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8/6/2018
1
The Quality Payment Program:
Sarah Leake, MBA, CPHIMS
Deb Anderson, CPHIMS
August 8, 2018
Year 2 (2018) Overview
Disclaimer
2
This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently, so links to the source documents have been provided within the document for your reference.
This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
Important Note: This presentation was developed under contract with Centers for Medicare & Medicaid Services (CMS). Slides are courtesy of CMS from various CMS webinars and presentations about the Quality Payment Program.
Learning Topics
3
1) Examine the Quality Payment Program and how it
applies to clinics and clinicians
2) Identify steps and prepare for QPP-MIPS in 2018
3) Understand the capabilities of a Certified Electronic
Health Record Technology (CEHRT) in relationship to
MIPS
4) Review reporting and submission for MIPS and
Medicaid
5) Identify resources, tools and technical assistance
available for support in the MIPS program
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2
Quality Payment Program Overview
4
Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015
5
Bipartisan legislation. MACRA intended to:
1. Repeal the Sustainable Growth Rate (SGR)
2. Improve care for Medicare beneficiaries
3. Reauthorize the Children’s Insurance Program (CHIP)
4. Change the physician payment system from focus on
quantity of services to quality of care
Origin of Quality Payment
Program (QPP)
6
• Increases focus on quality of care and value of
care delivered
• Moving toward patient-centric health care
system
– Delivers better care
– Smarter spending
– Healthier People
• Offers two tracks of participation
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MACRA =
Quality Payment Program
7
MACRA is being implemented as the Quality
Payment Program (QPP)
The QPP encompasses two pathways:
MIPSThe Merit-based Incentive
Payment System
If you decide to participate in MIPS,
you will earn a performance-based
payment adjustment through MIPS
orAPMs
Advanced Alternative
Payment Models
If you decide to participate in an
Advanced APM, you may earn a
Medicare incentive payment for
sufficiently participating in an
innovative payment model
What is an Alternative Payment Model (APM)?
APMs are new approaches to
paying for medical care through
Medicare that incentivize quality
and value.
8
What is an Alternative
Payment Model (APM)?
9
APMs are new approaches to paying for medical care
through Medicare that incentivize quality and value.
Per MACRA, APMs include:
• CMS Innovation Center model (under
section 115A, other than Health Care
Innovation Award)
• Medicare Shared Savings Program (MSSP)
• Demonstration under Health Care Quality
Demonstration Program
• Demonstration required by federal law
MACRA does not change how any APM rewards value. APM
participants who are not “QPs” will receive favorable scoring under
MIPS. Only some of these APMs will be Advanced APMs.
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To be an Advanced APM, the following three requirements must be met.
Advanced APMs must meet
certain criteria
Requires
participants to use
certified EHR
technology
Provides payment
for covered
professional
services based on
quality measures
comparable to
those used in MIPS
quality performance
category
Either:
1) Is a Medical
Home Model
expanded under
CMS Innovation
Center OR
2) Requires
participants to
bear a more than
nominal amount
of financial risk
1 2 3
The MIPS Reporting Option
11
What is MIPS?
12
Prior to 2017 there were multiple quality and value
reporting programs for Medicare clinicians.
MACRA/QPP streamlines (combines) legacy programs
into a single, improved reporting program: MIPS
MIPS
Physician Quality Reporting Program
(PQRS)
Value-based Payment Modifier
(VM)
Medicare EHR Incentive Program
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Which clinicians does the
Quality Payment Program affect?
Will it affect me?
Short answer:
Quality Payment Program affects clinicians who
participate in Medicare Part B.
Clinician Impact
13
?
QPP MIPS Program Eligibility
14
No change in the types of clinicians eligible to participate
in 2018. For 2017 and 2018, the types of clinicians are as
follows:• Physicians
Doctors of
Medicine
Doctors of
Osteopathy
• Dentists
• Optometrists
• Chiropractors
• Podiatrists
• Physician assistants
• Nurse practitioners
• Clinical nurse
specialists
• Certified registered
nurse anesthetists
Who is included in MIPS for
2018?
15
Change to the Low-Volume Threshold for 2018.
• Includes MIPS-eligible clinicians billing more than
$90,000 a year in Medicare Part B allowed charges
AND providing care for more than 200 Medicare
patients a year.
– In 2017: MIPS-eligible clinicians billing more than $30,000 a
year in Medicare Part B allowed charges AND providing care
for more than 100 Medicare patients a year.
• Voluntary reporting remains an option for those
clinicians who are exempt from MIPS.
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Who Is Exempt? MIPS Year 2 (2018)
16
No change from 2017 in basic-exemption criteria
for those newly enrolled in Medicare criteria:
• Enrolled in Medicare for the first time during the
performance period = exempt until following
performance year
Below the low-volume threshold:
• Medicare Part B allowed charges less than or equal to
$90,000 a year OR those who see 200 or fewer
Medicare Part B patients a year
Significantly participating in Advanced APMs:
• Receive 25 percent of their Medicare payments OR
see 20 percent of Medicare patients through an
Advanced APM
How is Special Status
Determined for QPP
• CMS retrieves and analyzes Medicare Part B claims
data
• Special rules under QPP will affect the number of total
measures, activities or entire categories that an
individual clinician or group must report
SPECIAL STATUS providers have reduced requirements
for MIPS reporting:
• Small practices
• Rural
• Health Professional Shortage Area (HPSA)
• Non-Patient Facing
• Hospital based
2018 Special Status
for Clinician
https://qpp.cms.gov/participation-lookup/about
Adjustments
Improvement Activity and Quality
Promoting Interoperability
Improvement Activity
Promoting Interoperability
Promoting Interoperability
Improvement Activity
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How do clinicians
participate in MIPS?
19
Individual: Under National Provider Identifier (NPI) number
and Taxpayer Identification Number (TIN) where they reassign
benefits
Group:
a) Two or more clinicians identified by their National
Provider Identifier (NPIs) who have reassigned their
billing rights to single Tax Identification Number (TIN)*
b) As an APM Entity
Virtual Group: Made up of solo practitioners and groups of 10
or fewer eligible clinicians who come together “virtually” (no
matter what specialty or location) to participate in MIPS for a
performance period for a year
* If clinicians participate as a group, they are assessed as group across all
four MIPS performance categories
Strategy for TINs with more
than one eligible clinician
20
TIN can decide to report as
individuals or a group
If the group decides to report
as a group, provider data
from ALL providers is
aggregated in entire group
performance
If group gets positive payment
adjustment, all included and
exempt group members
receive adjustment
When reporting as a group,
ALL eligible clinicians
(included and exempt) are
incorporated
Determining Your Eligibility and Special Status
21
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QPP Webpage
Check Eligibility
22
MIPS Eligibility Lookup Tool
23
Individual and Group Details
Example
24
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Special Status Example Screen
25
Exercise 1:
Determine your MIPS Status
26
Go to qpp.cms.gov
website
Type in your individual NPI(s) in
lookup tool
Determine answers to
these questions:
• Are you eligible?
• Are you included?
• Are you included as an
individual? Are you
included as a group?
• Do you have a special
status?
A Closer Look into MIPS Categories
27
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MIPS Category: Cost
28
10 percent of Final Score in 2018
No reporting requirement
CMS will assesses clinicians on Medicare
adjudicated claims data for two measures
1. Medicare Spending per Beneficiary (MSPB)
2. Total per capital cost measures
Expect proposed new cost measures in the future
Cost Category – Improvement
29
Two Cost Measures
1. Total per Capita:
Measures of all Medicare Part A and Part B cost during performance period
2. Medicare Spending per Beneficiary (MSPB):
Determines what Medicare pays for services performed by individual clinician during MSPB episode: the period immediately before, during and after patient’s hospital stay
Analyze How to
Lower Costs
• Transitional care
management
• Chronic care
management
• Keep patients out of
hospitals
• Confirm visits to provider/
specialists outside your
facility
MIPS Category: Quality
30
50 percent of Final Score in 2018
More than 270 measures available• Most participants: Report up to six quality measures,
including an outcome measure, for a 12-month period.
Report eCQMs through EHR (if available for 2018 reporting)
Other options:
• Data extracted through EHR and registry submission
• Claims coding to include Quality G-Code (individual only)
Quality Measure Selection tool: https://qpp.cms.gov/measures/quality
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11
MIPS Category:
Improvement Activities
15 percent of Final Score in 2018
Attest to participation in activities that improve
clinical practice▪ Examples: Shared decision-making, patient safety,
coordinating care, increasing access
Minimum 90-day period
Choose two high weight or four medium weight
activities
Expanded Practice Access Population Management Care Coordination
Beneficiary EngagementPatient Safety & Practice
AssessmentParticipation in an APM
Achieving Health EquityIntegrating Behavioral and Mental
Health
Emergency Preparedness &
Response
MIPS Category:
Improvement Activities Cont.
Groups with 15 or fewer participants, non-patient
facing clinicians or those in a rural or health
professional shortage area: ▪ Have less requirements - attest to completing ONE high
weight or TWO medium weight activity for a minimum of
90 days.
112 activities over nine subcategories:
For a full list of activities, please visit QPP.CMS.gov
Medicare EHR Incentive Program Is
NOW Promoting Interoperability
33
Overall goal of Meaningful Use incentive
program is to strengthen sharing of health care
data between providers
• Make the program more flexible and less
burdensome
• Emphasize measures that require the exchange of
health information between providers and patients
• Incentivize providers to make it easier for patients to
obtain their medical records electronically
Use of Technology for Continuity of Care
https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-
Interoperability-Fact-Sheet.pdf
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MIPS Category:
Promoting Interoperability (PI)
34
25 percent of Final Score in 2018
Promotes patient engagement and the electronic
exchange of information using certified EHR technology
In 2018, there are two measure sets for reporting:• PI for those using 2015 edition CEHRT
• PI 2017 transition for 2014 edition CEHRT
5 percent bonus score for submitting to additional public
health agency or clinical data registry not reported under
performance score
Some Improvement Activities are eligible for 10 percent
PI bonus if CEHRT is used to complete Improvement
Activity
2018 PI Transition Measures
and Scoring (2014 CEHRT)
35https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-Interoperability-Fact-Sheet.pdf
Bonus Score
(up to 25%)
Performance
Score
(up to 90%)
Required
Base Score
(50%)
2018 PI Measures and Scoring
(2015 CEHRT)
36https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-Interoperability-Fact-Sheet.pdf
Required
Base Score
(50%)
Bonus Score
(up to 25%)
Performance
Score
(up to 90%)
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Submission Methods for MIPS
37
Category Individual Group
Quality
• Qualified Clinical Data
Registry (QCDR)
• Qualified Registry
• EHR
• Claims
• QCDR
• Qualified Registry
• EHR
• Administrative Claims
• CMS Web Interface
• CAHPS for MIPS Survey
Improvement
Activities
• QCDR
• Qualified Registry
• EHR
• Attestation
• QCDR
• Qualified Registry
• EHR
• CMS Web Interface
• Attestation
Advancing
Care
Information
• QCDR
• Qualified Registry
• EHR
• Attestation
• QCDR
• Qualified Registry
• EHR
• CMS Web Interface
• Attestation
Cost• No submission required
• CMS will use claims data
• No submission required
• CMS will use claims data
MIPS: CMS Web Interface
38
MIPS participation via CMS Web Interface is only available to
groups with 25 or more eligible clinicians.
Registration period is April 1 through June 30, 2018.
If your group registered for CMS Web Interface in 2017 to
report for MIPS, CMS automatically registered your group to
use CMS Web Interface in 2018.
If your group would like to participate through another data
submission option, you should cancel your election in the
registration system between April 1 and June 30, 2018.
Must register to administer Consumer Assessment of
Healthcare Providers and Systems (CAHPS) for MIPS survey.
Source: https://qpp.cms.gov/mips/individual-or-group-participation/about-group-registration
A Look into MIPS Performance Scoring for 2018
39
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MIPS Performance Categories
for Year 2 (2018)
40
Comprised of four performance categories in 2018
MIPS Year 2 (2018) Performance PeriodChange: Increase to Performance Period
2017 Pick Your Pace Year
Performance
Category
Minimum
Performance
Period
Quality
90-days minimum;
full year (12 months)
was an option
Cost
Not included.
12 months for
feedback only.
Improvement
Activities90 days
Promoting
Interoperability90 days
2018 Transition Year
Performance
Category
Minimum
Performance
Period
Quality 12 months
Cost 12 months
Improvement
Activities90 days
Promoting
Interoperability90 days
41
MIPS Year 2 (2018) MIPS: Performance
Threshold & Payment Adjustment
42
How can I achieve 15 points?• Report all required Improvement Activities
• Meet the Advancing Care Information base score and submit one quality
measure that meets data completeness
• Meet the Advancing Care Information base score by reporting the five
base measures and submit one medium-weighted Improvement Activity
• Submit six quality measures that meet data completeness criteria
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2017 and 2018
Score Comparison
43
>70
points
• Positive adjustment
• Eligible for exceptional
performance bonus –
minimum of additional 0.5%
4-69
points
• Positive adjustment
• Not eligible for exceptional
performance bonus
3
points• Neutral payment adjustment
0
points
• Negative adjustment of -4%
• 0 points = does not
participate
>70
points
• Positive adjustment greater than 0%
• Eligible for exceptional performance
bonus – minimum of additional 0.5%
15.01-
69.99
points
• Positive adjustment greater than 0%
• Not eligible for exceptional
performance bonus
15
points• Neutral payment adjustment
3.76-
14.99
points
• Negative payment adjustment
between -5% and 0%
0-3.75
points• Negative adjustment of -5%
Payment Adjustment Increase
Transition Year 1 (2017) Final Year 2 (2018) Final
MIPS Estimator Tool
44https://www.mipsestimator.org/
MIPS Year 2 (2018)Extreme and Uncontrollable Circumstances (2)
45
The Final Rule with Comment Period for Year 2
extends Transition Year hardship exception
reweighting policy for Promoting Interoperability
performance category to now include Quality,
Cost and Improvement Activities.
The hardship exception application deadline is
December 31, 2018.
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Exercise 2: Decide Your Reporting Goal & Plan
46
Answer worksheet questions #5, #6, #7• Do you plan to report MIPS?
• If you use an EHR, have you participated in MIPS or
Meaningful Use in the past?
• If you participated in MIPS in 2017, how did you
participate?
• How might you participate in the four MIPS Categories?– Quality
– Promoting Interoperability
– Improvement Activity
– Cost (CMS calculated, but how might you improve this score?):
How much can MIPS adjust
payments?
Based on a MIPS Composite Performance Score, clinicians will receive +/-or
neutral adjustments up to the percentages noted.
What to Expect from your EHR?
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17
Using EHR for MIPS Activity
Category EHR Functionality
Cost and
CQM reporting for Medicaid
• Extract data and reports on high risk patients for care
coordination
• Sharing of patient information for referrals or ER/Hospital
visits
Quality • CQM reporting in QRDA I or III format
• Submission capability by practice or vendor
• Report and extract data for CQM improvement projects
Improvement Activity • Special bonus in PI for use of EHR in IA activities
• Capabilities of data and reporting for IA – Telehealth,
Behavior Health, etc.
Promoting Interoperability
and Medicaid
• Direct messaging
• PHR availability
• Health information exchange
• Reporting for registries
Promoting Interoperability
Overall of Meaningful Use incentive program to
strengthen sharing of health care data between
providers
• Make the program more flexible and less
burdensome,
• Emphasize measures that require the exchange of
health information between providers and patients,
and
• Incentivize providers to make it easier for patients to
obtain their medical records electronically
50https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-
Interoperability-Fact-Sheet.pdf
Use of Technology for Continuity of Care
Reporting for Medicaid
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18
Meaningful Use in Medicaid(now Promoting Interoperability)
52
http://ehrincentives.guam.gov/Attachments/Guam_EHR_Incentive_Outreach_Presentation.pdf
Merit-based
Incentive
Payment System
(MIPS) applies to
services under
Medicare Part B.
MIPS does NOT
replace
Medicaid’s EHR
Incentive
Program, which
continues
through program
year 2021.
Clinicians eligible
for Medicaid EHR
Incentive
Program will
continue to attest
to state Medicaid
agencies to
receive incentive
payments.
If those clinicians
serve patients in
Medicare Part B,
they may also
participate in
MIPS.
Medicaid Promoting
Interoperability
Medicaid is STILL available for participation through 2021.
Requirements for Providers:
• Meet or exceed the PI measure thresholds
• Report 30 percent Medicaid volume in required time period
• Has submitted to a Medicaid EHR program prior to 2017
Hospitals earn no incentive but will receive Penalty if they
do not Report Meaningful use in the Medicare Program
53
.
Promoting Interoperability(MU)
Measures Modified Stage 2
• Protect Patient Health Information
• Clinical Decision Support
• CPOE
• Electronic Prescribing (eRx)
• Health Information Exchange >10%
• Patient Specific Education
• Medication Reconciliation
• Patient Electronic Access >5%
• Secure Messaging (EPs only) >5%
• Public Health and Clinical Data Registry Reporting
54
https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medicaid_Modif
iedStage2_2018.pdf
Same measures as 2017.
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Promoting Interoperability(MU)
Measures Stage 3
• Objective 3 Patient Electronic Access
– Provide Patient Access - 80%
– Patient Education - 35%
• Objective 4 Coordination of Care (must attest on all three measures but
meet at least two measure thresholds)
– VDT- 5% (2018) and 10% (2019
– Secure Messaging- 5% (2018) and 25% (2019)
– Patient Generated Health Data - 5%
• Objective 5 Health Information Exchange (must attest on all three
measures but meet at least two measure thresholds)
– Send a Summary of Care - 50%
– Request/Accept Summary of Care - 40%
– Clinical Information Reconciliation - 80%
55
https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medica
id_Stage3_2018.pdf
Wyoming Medicaid
• EHR Incentive Website
http://wyomingincentive.wyo.gov/
• State Level Registry
https://wyslr.com/
• Provider Stage 3 Objectiveshttps://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContent
s_EP_Medicaid_Stage3_2018.pdf
Resources and Strategy
57
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20
Quality Payment Program
Resources
58
Utilize Quality Payment Program Resources:
Centers for Medicare & Medicaid Services
(CMS): https://qpp.cms.gov• Help and Support:
https://qpp.cms.gov/about/help-and-support
• QPP Resource Library:
https://www.cms.gov/Medicare/Quality-Payment-
Program/Resource-Library/Resource-library.html
This is your FRIEND!
59
QPP Landing Page
Where to Find Resources
60
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21
Sign into QPP with Enterprise Identity
Management (EIDM) Credentials
61EIDM Training Video – Submitting a Role Request and completing RIDP https://www.youtube.com/watch?v=OmL4JOOQ7Rc
MIPS Strategic Alignment
62
When choosing MIPS category activity:
Review current quality
program requirements,
align project for biggest
ROI or alignment across
programs (MIPS,
department of health
programs, CCM, CPC+,
PCMH, payer, etc.)
If possible, choose a
measure or activity that
benefits more than one
MIPS category, including
IA and Cost
Clinic Quality Crosswalk (Example for Wyoming)
Healthcare TopicsMedicaid
MU MIPS
WDH
CDP 1305 QIN/QIO
Million
Hearts
GPRA for
IHS
PCMH
NCQA
Care Delivery Topics
Care Coordination x x x x
Behavior Health Integration x x x
Beneficiary Engagement x x x x x
Chronic Care Management x x x x x x
Use of CEHRT/Data x x x x x
Chronic Conditions
Cardiovasular x x x x x x x
Diabetes x x x x x x
Quality Measures
Diabetes A1c Poor Control x x x x x x x
Controlling High Blood Pressure x x x x x x x
Closing the Referral Loop x x x x
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22
Quality Reporting Efficiency
CCM/TCM - Example
• Report clinical quality measure CMS 50/ID 374
(closing the referral loop) for one of your quality
measures (it is a high priority measure)
• Can attest to IA – medium activity (care
coordination IA_CC_1 )
• Qualifies for a 10 percent PI category bonus
• Improve on Cost Category due to TCM focus
*check for current benchmark/submission methods
IMPROVEMENT ACTIVITY QUALITY COST
PROMOTING INTEROPERABILITY
Questions?
Developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization
(QIN-QIO) for Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the
Northern Mariana Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. Contents presented do not necessarily reflect CMS policy. 11SOW-MPQHF-WY-D1-18-18
Additional Resources
66
8/6/2018
23
Learning Opportunities
CMS has created several learning modules aimed
at helping you understand and succeed in the QPP
program. You can find those modules here:
https://learner.mlnlms.com/Default.aspx
Check out our Quality Health Blogs
MIPS and MU (now Promoting Interoperability)http://mpqhf.org/blog
Tools and Assessment
Get customized support for your practice by filling
out a short assessment – Mountain-Pacific:
http://mpqhf.com/QIO/qpp-enroll/
MIPS Estimator: https://www.mipsestimator.org/
Provider eligibility look up tool: http://qpp.cms.gov/
For more information, contact a QPP expert:
Mountain-Pacific Quality Health
Please contact us for assistance!
Visit us online at
www.mpqhf.org
Deb Anderson
(307) 772-1096
Sarah Leake
(406) 461-4504