Proposals for the Quality Payment Program in 2019...•Call for quality measures. •Measures from prior year’s process implemented. •MACRA proposed regulation issued, notice and

Proposals for the Quality Payment Program in 2019David Heller

Corporate Counsel, Regulatory Affairs

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• Overview

• Who’s in, who’s out?

• Reporting and scoring

• Promoting Interoperability

• Quality and Clinical Practice Improvement Activities

• Alternative Payment Models

Agenda


Adjusted Medicare Part B payment to clinician

MIPS Payment Adjustments

2022+

±4% for 2017’s

performance

±5% for 2018’s

performance

±7% for

2019’s

performance

±9% for 2020’s

performance and

future years

• The potential

maximum adjustment

% will increase each

year from 2019 to

2022.

Maximum

adjustments

• Composite

performance score,

clinicians will receive

+/- or neutral

adjustments up to the

percentages shown

here.

Based on MIPS

2021

2020

2019


Top takeaway: full MIPS implementation marches forward

Heightened thresholds

Promoting Interoperability

Expanded eligibility

Other notable themes

21st Century Cures

Patients over

Paperwork

Meaningful

Measures

Overview

The House The Senate Bottom line

92 yeas

2 nays

392 yeas

37 nays

2 abstained

MACRA, MIPS, APMs are not going away

MACRA, by the votes


Provider

flexibility

Interoperability

Physician

burden a

serious

concern

Looking at

possible

scaleback

of MU, ACI

Support

from both

sides of

the aisle

Measures

cost and

quality

It’s here to stay, with some tweaks possible.

MACRA

8 I

What is MACRA?

MACRA MIPS (standard)

MIPS (MIPS APMs)

Advanced APMs


A single MIPS composite performance score will factor in performance in four weighted

categories on a scale of 0-100.

What is MIPS?

QUALITYRESOURCE

USE/COST

CLINICAL PRACTICE

IMPROVEMENT

ACTIVITES

PROMOTING

INTEROPERABILITY

Replaces PQRS.

Accounts for 45%

of total

performance

score in year

two.

Replaces VBM.

Accounts for 15%

of total

performance

score in year

two.

Accounts for 15%

of total

performance

score in year

two.

Replaces

Medicare MU.

Accounts for 25%

of total

performance

score in year

two.

Medicaid MU goes on separately

Medicaid meaningful

useMIPS

Regulatory cycle: H1

Jan. Feb. March April May June

• NQF MAP convenes.

• Quality MUC template published.

• Call for ACI measures.

• Call for IA measures.

• Call for quality measures.

• Measures from prior year’s process

implemented.

• MACRA proposed

regulation issued, notice

and comment begins.

• CMMI may issue new

innovation models.

• IA measures

submission

closes EOM.

• Closure of call for new

quality measures.

• CMMI may issue new

innovation models.

• CMMI new innovation

models may issue.

• PTAC votes on physician

designed APMs (quarterly

meetings).

Regulatory cycle: H2

July Aug. Sep. Oct. Nov. Dec.

• MACRA notice and comment

closes early in the month.

• Proposed Physician Fee Schedule

is issued, notice and comment

opens.

• CMMI may issue new innovation

models.


notice and comment continues.

• PTAC meets on proposed APMs.

• CMMI may issue new innovation

models.

• PTAC meets on

proposed APMs.

• PTAC issues RFP for

new APMs.

• MACRA final regulation issued by Nov. 1, final

list of new measures.

• Physician fee schedule finalized (may be

combined with MACRA regulation).

• PTAC votes on physician designed APMs

(quarterly meetings).


notice and comment closes early in

the month.

• PTAC meets on proposed APMs.

Who’s in, who’s out?

Who is eligible to participate in MIPS?

Years

1 and 2Years

3+

Proposing to also include physical and

occupational therapists, clinical social

workers, and clinical psychologists.

HHS Secretary

proposed to

broaden EC groups

to include others,

such as:

Physicians (MD/DO and DMD/DDS),

PAS, NPS, clinical nurse specialists,

certified registered nurse anesthetists.

Less than

$90,000 in

Part B

revenue.

Fewer than

200 Medicare

unique

beneficiaries

Less than

200 covered

professional

services

under PFS

Meet 1-2, can

voluntarily opt-in.

Meet all 3,

mandatory

exclusion.

Exclusionary thresholds and the MIPS “opt-in”

Reporting & scoring


Eligible clinicians can participate in MIPS as an individual or group.

Eligible clinician reporting

GROUP

A group, as defined by taxpayer

identification number (TIN), would be

assessed as a group practice across all

four MIPS performance categories.

INDIVIDUAL VIRTUAL

Implemented in 2018

performance period, defined

with a virtual group identifier,

TIN, and NPI combination.

Reporting timelines for 2019 and future years

90 days for Promoting Interoperability.1

90 days for Improvement Activities.

Full year for Quality.

Full year for Cost.

2

3

4

Virtual Group Reporting’s second year

Up to 10 ECs

per Tax ID.

Election by

Dec. 1.

Allows small practices

to scale reporting and

performance.

Assess quality

and cost

uniformly.

Applications open in

September.

No limit on the

number of TINs.


Performance thresholds, the MIPS composite score, and your bottom line

0 30 80 100

In the 2019 performance period,

ECs who earn a composite score

between 0-30 are subject to a 0%-

7% penalty in 2021. 30 is the

performance threshold, increased

from 15 in 2018.

ECs who earn a composite score

between 30-80 are eligible for a

0%-7% incentive in 2021.

ECs who exceed 80 are eligible

for increased MIPS bonuses,

which will be paid out of a

pool of $500 million that is not

subject to budget neutrality.

60%15%

25%

0%Promoting

Interoperability

Quality

Clinical Practice

Improvement

Activities

MIPS scoring in 2017

50%

15%

25%

10%Quality

Clinical Practice

Improvement

Activities

Final Rule: MIPS scoring in 2018

Cost


45%

15%

25%

15%Quality

Clinical Practice

Improvement

Activities

Proposed MIPS scoring in 2019

Cost


40%

15%

25%

20%Quality

Clinical Practice

ImprovementActivities


Cost


35%

15%25%

25%

Quality

Clinical Practice

Improvement

Activities


Cost


30%

15%25%

30%

Quality

Clinical Practice

Improvement

Activities

MIPS scoring in 2022

Cost


Small practice bonus

2024

Bonus

moved to

Quality

Complex patient bonus continues

Bonus based

on average

HCC scores

Facility-based measurement has arrived

Cost


• Medicare Spending per Beneficiary (MSPB).

• Introducing 8 episode-based measures.

How is Cost measured?


What’s in a name?

Meaningful UseAdvancing Care

InformationPromoting

Interoperability


Which certified edition?

2015 Certified

Edition of EHR

Technology is

required

The new objectives

BUSINESS

ECOSYSTEM

E-prescribing

Up to 10 points

Public Health and Clinical

Data Exchange

Up to 10 points

Provider to Patient Exchange

Up to 40 pointsVerify Opioid Treatment

Agreement

Up to 5 bonus points

Health Information Exchange

Up to 40 points

Promoting

Interoperability

PDMP

Up to 5 bonus points

Security Risk Analysis still required to receive any credit.

Other notable changes

Receive summary of care and

clinical information

reconciliation combined

“Support Electronic

Referral Loops”

Performance scoring

CommonWell to become

Carequality implementer.Future projects and

integration.

Working to create Carequality

compliant version of CommonWell

record locator service.Initial C-CDA

integration.

Carequality and CommonWell Health Alliance partnership

Quality & Clinical Practice Improvement Activities

Quality proposals

Clinical

GuidelinesIf clinical guidelines for a measure become

outdates its impact on your score is neturalized.

Reporting ECs, Groups, and Virtual Groups may use more

than one collection type.

Removing

measuresPhase out process introduced for topped out

measures.

Data Data completeness threshold remains at 60%.

More outcomes measures and more high priority measures.

What’s coming with Quality

COMPANY 41

1

May see continued focus on EHR reporting/eCQMs.

Opioid measures.

Proposed new scoring methodologies for future years.

2

3

4

More improvement activities

CEHRT bonus

removed from

this category.

6 new activities,

5 activities

modified, one

activity removed

Alternative Payment Models

Advanced APM impact to providers

20242026+

202020182016

5%

Lump

Sum

Bonus

Revenue-based risk definition extended through 2024

Nominal risk Revenue standard

8% of average estimated total

Medicare Parts A & B revenue

The Medical Home Model – A more gradual ramp

Or

General

definition

Quality

incentive or

PMPM at risk

2018: 2% 2019:

3%

2020:

4% 2021:

5%

RISK


New minimum CEHRT threshold proposed

75%

Which payers?

1

2

3

All payer combination options

Medicaid & CHIP

CMS Multi-Payer models


• Comprehensive Primary Care Plus (CPC+) (Medical Home Model)

• Next Generation ACO

• MSSP Track 1+, Track 2, Track 3

Sample Advanced APMs

Who’s in the APM track?

201720152024+20232022202120202019

Payments

25%

Patients

20%

Payments

50%

2019-2020

• Medicare APMs

only

2021+

•Include private

payers

Payments

75%

Patients Patients

35% 50%

Performance thresholds and Cost in the future

0 3 30 80 100

The performance threshold in

2022 will be set as the mean or

median of prior MIPS composite

scores, unless Congress amends

MACRA.

30%

15%25%

30%

Cost

To change how CMS sets

thresholds and Cost’s portion of

the score for future years, an act

of Congress would be required.

1

2

3

Measure quality and costFirst, clinicians become accustomed to

capturing metrics and measuring

performance on quality and cost.

Implement technological and clinical processesAs MIPS ramps up, clinicians are incented to implement

process changes that can quanitifiably move the needle

on quality and cost.

Prepare for riskBy changing the way the clinicans deliver care over time, clinicans are

equipped to take advantage of risk-bearing contracts that reward superior

care over volume.

Congress’ vision: From MIPS to APMs

Questions


• ACI: Advancing Care Information

• APM: Alternative Payment Model

• CPIA: Clinical Practice Improvement Activities

• EC: Eligible Clinician

• HHS: The US Department of Health & Human Services

• MACRA: Medicare Access & CHIP Reauthorization Act of 2015

• MIPS: Merit-based Incentive Payment System

• MU: Meaningful Use

• NP: Nurse Practitioner

• NPRM: Notice of Proposed Rulemaking

• PA: Physician Assistant

Acronyms cheat sheet


• Medicare Program; Revisions to Payment Policies Under the Physician Fee

Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings

Program Requirements; Quality Payment Program; and Medicaid Promoting

Interoperability Program

• Proposed Rule for the Quality Payment Program Year 3 fact sheet

• CMS webinar on Proposed Rule for Quality Payment Program Year 3

• Qpp.cms.gov

• CMS Quality Payment Program training videos

Resources

https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-QPP-proposed-rule-fact-sheet.pdf

https://www.youtube.com/watch?v=MTmyw_gzOHE&feature=youtu.be

qpp.cms.gov

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

Documents

Proposals for the Quality Payment Program in 2019...•Call for quality measures. •Measures from prior year’s process implemented. •MACRA proposed regulation issued, notice and