MACRA Webinar Slides - June 2016

© 2016 American Psychiatric Association. All rights reserved.

PAYMENT REFORM & QUALITY REPORTING UNDER THE MACRA Eileen Shannon Carlson, RN, JD APA Director of Reimbursement Policy June 29, 2016

© 2016 American Psychiatric Association. All rights reserved. 2

DISCLOSURES

Faculty and Planner Disclosures Principal Faculty: Eileen Shannon Carlson, RN, JD, Director of Reimbursement Policy. Program Planners: Samantha Shugarman, MS, Deputy Director of Quality; Nevena Minor, MPP, Deputy Director of Payment Advocacy; and Nathan Tatro, MA, Health Information Technology Specialist. All of the American Psychiatric Association, Arlington, VA and report no competing interests. Target Audience Psychiatrists and their staff who wish to improve their knowledge of Medicare payment policies and quality reporting programs. Educational Objectives By attending this live webinar, psychiatrists will learn about • how the Medicare Access and CHIP Reauthorization Act (MACRA) is transforming Medicare payment and quality programs; • quality reporting under the Merit-Based Incentive Payment System (MIPS); and • MACRA incentives for “advanced” alternative payment models.


AGENDA

I. Introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) II. The Merit-Based Incentive Payment System (MIPS) quality reporting program

A. New reporting requirements & financial incentives and penalties B. Key issues for psychiatrists

III. MACRA incentives for participating in new models of care A. Overview B. Opportunities and issues for psychiatrists

IV. APA and other resources – Including where to go for questions V. How to get CME credit


MEDICARE ACCESS & CHIP REAUTHORIZATION ACT

Enacted in 2015,

MACRA stabilized Medicare

payments for physician services

• Repealed the SGR (sustainable growth rate) – Automatic reductions for almost 2 decades (21.2% in 2015) & payments have not kept up with rising costs.

• Replaced SGR with positive payment updates for all

physician services under Medicare Part B: o July 2015 through 2019: 0.5% o 2020 through 2025: 0% o 2026 & beyond:

— 0.75% - “Qualifying” participants in “advanced” alternative payment models

— 0.25% - All other physicians & non-physicians


MEDICARE & CHIP REAUTHORIZATION ACT

Physicians

All physicians subject to Value-Based

Payment Modifier (VBM) in 2017-2018

Physicians can “opt-out” of Medicare

indefinitely

Quality programs cannot set “standard of care” in lawsuits

Medicare can cut payments up to 50%

for overdue taxes

Beneficiaries

Medicare premiums rise for high-income beneficiaries in 2018

No more “first-dollar” coverage by Medigap plans, starting 2020

Program Funding

Teaching Health Center GME Payment

Program – includes psychiatric residents

Children’s Health Insurance Program

Medicare Advantage special needs plans

Medicare-dependent hospital program

Medicaid Programs

“Qualifying individual” program (just above poverty

level)

Transitional medical assistance (coverage during transition to

employment)


MEDICARE & CHIP REAUTHORIZATION ACT

• MACRA Proposed Rule – “Quality Payment Program”/QPP • Centers for Medicare & Medicaid Services (CMS) issued April 27 • APA submitted comments June 27 • Final rule due November 1

• Merit-Based Incentive Payment System • Quality: Replace Physician Quality Reporting System (PQRS) • Resource Use: Replaces Value-Based Payment Modifier (VBM) • Advancing Care Information (ACI): Replaces Meaningful Use of EHRs • Clinical Practice Improvement Activities (CPIA): New category

• Incentives for “advanced” alternative payment models • 5% bonuses 2019-2024 • For “qualifying participants” with sufficient Medicare revenue/patients through

these models

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)


MERIT-BASED INCENTIVE PAYMENT SYSTEM

MIPS Bonuses & Penalties • Only apply to Medicare Part B payments for physician services. • Up to 4% in 2019, 5% in 2020, 7% in 2021, and 9% starting in 2022. • Extra “exceptional performance” bonus up to 10%/$500 million per year (2019-2024). • Based on “composite performance score” of each individual or group, from comparing

performance with average of all “eligible clinicians.” • Not reporting, or falling in lowest quartile, earns the highest penalty for that year.

MIPS Reporting • Methods: CMS plans to preserve reporting methods available for current programs

(claims, qualified registries, QCDRs, EHRs, administrative claims, web interface for groups), adding attestation for ACI and CPIA.

• Period: APA supports beginning July 2017 (not January) to give psychiatrists more time to prepare.

• Virtual Group Reporting: Small practices (up to 10 clinicians) can report & be assessed together. APA opposed proposed rule’s delaying to 2018; should be option from very start of the program.

• Registry Reporting: MIPS encourages and provides advantages for reporting via QCDRs. The APA is developing a quality registry through which psychiatrists can do MIPS reporting.


MERIT-BASED INCENTIVE PAYMENT SYSTEM

Psychiatrists are exempt from MIPS reporting & adjustments if they: • Fall below the MIPS “low-volume threshold”

– Proposed Rule: Up to and including 100 Medicare patients & $10,000 Medicare billings/year

– APA Comments: Up to 150 patients & $30,000/year • First enrolled in Medicare during the reporting year; • Only served Medicare patients through Medicare Advantage; • They were a “qualifying participant” in an “advanced” APM; • Or a “partially qualifying” participant who elected not to report. Other psychiatrists or group practices that receive Medicare Part B payments: Must decide whether to participate in MIPS or just take the penalty. (Not reporting gets the highest annual penalty.) • Psychiatrists have highest rate of opting out. • APA urged CMS to adopt MIPS policies that encourage more psychiatrists

to see Medicare patients. • CMS estimates in 2019, 20,854 psychiatrists will receive MIPS scores &

12,471 will be exempt.


MIPS QUALITY CATEGORY

• 50% of MIPS score in 2019, 45% in 2020, 30% starting in 2021. • Continues current (valid) PQRS, QCDR (qualified clinical data registry)

& VBM quality measures. • $75 million to update & develop new quality measures. • Emphasis on new outcome, patient experience, care coordination,

appropriate/over-use, global & population measures. • CMS may include inpatient hospital, other facility measures. • New quality measures must be published in a peer-reviewed journal &

either endorsed by NQF or evidence-based. New QCDR measures require approval by CMS but not NQF.

• Final MIPS “Quality Measure Development Plan” issued in May (APA commented on draft plan).

• GAO report due by October on aligning measures across payers.


MIPS QUALITY CATEGORY

Proposed Rule: • Requires only 6 measures, with 1 cross-cutting and 1 outcome (if

available). PQRS requires 9 measures across 3 “domains.” • New category of “Mental/Behavioral Health” with 12 measures:

– Anti-Depressant Medication Management – Preventive Care & Screening: Screening for Clinical Depression & Follow-Up Plan – Elder Maltreatment Screen & Follow-Up Plan – Dementia: Cognitive Assessment – Dementia: Functional Status Assessment – Dementia: Neuropsychiatric Symptom Assessment – Dementia: Management of Neuropsychiatric Symptoms – Dementia: Counseling Regarding Safety Concerns – Dementia: Caregiver Education & Support – Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific

Comorbid Conditions – Adherence to Antipsychotic Medications for Individuals with Schizophrenia – Follow-up After Hospitalization for Mental Illness


MIPS RESOURCE USE CATEGORY

• Value-Based Payment Modifier (VBM) will apply to ALL physicians (regardless of practice size) in 2017 and 2018, then end in 2019. Current VBM penalties (plus rare bonuses) are up to 4%.

• MIPS Resource Use counts 10% in 2019, 15% in 2020, then 30% in 2021 and after.

• No reporting required; CMS will calculate. • MIPS will measure resource use based upon new categories and codes

for care episode, patient condition, and physician relationships. • These codes will be added to all Medicare claims starting 2018. • The APA is working with member experts to develop

recommendations for appropriate care episode and patient condition groupers that are relevant to psychiatrists and their patients.


ADVANCING CARE INFORMATION (ACI)

• Counts 25% in MIPS. – May decrease if 75% of eligible clinicians adopt EHRs and become “meaningful

users.”

• Replaces EHR Incentive Program’s “Meaningful Use” (MU). – Measures emphasize interoperability, information exchange & security. – More “customizable” than MU & eliminates high reporting thresholds. – No longer need to report quality measures (as with MU).

• Submit measure numerators & denominators through a registry, EHR, QCDR, attestation & CMS web interface (forthcoming).




ACI OBJECTIVES & MEASURES



REQUIRED ACI MEASURES

1) Protect Patient Health Information Objective: Security Risk Analysis measure • YES is required to be eligible for base score. 2) Electronic Prescribing Objective: “ePrescribing” measure • Must select YES or NO; or numerator (>1) or denominator .

3) Patient Electronic Access, Coordination of Care Through Patient Engagement & Health Information Exchange: All measures • Must indicate YES or NO for base score. • Must select numerator or denominator for performance score. 4) Public Health and Clinical Date Registry Reporting Objective: Immunization Registry Reporting measure • All measures optional except “Immunization Registry Reporting“ measure. Eligible

clinicians who do not provide immunizations that are available in their public health jurisdictions are exempt & should report NULL.


CLINICAL PRACTICE IMPROVEMENT ACTIVITY

• Counts 15% of MIPS score. New category, not previously reported. • Select from CMS “CPIA Inventory;” 94 options in proposed rule. • “High-weighted” count 20 points; “medium-weighted” count 10. • 60 points generally needed for highest CPIA score. • Only 2 activities (high or medium) needed for highest score (1 activity

for half score) for: – All small practices (up to 15 clinicians) – All practices in rural areas – All practices in HPSA (health professional shortage area) – All non-patient-facing clinicians

• Automatic full credit: Part of certified patient-centered medical home. • Automatic half credit: Part of “advanced” alternative payment model.


CLINICAL PRACTICE IMPROVEMENT ACTIVITY

8 CPIA Categories • Integrated Behavioral and Mental Health; Expanded Practice Access;

Population Management; Care Coordination; Beneficiary Engagement; Patient Safety and Practice Assessment; Achieving Health Equity; Emergency Response and Preparedness.

How to report? • Qualified registry, Qualified Clinical Data Registry (QCDR), EHR, CMS Web

Interface (group reporting of 25 or more), or attestation. • If feasible, CMS may supplement with administrative claims data. • First year (2017) clinicians, or third party entity submitting data on behalf

of provider, must submit a yes/no response to activities in CPIA Inventory. • Must be performed for 90 days during reporting year.


SELECT HIGH-WEIGHT CPIA ACTIVITIES

APA advocates expanding current list of 11, which now include: • Offering integrated behavioral health services for patients with

behavioral health needs, dementia & uncontrolled chronic conditions. • Integration facilitation, and promotion of the colocation of mental

health services in primary and/or non-primary clinical care settings. • Use of a qualified clinical data registry (QCDR) to produce feedback

reports on practice patterns & treatment outcomes. • Participation in the CMS “Transforming Clinical Practice Initiative.” • Provide 24/7 access to advice about urgent & emergent care, including

access to medical record. • Collection & follow-up on patient experience and satisfaction data on

beneficiary engagement, including development of improvement plan. • Seeing new and follow-up Medicaid patients in a timely manner.


SELECT MEDIUM-WEIGHT CPIA ACTIVITIES

• Integrated prevention & treatment using quality measures, screening & assessment tools for tobacco use, unhealthy alcohol use & depression.

• Annual registration & active use of prescription drug monitoring program. • Completion of training & obtaining approved waiver for provision of MAT

for opioid use disorders using buprenorphine. • Use of telehealth services & analysis of data for quality improvement. • Diabetes screening for people w/schizophrenia or bipolar disorder who

take antipsychotics. • Participation in certain Maintenance of Certification Part IV activities. • Several activities for participation in a QCDR. • Manage medications to maximize efficiency, effectiveness & safety. • Credit for some private payer clinical practice improvement activities. • Collecting patient satisfaction data on care & improvement plan.

INCENTIVES FOR PARTICIPATING IN “ADVANCED” ALTERNATIVE PAYMENT MODELS


“ADVANCED” ALTERNATIVE PAYMENT MODELS

Incentives

• Physicians receive incentives for being “qualifying” or “partially qualifying” participants in “advanced” alternative payment models (APMs)

2019-2024

• “Qualifying” participants receive 5% bonus & are exempt from MIPS reporting

• “Partially” qualifying participants can choose whether to report under MIPS

2026 &after

• Slightly higher annual update for “qualifying” participants (0.75% versus 0.25%)



What does MACRA require for an “advanced” APM? • Medicare Shared Savings Program (MSSP) accountable care

organizations (ACOs); approved by CMMI; or required by federal law • Uses certified EHR technology • Ties payment to quality measures similar to those for MIPS • Incurs more than “nominal” risk – except patient-centered medical

homes How is CMS defining “advanced” APMs for 2019? ONLY: • MSSP ACOs in Tracks 2 & 3 • Next Generation ACOs • Comprehensive Primary Care Plus (CPC+) • 2 End-stage renal disease and oncology care models



“Qualifying” & “Partially Qualifying” APM participants • “Qualifying” participants: Receive 5% bonus if significant portion of

Medicare payments tied to one or more “advanced” APMs: 25% in 2019-2020; 50% in 2021-2022; and 75% starting in 2023.

– There is some flexibility in later years to qualify based upon payments from all payers, and for participating in non-Medicare APMs.

• “Partially qualifying” participants: Slightly lower percentages – Do not qualify for bonus but may opt out of MIPS reporting, or get credit under

MIPS for CPIA.

Benchmarks, “more than nominal risk,” etc. • CMS will define “nominal risk,” financial benchmarks, timeline for

APM approval, role of PTAC, etc., in the final rule & coming years.



Issues & opportunities for psychiatrists • Psychiatrists need to get credit for their contributions to the listed

“advanced” APMs, through accurate attribution. The APA urges CMS to clarify this will occur.

• No current mental health models meet proposed criteria. More flexibility is needed. The APA is working to identify opportunities for psychiatrists to develop new models of care, like the Collaborative Care Model.

• A major barrier for mental health APMs is the proposed rule’s requirement that half of “advanced” APM participants use CEHRT.

• The Physician-Focused Payment Model Technical Advisory Committee (PTAC) has no authority to approve new “advanced” APMs.

• Psychiatrists can earn credit under MIPS CPIA category for participating in APMs that do not meet “advanced” criteria.

MACRA RESOURCES & ASSISTANCE FOR PSYCHIATRISTS


APA RESOURCES & ASSISTANCE

New MACRA Web Pages: www.psychiatry.org/MACRA , include APA Comments on MACRA Proposed Rule & background on MACRA, MIPS & APMs. APA Staff: Can be contacted by APA members. • MIPS Quality & Resource Use: Samantha Shugarman, [email protected] • MIPS ACI/EHRs: Nathan Tatro, [email protected] • MIPS CPIA: Nevena Minor, [email protected] • MACRA APMs: Eileen Carlson, [email protected] • APA Practice Management Helpline, 1-800-343-4671: Coding, reimbursement

& practice management questions.

CMS Transforming Clinical Practice Initiative (TCPI): APA participates in the TCPI. Practice Transformation Networks (PTNs) can assist psychiatrists with quality improvement, workflow redesign, data collection and analysis, and EHR optimization. Connect with a PTN in your region by visiting www.psychiatry.org/sansgrant or contacting [email protected].

http://www.psychiatry.org/MACRA

mailto:[email protected]




http://www.psychiatry.org/sansgrant



AMA RESOURCES

Registration required (not AMA membership) – at www.ama-assn.org Summary of proposed regulation: https://download.ama-assn.org/resources/doc/washington/macra-summary-05052016.pdf ***4 steps to prepare for Medicare’s new payment systems: http://www.ama-assn.org/ama/ama-wire/post/4-steps-prepare-medicares-new-payment-systems ***MACRA Checklist: Steps You Can Take Now to Prepare: http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-new-payment-systems.page A guide to physician-focused payment models: http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-alternative-payment-models.page Key points of the Merit-based Incentive Payment System: http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-merit-based-incentive-program.page

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

https://download.ama-assn.org/resources/doc/washington/macra-summary-05052016.pdf

https://download.ama-assn.org/resources/doc/washington/macra-summary-05052016.pdf

http://www.ama-assn.org/ama/ama-wire/post/4-steps-prepare-medicares-new-payment-systems

http://www.ama-assn.org/ama/ama-wire/post/4-steps-prepare-medicares-new-payment-systems

http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-new-payment-systems.page









http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-alternative-payment-models.page











http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-merit-based-incentive-program.page














CMS RESOURCES

Quality Payment Program Website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html. Resources available on the site include: • Video overview of the Quality Payment Program • Fact sheet describing the support and flexibility for small practices • Overview of the Quality Payment Program (long & short versions) • Advancing Care Information slide deck • Merit-Based Incentive Payment System (MIPS) overview • Quality Performance Category under MIPS training deck • Resource Use Performance Category under MIPS training deck • Clinical Practice Improvement Activities Performance Category under MIPS training

deck • All-Payer Overview • Information on latest webinars CMS is planning. Program Events page has access to

a listing of future events, plus links to recordings of past presentations.

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



CME INFORMATION


CME INFORMATION

Individuals can claim credit for participating in an accredited version of this webinar by visiting http://apapsy.ch/macra-payment-and-reporting after July 5, 2016. This recording will be available until November 30, 2016. The American Psychiatric Association (APA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The APA designates this activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

http://apapsy.ch/macra-payment-and-reporting

Documents

MACRA Webinar Slides - June 2016