ScoreAccounts for 50 points of the total Advancing

Care Information category score.

To receive the base score, physicians must simplyprovide the numerator/denominator or yes/no for each

objective and measure


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CMS proposes six objectives and their measures that would require

reporting for the base score:


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THE PERFORMANCE SCOREThe performance score accounts for up to 80 points towards the total

Advancing Care Information category score

Physicians select the measures that best fit their practice from the

following objectives, which emphasize patient care and informationaccess:


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PROPOSED RULE

MIPS: Performance Category Scoring

Summary of MIPS Performance CategoriesPerformance Category Maximum Possible

Points per PerformanceCategory

Percentage of OverallMIPS Score

(Performance Year 1 -2017)

Quality: Clinicians choose six measures to report to CMS that best

reflect their practice. One of these measures must be an outcome

measure or a high-value measure and one must be a crosscuttingmeasure. Clinicians also can choose to report a specialty measure

set.

80 to 90 points

depending on group

size

50 percent

Advancing Care Information: Clinicians will report key measures

of interoperability and information exchange. Clinicians arerewarded for their performance on measures that matter most to

them.

100 points 25 percent

Clinical Practice Improvement Activities: Clinicians can choose

the activities best suited for their practice; the rule proposes over90 activities from which to choose. Clinicians participating inmedical homes earn “full credit” in this category, and those

participating in Advanced APMs will earn at least half credit.

60 points 15 percent

Cost: CMS will calculate these measures based on claims and

availability of sufficient volume. Clinicians do not need to report

anything.

Average score of all

cost measures that can

be attributed

10 percent


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A single MIPS composite performance score will factor in performance in4 weighted performance categories on a 0-100 point scale :

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PROPOSED RULE

MIPS: Calculating the Composite Performance Score(CPS) for MIPS

Quality Resourceuse

Clinicalpractice


:

Advancingcare

information

=

MIPSComposite


The CPS will becompared to the MIPS

performance threshold

to determine the

adjustment percentage

the eligible clinician will

receive.


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MIPS composite performance scoring method that accounts for:

• Weights of each performance category

• Exceptional performance factors

• Availability and applicability of measures for different categories

of clinicians

• Group performance

• The special circumstances of small practices, practices located inrural areas, and non-patient- facing MIPS eligible clinicians

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PROPOSED RULE

MIPS: Calculating the Composite Performance Score(CPS) for MIPS


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Calculating the Composite Performance Score (CPS)for MIPS

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Category Weight Scoring

Quality 50% • Each measure 1-10 points compared to historicalbenchmark (if avail.)

• 0 points for a measure that is not reported• Bonus for reporting outcomes, patient experience,

appropriate use, patient safety and EHR reporting

• Measures are averaged to get a score for the categoryAdvancingcareinformation

25% • Base score of 60 points is achieved by reporting at leastone use case for each available measure

• Up to 10 additional performance points available permeasure

• Total cap of 100 percentage points available

CPIA 15% • Each activity worth 10 points; double weight for “high”

value activities; sum of activity points compared to a target

Resource Use 10% • Similar to quality

Unified scoring system:1.Converts measures/activities to points2.Eligible Clinicians will know in advance what they need to do to achieve top performance

3.Partial credit available


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HOW DO I GET MY DATA TO CMS?

DATA SUBMISSION FOR MIPS

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PROPOSED RULE

MIPS Data Submission OptionsQuality and Resource Use

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Quality

Resource use

Group Reporting

Claims QCDR Qualified Registry EHR Vendors Administrative Claims (No

submission required)

QCDR Qualified Registry EHR Vendors CMS Web Interface

(groups of 25 or more) CAHPS for MIPS Survey

Administrative Claims (Nosubmission required)

Administrative Claims(No submission required)

Administrative Claims(No submission required)

Individual Reporting


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PROPOSED RULE

MIPS Data Submission OptionsAdvancing Care Information and CPIA

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Attestation QCDR Qualified Registry EHR Vendor

Attestation QCDR Qualified Registry EHR Vendor CMS Web Interface

(groups of 25 or more)

Attestation QCDR Qualified Registry EHR Vendor Administrative Claims (No

submission required)

Attestation QCDR Qualified Registry EHR Vendor CMS Web Interface

(groups of 25 or more)

:

Advancingcare

information

CPIA

Group ReportingIndividual Reporting


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PROPOSED RULE

MIPS PERFORMANCE PERIOD& PAYMENT ADJUSTMENT

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A MIPS eligible clinician’s payment adjustment percentage is based onthe relationship between their CPS and the MIPS performancethreshold.

A CPS below the performance threshold will yield a negative paymentadjustment; a CPS above the performance threshold will yield a neutral

or positive payment adjustment.

A CPS less than or equal to 25% of the threshold will yield themaximum negative adjustment of -4%.

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PROPOSED RULE

MIPS: Payment Adjustment

=

MIPSComposite


Quality Resourceuse

Clinicalpractice


:

Advancingcare

information


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+/-Maximum

Adjustments

AdjustedMedicare PartB payment to

clinician

Merit-Based Incentive Payment System(MIPS)

+4%+5%

+7%+9%

2019 2020 2021 2022 onward

Based on a CPS, clinicians will receive +/- or neutral adjustments up to the percentages below.

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How much can MIPS adjust payments?

-4%The potential maximum

adjustment % will

increase each year from

2019 to 2022

-5%-7%-9%


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+/-Maximum

Adjustments

Merit-Based Incentive Payment System(MIPS)

+4%+5%

+7%+9%

2019 2020 2021 2022 onward

Note: MIPS will be a budget-neutral program. Total upward and downward adjustments will be balanced so that the average change is0 .

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How much can MIPS adjust payments?

-4%-5%-7%-9%

*Potential for

3Xadjustment


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MIPS: Scaling Factor Example

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Dr. Joy Smith, who receives the +4% adjustment for MIPS, could

receive up to +12% in 2019. For exceptional performance she couldearn an additional adjustment factor of up to +10%.

Note: This scaling process will only apply to positive adjustments, notnegative ones.

*Potential for

3Xadjustment

+ 4%

+ 12%


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2017 2018 July 2019 2020

PROPOSED RULE

MIPS Timeline

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PerformancePeriod

(Jan-Dec)

1st FeedbackReport(July)

Reportingand DataCollection

Analysis and Scoring

2nd FeedbackReport(July)

TargetedReview Basedon 2017 MIPSPerformance

MIPSAdjustments

in Effect


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Incentives for Advanced APM Participation


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APMs are new approaches to paying for medical care through Medicare thatincentivize quality and value.

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What is an Alternative Payment Model (APM)?

CMS Innovation Center model (undersection 1115A, other than a Health CareInnovation Award)

MSSP (Medicare Shared Savings Program)

Demonstration under the Health CareQuality Demonstration Program

Demonstration required by federal law

As defined byMACRA,

APMs

include:


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The APM requires participants to usecertified EHR technology.

The APM bases payment on qualitymeasures comparable to those in theMIPS quality performance category.

The APM either: (1) requires APM

Entities to bear more than nominalfinancial risk for monetary losses;OR (2) is a Medical Home Modelexpanded under CMMI authority.

Advanced APMs meet certain criteria.

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As defined by MACRA,advanced APMs must meet

the following criteria:


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PROPOSED RULEMedical Home Models

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Medical Home Models:

Have a unique financial risk criterion for becoming an AdvancedAPM.

Enable participants (who are notexcluded from MIPS) to receive the

maximum score in the MIPS CPIAcategory.

A Medical Home Model is an APM that hasthe following features: Participants include primary care

practices or multispecialty practices thatinclude primary care physicians andpractitioners and offer primary careservices.

Empanelment of each patient to aprimary clinician; and

At least four of the following:• Planned coordination of chronic and

preventive care.• Patient access and continuity of care.• Risk-stratified care management.

• Coordination of care across themedical neighborhood.• Patient and caregiver engagement.• Shared decision-making.• Payment arrangements in addition

to, or substituting for, fee-for-service payments.


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NOTE: MACRA does NOT change how any particular

APM functions or rewards value. Instead, it createsextra incentives for APM participation.

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PROPOSED RULE


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PROPOSED RULE

Advanced APM Criterion 1:Requires use of CEHRT

52

An Advanced APM must requireat least 50% of the eligibleclinicians in each APM Entity touse CEHRT to document and

communicate clinical care. Thethreshold will increase to 75%after the first year.

For the Shared Savings Programonly, the APM may apply a

penalty or reward to APMentities based on the degree of CEHRT use among its eligibleclinicians.

:

CertifiedEHR use

Example: An Advanced APM has a

provision in its participationagreement that at least 50% of an

APM Entity’s eligible clinicians must

use CEHRT.

APMEntity

EligibleClinicians

PROPOSED RULE


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PROPOSED RULE

Advanced APM Criterion 2:Requires MIPS-Comparable Quality Measures

53

An Advanced APM must base payment on qualitymeasures comparable to those under the proposedannual list of MIPS quality performance measures;

No minimum number of measures or domainrequirements, except that an Advanced APM must have

at least one outcome measure unless there is not anappropriate outcome measure available under MIPS.

Comparable means any actual MIPS measures or other measures that areevidence-based, reliable, and valid. For example:

• Quality measures that are endorsed by a consensus-based entity; or

• Quality measures submitted in response to the MIPS Call for Quality Measures;or

• Any other quality measures that CMS determines to have an evidence-based focus to be reliable and valid.

QualityMeasures


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PROPOSED RULE


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PROPOSED RULE

Advanced APM Criterion 3:Financial Risk Criterion

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OR

Financial Risk Standard

Withhold of payment to the APM Entityor eligible clinicians

OR

Reduction in payment rates to the APMEntity or eligible clinicians

Direct payment from the APM Entity

The Advanced APMrequires one or

more of thefollowing if actual

expendituresexceed expected

expenditures:

PROPOSED RULE


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PROPOSED RULE

Advanced APM Criterion 3:Financial Risk Criterion

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The amount of risk underan Advanced APM must atleast meet the followingcomponents:

Total risk of at least4% of expectedexpenditures

Marginal risk of atleast 30%

Minimum loss ratio(MLR) of no more than4%.

Nominal AmountStandard

Illustration of the amountof risk an APM Entity mustbear in an Advanced APM:

PROPOSED RULE


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PROPOSED RULE

Advanced APM Criterion 3:Example

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An APM consists of a two-sided shared savingsarrangement:

If the APM Entity’s actual expendituresexceed expected expenditures (the“benchmark”), then the APM Entity must pay

CMS 60% of the amount that expendituresthat exceed the benchmark .

The APM Entity does not have to make anypayments if actual expenditures exceed thebenchmark by less than 2% of thebenchmark amount.

There is a stop-loss provision so that theAPM Entity could pay up to but no more thana total amount equal to 10% of thebenchmark.

The following is anexample of a riskarrangement that wouldmeet the Advanced APMfinancial risk criterion:

PROPOSED RULE


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PROPOSED RULE

Advanced APM Criterion 3:Medical Home Model Financial Risk Criterion

58

OR

Medical Home Model FinancialRisk Standard

Withhold of payment to the APM Entity oreligible clinicians

OR

Reduction in payment rates to the APMEntity or eligible clinicians

Direct payment from the APM Entity

Reduces an otherwise guaranteedpayment or payments

OR

The Medical Home

Model requiresone or more of the

following if theAPM Entity fails

to meet aspecified

performancestandard:

PROPOSED RULE


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PROPOSED RULE

Advanced APM Criterion 3:Medical Home Model Nominal Amount Standard

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To be an Advanced APM, the amountof risk under a Medical Home Modelmust be at least the followingamounts:

2.5% of Medicare Parts A andB revenue (2017)

3% of Medicare Parts A and Brevenue (2018)

4% of Medicare Parts A and B

revenue (2019) 5% of Medicare Parts A and B

revenue (2020 and later)

Medical Home Model NominalAmount Standard:

Subject to Size Limit

The Medical Home Model standardsonly apply to APM Entities with ≤ 5

eligible clinicians in the APM Entity’sparent organization


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Shared Savings Program (Tracks 2 and 3)

Next Generation ACO Model

Comprehensive ESRD Care (CEC) (large dialysis

organization arrangement)

Comprehensive Primary Care Plus (CPC+)

Oncology Care Model (OCM) (two-sided risk track

available in 2018)

Proposed RuleAdvanced APMs

Based on the proposed criteria, which current APMs willbe Advanced APMs in 2017?


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How do I become a Qualifying APM Participant (QP)?

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You must have a certain % of yourpatients or payments through an

Advanced APM.

QPAdvanced APM

Be excluded from MIPS

QPs will:Receive a 5% lump sum bonus

Bonus applies in 2019-2024; thenQPs receive higher fee schedule

updates starting in 2026


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1. QP determinations are made at theAdvanced APM Entity level.

2. CMS calculates a “Threshold Score”for each Advanced APM Entity.

3. The Threshold Score for each methodis compared to the correspondingQP threshold.

4. All the eligible clinicians in theAdvanced APM Entity become QPs forthe payment year.

QPEligible Clinicians

Eligible Clinicians toQP in 4 STEPS

The period of assessment (QP Performance Period) for each payment year will bethe full calendar year that is two years prior to the payment year (e.g., 2017performance for 2019 payment).

Aligns with the MIPS performance period.

PROPOSED RULE

How do Eligible Clinicians become QPs?


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PROPOSED RULE


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STEP 1

QP determinations aremade at the AdvancedAPM Entity level.

All participating

eligible clinicians areassessed together.

Advanced APM

Advanced APM Entities

Eligible Clinicians


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PROPOSED RULE


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STEP 2

CMS will calculate a percentage “Threshold Score” for each Advanced APMEntity using two methods (payment amount and patient count).

Methods are based on Medicare Part B professional services andbeneficiaries attributed to Advanced APM Entities.

CMS will use the method that results in a more favorable QP determinationfor each Advanced APM Entity.

Attributed (beneficiaries for whose cost andquality of care the APM Entity is responsible)

Attribution-eligible (all beneficiarieswho could potentially be attributed)

These definitionsare used for

calculatingThreshold Scoresunder both

methods.


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PROPOSED RULE


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Payment Amount Method

$$$ for Part B professionalservices to attributedbeneficiaries

$$$ for Part B professionalservices to attribution-eligible beneficiaries

Payments

=ThresholdScore %

Patient Count Method

# of attributedbeneficiaries given Part Bprofessional services

# of attribution-eligiblebeneficiaries given Part Bprofessional services

=ThresholdScore %

Patients

STEP 2

The two methods for calculation are Payment Amount Method and PatientCount Method.


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PROPOSED RULE


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Medicare Option – Payment Amount Method

PaymentYear

2019 2020 2021 2022 2023 2024+

QPPaymentAmountThreshold

25% 25% 50% 50% 75% 75%

Partial QP

PaymentAmountThreshold

20% 20% 40% 40% 50% 50%

Medicare Option – Patient Count Method

PaymentYear

2019 2020 2021 2022 2023 2024+

QPPatientCountThreshold

20% 20% 35% 35% 50% 50%

Partial QP

PatientCountThreshold

10% 10% 25% 25% 35% 35%

PatientsPayments

STEP 3

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


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STEP 4

All the eligibleclinicians in theAdvanced APM Entitybecome QPs for thepayment year.

PROPOSED RULE


Advanced APM

Advanced APM Entities

Eligible Clinicians

ThresholdScores above

the QPthreshold =QP status

Threshold Scoresbelow the QP

threshold = no QPs

Wh b i M di id APM


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What about private payer or Medicaid APMs?Can they help me qualify to be a QP?

68

Starting in 2021, some arrangements with othernon-Medicare payers can count toward

becoming a QP.

IF the “Other Payer APMs” meet criteria similar to those for Advanced

APMs, CMS will consider them “Other Payer Advanced APMs”:

“All-PayerCombination

Option”

QualityMeasures

FinancialRisk

:

CertifiedEHR use

O O


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PROPOSED RULE

APM Incentive Payment

69

The “APM Incentive Payment” will be based on the estimated aggregatepayments for professional services furnished the year prior to thepayment year.

E.g., the 2019 APM Incentive Payment will be based on 2018 services.

Be excluded from MIPS

QPs will:

Receive a 5% lump sum bonus

Bonus applies in payment years 2019-2024;then QPs receive higher fee schedule updates

starting in 2026

PROPOSED RULE

QP Determination and


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QP Determination andAPM Incentive Payment Timeline

2017 2018 2019

QP PerformancePeriod

Incentive PaymentBase Period

Payment Year

QP status based onAdvanced APM

participation here.

Add up payments for aQP’s services here.

+5% lump sumpayment made here.(and excluded from MIPS

adjustments)

2018 2019 2020

QP Performance

Period

Incentive Payment

Base Period

Payment Year

Repeat the cycle each year…


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When will these Quality PaymentProgram provisions take effect?

71

MIPS adj st ts a d APM I ti Pa t


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2017 2018 2019 2020 2021 2022 2023 2024 2025

+5% +7% +9%+4%MIPS

APM

QP inAdvanced

+5% bonus

(excluded from MIPS)

MIPS adjustments and APM Incentive Payment

will begin in 2019.

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-4% -5% -7% -9%Maximum MIPS Payment Adjustment (+/-)


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2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

2026

& on

FeeSchedule

Fee schedule updates begin in 2016.

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+0.5 each year No change

+0.25

or

0.75

QPs will also get a +0.75%update to the fee scheduleconversion factor each year.

Everyone else will get a +0.25 update.


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2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

2026

& on

FeeSchedule

Putting it all together:

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+0.5 each year No change

+0.25

or

0.75

MIPS

APM

QP inAdvanced

4 5 7 9 9 9 9

ax Adjustment

(+/-)

+5

bonus

excluded from MIPS)

MACRA provides additional rewards for


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MACRA provides additional rewards forparticipating in APMs.

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Not in APM In APM In Advanced APM

Potential financial rewards

The Quality Payment Program provides


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The Quality Payment Program providesadditional rewards for participating in APMs.

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MIPS adjustments


The Quality Payment Program provides


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The Quality Payment Program providesadditional rewards for participating in APMs.

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MIPS adjustments

APM-specificrewards

+MIPS adjustments

APM participation =favorable scoring in

certain MIPS categories


The Quality Payment Program provides additional


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The Quality Payment Program provides additionalrewards for participating in APMs.

78


MIPS adjustments

APM-specificrewards

5% lump sumbonus

APM-specificrewards

+MIPS adjustments

+If you are a

Qualifying APMParticipant (QP)



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TAKE-AWAY POINTS

1) The Quality Payment Program changes the way Medicare paysclinicians and offers financial incentives for providing high valuecare.

2) Medicare Part B clinicians will participate in the MIPS, unless theyare in their 1st year of Part B participation, become QPs through

participation in Advanced APMs, or have a low volume of patients.

3) Payment adjustments and bonuses will begin in 2019.

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Other than payment adjustments,what else does MACRA change?

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MACRA supports care delivery


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Such as:

Allocates $20 million / yr. from 2016-2020 to small practices toprovide technical assistance regarding MIPS performance criteria or

transitioning to an APM.

Creates an advisory committee to help promote development of

Physician-Focused Payment Models

MACRA supports care deliveryand promotes innovation.

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PFPM = Physician-Focused Payment Model

Goal to encourage new APM options for Medicareclinicians

Independent PFPM Technical Advisory Committee

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TechnicalAdvisory

CommitteeSubmission of

model proposalsby Stakeholders

11 appointed care deliveryexperts that review proposals,

submit recommendations to HHSSecretary

Secretarycomments on CMS

website, CMSconsiders testingproposed models

For more information on the PTAC, go to: https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee

PROPOSED RULE

https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committeehttps://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committeehttps://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committeehttps://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee


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PROPOSED RULE

Physician-focused Payment Model (PFPM)

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Any PFPM that is selected for testing by CMS and meets the criteria for anAdvanced APM would be an Advanced APM.

Proposed definition:

An Alternative Payment Model wherein Medicareis a payer, which includes physician group practices (PGPs) or

individual physicians as APM Entities and targets the quality and

costs of physician services.

Payment incentivesfor higher-value care

Care deliveryimprovements

Informationavailability andenhancements

Proposedcriteria fallunder 3categories


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APPENDIX

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What if I’m in an Advanced APM but don’t quite meet


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If you meet a slightly reduced threshold (% of patients or payments in anAdvanced APM), you are considered a “Partial Qualifying APM Participant”(Partial QP) and can:

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What if I m in an Advanced APM but don t quite meetthe threshold to be a QP?

Opt outof MIPS

Participate inMIPSor

No payment

adjustment

Receivefavorable

weightsin MIPS

Partial QPAdvanced APM

CMS will publish the list of APMs that

use the standard on website prior tofirst day of performance period

Eligible clinicians must be included in

the APM participant list maintained by

CMS (as of 12/31/2017)

PROPOSED RULE


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PROPOSED RULE

APM Scoring Standard

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How does it work?

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

Aggregates eligible clinician MIPS scores to the APM Entity level.

All eligible clinicians in an APM Entity receive the same MIPS compositeperformance score.

Uses APM-related performance to the extent practicable.

Goals:

Reduce eligible clinician reporting burden.

Maintain focus on the goals and objectives of APMs.


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PROPOSED RULE


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Shared Savings Program (all tracks)

Next Generation ACO Model

Comprehensive ESRD Care (CEC) (large dialysisorganization arrangement)

Comprehensive Primary Care Plus (CPC+)

Oncology Care Model (OCM)

All other APMs that meet criteria for the APM scoring

standard

To which APMs willthe APM scoringstandard apply?

PROPOSED RULE

APM S o i St d d


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APM Scoring StandardShared Savings Program

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Shared Savings Program ACOssubmit to the CMS WebInterface on behalf of their MIPSeligible clinicians.

The MIPS quality performancecategory requirements andbenchmarks will be used at the ACOlevel.

50%

No reporting requirement. N/A 0%

All MIPS eligible clinicianssubmit through ACO participantTINS according to the MIPSrequirements.

ACO participant TIN scores will beaggregated, weighted and averagedto yield one ACO level score.

20%

All MIPS eligible clinicianssubmit through ACO participantTINS according to the MIPSrequirements.

ACO participant TIN scores will beaggregated, weighted and averagedto yield one ACO level score.

30%

Quality

Resource use

ReportingRequirement Performance Score Weight

CPIA

:

Advancing careinformation

PROPOSED RULE



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APM Scoring StandardNext Generation ACO Model

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Next Generation ACOs submitto the CMS Web Interface onbehalf of their MIPS eligibleclinicians.

The MIPS quality performancecategory requirements andbenchmarks will be used at the ACOlevel.

50%


All MIPS eligible clinicianssubmit individually according tothe MIPS requirements.

ACO participant individual scores willbe aggregated, weighted andaveraged to yield one ACO level score.

20%


ACO participant individual scores willbe aggregated, weighted andaveraged to yield one ACO level score.

30%

Quality

Resource use


CPIA

:


PROPOSED RULE



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APM Scoring StandardAll Other APMs under the APM Scoring Standard

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Quality

Resource use

No assessment for the first MIPSperformance year. APM-specificrequirements apply as usual.

N/A 0%



APM Entity participant individualscores will be aggregated, weightedand averaged to yield one APMEntity level score.

25%


APM Entity participant individualscores will be aggregated, weightedand averaged to yield one APMEntity level score.

75%


CPIA

:


H ill th Q lit P t P ff t


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Am I in an APM?

• Excluded from MIPS• 5% lump sum bonus payment (2019-2024),

higher fee schedule updates (2026+)• APM-specific rewards

Subject toMIPS

Favorable MIPSscoring & APM-specific rewards

Bottom line: There will befinancialincentives for participating in an

APM, even if you don’t become aQP.

Am I in anAdvanced

APM?

Yes

Do I have enough paymentsor patients through my

Advanced APM?

Is this my first year inMedicare OR am I below

the low-volumethreshold?

Notsubject to

MIPS

Qualifying APM Participant (QP)

No

Yes No

Yes No

Yes No

How will the Quality Payment Program affect me?


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Disclaimer

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

This presentation was prepared as a service to the public and is notintended to grant rights or impose obligations. This presentation maycontain references or links to statutes, regulations, or other policy materials.The information provided is only intended to be a general summary. It is notintended to take the place of either the written law or regulations. Weencourage readers to review the specific statutes, regulations, and other

interpretive materials for a full and accurate statement of their contents.

Documents

CMS Slides on MACRA Quality Payment Program Proposed Rule