MACRA’s Quality Payment

Program

Session #1

Overview and Eligibility

Lisa Gall, DNP, FNP, LHIT-HP

Clinical Program Manager

Stratis Health

January 4, 2017

Objectives• Review key aspects of the Quality Payment Program (QPP)

and Value Based Care

• Learn about the two paths of the QPP1. Merit-Based Incentive Payment System (MIPS)

2. Alternative Payment Models (APMs)

• Determine eligibility requirements for QPP and impacts on payments

• Learn what your hospital and clinic staff need to know and how to work with clinicians affected by QPP

• Review the QPP timeline and 2017 Transition Year “Pick Your Pace” Options

1

Stratis Health• Independent, nonprofit, Minnesota-based

organization founded in 1971– Mission: Lead collaboration and innovation in health

care quality and safety, and serve as a trusted expert in facilitating improvement for people and communities

– Working at the intersection of research, policy, and practice–

• Part of the Lake Superior Quality Innovation Network serving Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

• Program areas– Health disparities

– Health information technology

– Rural health

2

Quality Payment Program

and Value Based Care

3

Medicare Access and CHIP

Reauthorization Act of 2015

Source: CMS Quality Payment Program – Train-The-Trainer

Current CMS Programs to be

Integrated into MIPS

Source: CMS Quality Payment Program – Train-The-Trainer

What is Value Based Care?

Reimbursement shifts from Volume to Value

Rewards positive individual and population outcomes

6

Patient Experience

Cost Quality Value

CMS MACRA/MIPS

Quality Payment Program

• Moves away from “all or nothing” reporting under current MU and PQRS• Choose metrics that make most sense

• Rewards Value and positive outcomes• Negative/neutral/positive MPB payment adjustments

• Exceptional care bonus for first few years • $500M divided among highest performers

• Eligible Clinicians scored under 4 MIPS Categories• Transition Year 2017 has lower scoring thresholds under 3

MIPS Categories

The Merit-Based Incentive

Payment System

8

• Medicare Part B Clinicians move to performance based payment

• Clinicians choose activities and measures meaningful to their

practice

• Reporting standards align with Advanced APMs where possible

Source: CMS Quality Payment Program – Train-The-Trainer

Who is Eligible for the QPP

and How are Medicare

Payments Affected?

9

MIPS Eligible Clinicians

Physicians include: Doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, or optometry, and doctor of chiropractic

10

Physician

Nurse Practitioner

Physician Assistant

Clinical Nurse Specialist

Certified Registered Nurse Anesthetist

More to be added in 2019

Clinicians Excluded from MIPS

11Source: CMS Quality Payment Program – Train-The-Trainer

Non Patient Facing Clinicians

May Participate in MIPS… if…

12Source: CMS Quality Payment Program – Train-The-Trainer

Who is Impacted by the Quality

Payment Program

13Modified from : CMS Quality Payment Program – Train-The-Trainer

Who is Impacted by the

Quality Payment Program

14Modified from : CMS Quality Payment Program – Train-The-Trainer

Meaningful Use, Advancing

Care Information or Both?

15

• EPs continue to attest to Meaningful Use through the State’s EHR

Incentive Program

• 2016 is the last year for new EPs to start MU under Medicaid

• AIU or MU first year ($20,250)… up to six years of incentive payments

($8,500)

• Medicaid EPs that bill Medicare Part B PFS need to report to

BOTH programs Medicaid MU AND MIPS or APM beginning with

performance year 2017

• MU Excludes Hospital Based providers, QPP is based on Medicare

Part B Physician Fee payments (including hospital)

LSQIN Webinar: Transitioning from MU / PQRS / VM to the Quality Payment Program, Nov 2016. Haase, Hanson

Do you have any 2017 MIPS

Eligible Clinicians in 2017?

* Enter all that apply

1- No

2- Yes, previously reported to MU

3- Yes, never reported to MU

4- Yes, previously reported to PQRS

5- Yes, never reported to PQRS

16

Two Paths to the Quality

Payment Program

17

Quality Payment Program –

2 Tracks for Eligible Clinicians

Merit-based Incentive Payment System

Advanced Alternative

Payment Model

18

Eligible for 5% *MPBPFS bonus

if participating in Advanced

APM through Medicare Part B

Eligible for *MPBPFS performance

adjustment + high performance

bonus

* Medicare Part B Physician Fee Schedule

OR

QPP Path 1: MIPS (Merit-based

Incentive Payment System)

19Source : CMS Quality Payment Program – Train-The-Trainer

Alternative Payment Models

20Source: CMS Quality Payment Program – Train-The-Trainer

Advanced Alternative

Payment Models

21Source: CMS Quality Payment Program – Train-The-Trainer

Avoiding a Negative Payment

Adjustment Under MIPS is EASY!

22Source: CMS Quality Payment Program – Train-The-Trainer

MIPS Reporting – 2 Options

23Source: CMS Quality Payment Program – Train-The-Trainer

The Two Paths for QPP:

MIPS & APMs

MIPS: Quality category

MIPS Quality measures =

60-85% of MIPS Score

Source: CMS Quality Payment Program – Train-The-Trainer

25% of ACI Score may be reweighted to Quality

MIPS Quality measures

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

The Two Paths for QPP:

MIPS & APMs

MIPS: Improvement Activities

(IA) category

Improvement Activities =

15% of MIPS Score• New category - Designed to help participants prepare to

transition to APMs

• Choose one to four activities from 9 categories • expanded access, population management, care coordination,

beneficiary engagement, patient safety/practice assessment, participation in APM, health equity, behavioral health integration, emergency preparedness/response

• Activities are weighted:

• medium (10pts) or

• high (20pts)

• Special consideration for small, rural, underserved, (double points) non-patient facing clinicians, Medical Home and APM

Source: CMS Quality Payment Program – Train-The-Trainer

Improvement Activities

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

Reporting Improvement

Activities

10% bonus under ACI for completing 1 or more Improvement Activities using

Certified EHR Technology; 18 available IA use CEHRT

Source: CMS Quality Payment Program – Train-The-Trainer

The Two Paths for QPP:

MIPS & APMs

MIPS: Advancing Care

Information (ACI) category

Advancing Care Information =

25% MIPS Score

32Source: CMS Quality Payment Program – Train-The-Trainer

ACI Objectives/Measures

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

ACI Category: Base Measures

2015 CEHRT 2014 CEHRT

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

ACI Category: Performance Measures2015 CEHRT 2014 CEHRT

Source: CMS Quality Payment Program – Train-The-Trainer

Exemptions from ACI

• Exemptions available for ACI category

(just this category, not all MIPS categories!)

• There are no longer individual objective or measure exclusions

(as was the case for Meaningful Use)

…only whole ACI category exemption

• Categories of hardship exemption will be similar to hardship

exemptions under Meaningful Use EHR Incentive program

LSQIN Webinar: Transitioning from MU / PQRS / VM to the Quality Payment Program, Nov 2016. Haase, Hanson

ACI for Hospital Based MIPS

Eligible Clinicians

• Hospital based clinicians may choose whether or not to report under the ACI category

• Clinicians may apply for significant hardship exclusions

• Considerations:– Do you bill under Medicare PBPFS (including Method

II Billing)?

– Do you meet hardship or exclusions?

– Voluntary MIPS Reporting Option

37

The Two Paths for QPP:

MIPS & APMs

MIPS: Cost category

Cost: (Cancelled for 2017)

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

Cost: (Cancelled for 2017)• The Cost category has been set to 0% for 2017

• 10 episode measures being finalized

• As of 2018, performance feedback will be available

annually

• Category score will increase from 0 to 30% by 2021

(required by MACRA law)

• Clinicians will not select Cost measures

• Measures will be based on services delivered

• Based on TIN and NPI combination (previously only TIN

in Value Based Measure method in 2016 and prior)

LSQIN Webinar:Transitioning from MU / PQRS / VM to the Quality Payment Program, Nov 2016. Haase, Hanson

The Two Paths for QPP:

MIPS & APMs

Advanced APMs & MIPS

APMs

Alternative Payment Models• APMs are a new way to compensate providers for care

and services rendered to Medicare beneficiaries

• Promotes value and quality over volume by moving

away from the traditional Medicare FFS structure

• Goal of APMs is to reduce spending while improving

patient care

Source: CMS website:

Alternative Payment Models

43Source: CMS Quality Payment Program – Train-The-Trainer

Advanced APM Track

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

Alternative Payment Models

45Source: CMS Quality Payment Program – Train-The-Trainer

Advanced APMS in 2017

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

CMS recently added:

1. Oncology Care Model (OCM) - Two-Sided Risk

2. Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1-

CEHRT)

3. Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

Advanced APMS in 2018

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

Rewards for Participating in APMs

and Advanced APMs

48Source: CMS Quality Payment Program – Train-The-Trainer

How to earn a 5% APM

incentive payment in 20191. Meet Threshold in 2017 Performance Year:

– 25% of 2017 MPBPFS payments received through an Advanced APM

or– 20% of 2017 MPBPFS patients seen through an

Advanced APM

2. Submit quality data required by your Advanced APM in 2017 Performance Year

*If you haven't met these thresholds, you may need to submit MIPS data to avoid a downward payment adjustment.

49https://qpp.cms.gov/learn/apms

LSQIN Webinar: Transitioning from MU / PQRS / VM to the Quality Payment Program, Nov 2016. Haase, Hanson

Quality Payment Program

Timeline

50

MIPS 2017 Performance

Year Impacts 2019 payment

Performance Year

Data Submission

FeedbackPayment

Adjustment

51

2019March 31, 2018 20182017

QPP Timeline 2017-2022

52Source: CMS Quality Payment Program – Train-The-Trainer

2017 Transition Year for QPP:

APM and MIPS

53Source: CMS Quality Payment Program – Train-The-Trainer

2017 Transition Year:

Pick Your Pace

• You may begin reporting period January

1 if you are ready, or choose to start

any time before October 2, 2017

54https://qpp.cms.gov/

Dates for QP Determination

Source: CMS Quality Payment Program – Train-The-Trainer

Source: CMS Quality Payment Program – Train-The-Trainer

MIPS 2017 Transition Year Scoring (0-

100 Points)>-70 points Eligible for positive payment

adjustment and exceptional

performance bonus

4-69 points Positive payment adjustment. No

exceptional performance payment. No

negative

3 points Neutral payment adjustment

1-2 points Negative payment adjustment

Do nothing – 0 points -4% payment adjustment

Modified from: CMS Quality Payment Program – Train-The-Trainer

QPP: Impact on Providers Working

in RHCs, FQHCs, and CAHs• Subject to MIPS Payment Adjustments if provider:

– Is an “Eligible Clinician (EC)” AND

– Sees than 100 Medicare patients OR

– Bills more than $30,000 to Medicare PBPFS in the performance year • Including Method II CAH Billing for Professional Services

– CMS makes eligibility determinations regarding low-volume status using historical data to inform MIPS eligible clinicians and groups of their low-volume status prior to the performance period

• initially based on 12 months of data from September 1, 2015 to August 31, 2016

• Future will be based on two 12 month periods before and during performance year

• Examples of Method II Medicare B Professional Services (* Excludes Facility Charges)

• ER visits

• CRNA services

• Colonoscopy Services

• Surgical Procedures

QPP Website and Help Desk

CMS Website

• Quality Payment Program Help Desk

• (866) 288-8292

• 8am – 8pm EST / 7am – 7pm EST

• Email: QPP@cms.hhs.gov

Quality Payment

Program Resources• MACRA (CMS) Home Page and links to materials

• CMS Quality Payment Program Home Page (NEW!)

Resources

• QPP Final rule published Oct. 14, 2014 (2,398 pages)

• QPP Executive Summary (24 pages)

• QPP: Quality Measures page

• QPP resources page (past and upcoming webinars about QPP)

• Lake Superior Quality Innovation Network

• Previous and upcoming webinars

CMS Acronyms

• AAPM – Advanced Alternative Payment Model

• ACI – Advancing Care Information (New MU)

• APM – Alternative Payment Model

• IA –Improvement Activities

• MACRA - Medicare Access & CHIP Reauthorization Act

• MIPS – Merit-Based Incentive Payment System

• MPBPFS – Medicare Part B Physician Fee Schedule

• PQRS – Physician Quality Reporting System

• VBM or VM – Value Based Modifier

Thank you for attending!

Questions?

62

Questions?

Lisa Gall, DNP, FNP, LHIT-HP

952-853-8503 (w)

320-630-9116 (c)

lgall@stratishealth.org

www.stratishealth.org

63

Stratis Health is a nonprofit organization that leads

collaboration and innovation in health care quality and

safety, and serves as a trusted expert in facilitating

improvement for people and communities.