April21,2018

MACRA’sQualityPaymentProgram:2018UpdateonMedicare’sNewProgramfor

PayingPhysiciansandOtherHealthcareProfessionals

JohnMcInnes,MD,JD,Arnold&Porter

OEIS2018FiJhAnnualNaKonalScienKficMeeKng

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Agenda

•  ReviewofMACRAFundamentals

•  OverviewofSelectMACRA2018FinalRuleProvisions

•  Ques@ons&Discussion

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MACRAFUNDAMENTALS

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MACRAFundamentals

•  TheMedicareAccessandCHIPReauthoriza@onActof2015(MACRA)establishedanewMedicarepaymentsystemforphysiciansandotherhealthcareprovidersbeginningin2019.

•  MostsignificantchangeinMedicare’spaymentsystemforphysiciansin25years.

•  Repealedtheannual~25%paymentcliffsfromtheSustainableGrowthRate(SGR)formulaandreplaceditwithanew2-tracksystemthatmakesadjustmentstowhatwouldotherwisebepaidunderMedicare’sPhysicianFeeSchedule.

•  Maintainsfocusonmovingfrom“volumetovalue,”heighteningproviderincen@vestomaketreatmentdecisionsconsideringqualityandresourceuse.

•  CurrentAdministra9on–“Pu<ngPa9entsFirst”and“Pa9entsOverPaperwork.”

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QualityPaymentProgram(QPP)

•  PaymentsystemestablishedbyMACRAiscalledtheQualityPaymentProgram(QPP)

•  Consistentwiththestatute,theQPPhas2pathways:–  Merit-BasedIncen@vePaymentSystem(MIPS)

–  AdvancedAlterna@vePaymentModels(APMs)

•  BothpathwaysadjustMedicarefee-for-servicepaymentsforPartBservicestoincen@vize:–  QualityCareandBeaerHealthOutcomes

–  Efficiency(i.e.,costsavings)

–  Useofelectronichealthrecords(EHR)

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QualityPaymentProgram(QPP)–2018FinalRulePrinciples:

1)  Supportscareimprovementbyfocusingonbeaeroutcomesforpa@ents,andpreservingtheindependentclinicalprac@ce;

2)  Promotestheadop@onofAdvancedPaymentModels(APMs)thatalignincen@vesforhigh-quality,low-costcareacrosshealthcarestakeholders;and

3)  Advancesexis@ngdeliverysystemreformefforts,includingensuringasmoothtransi@ontoahealthcaresystemthatpromoteshigh-value,efficientcarethroughunifica@onofCMSlegacyprograms.

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TheQPP’sTwoPathways:

Merit-BasedIncenKvePaymentSystem(MIPS)

AdvancedAlternaKvePaymentModels(APMs)

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MIPS APMs

PaymentadjustmentsstartJanuary1,2019,baseduponperformancein2017

! !

AppliestoMedicarefee-for-servicepayments(forphysicianservices),notMedicareAdvantage

! !

Intendedtorewardhigher-quality,lower-cost,higher-valuecare ! !

ReplacesthePhysicianQualityRepor@ngSystem(PQRS) ! !

ReplacestheValueModifier ! !

ReplacesMeaningfulUse ! !

MIPSandAdvancedAPMshavesomethingsincommon:

OR

MACRAStatute:QPPStartedin2017(PerformanceYear)for2019(Payment

Year),TwoNewPathways

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MIPSPathway AdvancedAPMPathway

Merit-Based

IncenKvePaymentSystem(MIPS)

PhysicianQuality

ReporKngSystem(PQRS)*

ValueBasedModifier(VBM)*

MeaningfulUseofEHR*

AdvancedAlternaKvePaymentModel(APM)

*3LegacyProgramsEndaKer2018PaymentYear(basedon2016Repor9ng)

2018MACRAFINALRULE

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MIPSPATHWAY

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Whopar@cipatesinMIPS?

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Threegroupsdonotpar@cipateinMIPS:1. DoctorsintheirfirstyearofMedicarepar@cipa@on;2. Lowvolumeprac@ces:

a.  ≤$90KinPartBallowedcharges,orb.  ≤200PartBbeneficiaries

3. AdvancedAPMpar@cipants

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MIPSHasFourComponentswithDifferentWeights:

MIPSCategories “AdvancingCare

informaKon”(akameaningfuluse

ofEHR)

Quality Resourceuse(cost)

ClinicalpracKce

improvementacKviKes

MIPSCompositePerformanceScore(CPS)

(0-100)

$

TheCPScomparedtothe“PerformanceThreshold”willdeterminethepaymentadjustment.

Merit-BasedIncen@vePaymentSystem(MIPS)(2018Performance

Year,2020PaymentYear)

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MIPS(2019PerformanceYear,2021PaymentYear–andBeyond)*

14*Requiredbystatute

MIPSPaymentAdjustments

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1.QualityPerformanceCategory

"  EligibleclinicianswillreportselecKonof6individualmeasuresormeasuresfrom“specialtymeasuresets”(availableforcertainspecialKes).

"  Mustincludeanoutcomemeasure,andifnotavailablethena“highpriority”measure(appropriateuse,paKentsafety,efficiency,paKentexperience,andcarecoordinaKonmeasures).

"  300+individualmeasurestochoosefrom;mostmeasuresfromPQRS.

"  Scoreforthiscategorywillbebasedonperformancecomparedtoabenchmark.Infutureyears,scorewillalsoaccountforimprovement.

$

QualityMeasureExamples

•  IndividualMeasures(CMSwillconKnueannualcallfornewmeasures):–  Diabetes:HemoglobinA1c(HbA1c)PoorControl(>9%)–  Diabetes:MedicalAhenKonforNephropathy–  Diabetes:FootExam–  ChronicObstrucKvePulmonaryDisease(COPD):InhaledBronchodilatorTherapy–  ChronicObstrucKvePulmonaryDisease(COPD):SpirometryEvaluaKon–  PneumoniaVaccinaKonStatusforOlderAdults–  PrevenKveCareandScreening:Cholesterol–FasKngLowDensityLipoprotein(LDL-C)TestPerformedANDRisk-StraKfiedFasKng

LDL-C

•  SpecialtyMeasureSets(madeupofasubsetofindividualmeasures):–  Allergy/Immunology/Rheumatology–  Cardiology–  GeneralPracKce/FamilyMedicine–  InternalMedicine

•  Cross-CulngMeasures–  CarePlan–  DocumentaKonofCurrentMedicaKonsintheMedicalRecord–  Controlling:HighBloodPressure–  PrevenKveCareandScreening:TobaccoUse:ScreeningandCessaKonIntervenKon

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2.ResourceUsePerformanceCategory

"  CostsbasedonMedicarebeneficiarieswhoareahributedtotheclinician.

"  Includes“totalcostpercapitaforallahributedbeneficiaries”and“Medicarespendingperbeneficiary”(MSPB)measuresfromValueModifierprogram.

"  Episode-basedmeasuressKllindevelopment.

"  NoreporKngrequirement--CMScalculatesbasedonMedicarePartAandBclaims(includingPartBdrugclaims).PartDclaimsmaybeincludedinfutureyears.

$

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3.ClinicalPrac@ceImprovementAc@vi@es(CPIA)PerformanceCategory

•  NewcategorydesignedtoincenKvizeacKviKesthatimproveclinicalpracKceorcaredeliveryandthatarelikelytoresultinimprovedhealthoutcomes.

•  90+proposedacKviKesover9categoriesweightedeither“high”or“medium”.

•  Examples:populaKonmanagementfordiabeKcs(high);evidence-baseddecisionaids(medium)

•  ToachievehighestpotenKalscore,mostcliniciansmustsubmit2high-weightedCPIAsor4medium-weightedCPIAs,oracombinaKon.

•  FullcreditforpaKent-centeredmedicalhomeparKcipaKon;minimumofhalfcreditforAPMparKcipaKon.

$

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4.AdvancingCareInforma@onPerformanceCategory

"  MeaningfulUserebrandedas“AdvancingCareInformaKon”

"  ACIPerformanceCategoryscore=basescore+performancescore+bonuspoint

–  BasescoreachievedforreporKngallthemeasuresforsixobjecKves─  e.g.thePa@entElectronicAccessobjec@vehastwomeasures:Pa@entAccessand

Pa@ent-SpecificEduca@on─  Performancescoreachievedbasedonperformancerate(numerator/denominator)on8

measuresacrossspecific3objecKves(withinthe6)─  BonuspointforreporKngoneormoreaddiKonalmeasuresinthePublicHealthand

ClinicalDataRegistryReporKngobjecKve(ImmunizaKonRegistryReporKngrequired)

$

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Calcula@ngtheCompositePerformanceScore

ScoresfromeachperformancecategorywillbeweightedandusedtocalculateCPSonascalefrom0to100.

$

50% 10% 15% 25%

ADVANCEDAPMPATHWAY

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WhatisanAlterna@vePaymentModel(APM)?

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APMsarenewapproachestopayingformedicalcarethroughMedicarethataredesignedtoincenKvizequalityandvalue.

AsdefinedbyMACRA,

APMsinclude:

#  CMSInnovaKonCentermodel(underSocialSecurityAct§1115A,otherthanahealthcareInnova@onAward)

#  MSSP(MedicareSharedSavingsProgram)

#  DemonstraKonundertheHealthCareQualityDemonstra@onProgram(SocialSecurityAct§1866C)

#  DemonstraKonrequiredbyfederallaw

WhatisanAdvancedAPM?

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#  TheAPMrequirespar@cipantstousecerKfiedEHRtechnology.

#  TheAPMbasespaymentonqualitymeasures“comparableto”thoseintheMIPSqualityperformancecategory.

#  TheAPMeither:(1)requiresAPMEn@@estobearmorethannominalfinancialriskformonetarylosses;OR(2)isaMedicalHomeModelexpandedunderCMMIauthority.

AsdefinedbyMACRA,AdvancedAPMsmustmeet

thefollowingcriteria:

WhataretheCurrentAdvancedAPMs?

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Basedontheproposedcriteria,thefollowingAPMswillbeAdvancedAPMs:

#  MedicareAccountableCareOrganizaKon(ACO)Track1+Model

#  SharedSavingProgramACO(Tracks2and3)

#  NextGeneraKonACOModel

#  VermontMedicareACOIniKaKve

#  ComprehensiveESRDCare(CEC)Model(LDOarrangement)

#  ComprehensiveESRDCare(CEC)(non-LDOtwo-sidedriskarrangement)

#  ComprehensivePrimaryCarePlus(CPC+)Model

#  OncologyCareModel(OCM)

#  ComprehensiveCareforJointReplacement(CJR)PaymentModel(Track1–CEHRT)

#  BundledPaymentsforCareImprovementAdvancedModel(BPCIAdvanced)

Mustbea“QualifyingPar@cipant”inanAdvancedAPMtobeassignedtotheAdvancedAPMPathway

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QualifyingParKcipants(QPs)Toqualify,cliniciansmustreceiveenoughoftheirpaymentsorseeenoughoftheirpa@entsthroughanAdvancedAPM.Thepar@cipa@onrequirementsarespecifiedinlawandincreaseover@me.

SignificantIncen@vestobeaQPinAdvancedAPMs

•  MACRAdoesnotchangehowanypar@cularAPMfunc@onsorrewardsvalue.Instead,itcreatesextraincen@vesforAPMpar@cipa@on.

•  For2019-2024,all�qualifyingAPMpar@cipants�willbeexcludedfromMIPSandwillreceivealump-sumbonusof5%oftotalMedicarePartBpaymentsreceivedintheprioryear.Bonuspaymentsstopawer2024.

•  Beginningin2026,qualifyingAPMpar@cipantswillreceivebaseMedicarePartBpaymentsusingaconversionfactorthatreceivesahigherannualupdatethantheMIPSupdate(0.75%comparedto0.25%).

•  CMSes@matesthatatmost10%ofeligibleclinicianswillbeassignedtotheAPMpathwayin2019.Longer-termoutlookunclear.DependspartlyonhowstringentthefinalCMScriteriatobean�Advanced�APM.

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Par@alQPs:Almost,ButNotQuiteThere

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Ifclinicianmeetsaslightlyreducedthreshold(%ofpa@entsorpaymentsinanAdvancedAPM),heorsheisconsidereda�ParKalQualifyingAPMParKcipant�(ParKalQP)andcan:" OptoutofMIPSandreceivenopaymentadjustmentupordown;or" Par@cipateinMIPSandbesubjectto�MIPSAMP�Alterna@veScoring(andreceiveaminimumCPIAcategoryperformancescoreof50%).

QPPPaymentSummary

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QUESTIONS&DISCUSSION

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