MIPS APM for ACOs: A Hybrid Reimbursement Model

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15th November, 2017 | Author: Sonu Abraham, Healthcare Business Analyst,

Vinod Chavan, Healthcare Consultant

CitiusTech Thought

Leadership

MIPS APM for ACOs:

A Hybrid Reimbursement Model

2

Objective

CMS announced the Quality Payment Program (QPP) final rule in October 2017, stating how itplans to implement the clinician payment changes to QPP, mandated under the Medicare Accessand CHIP Reauthorization (MACRA) act

The implementation of the MACRA act impacts different type of organizations, one such beingthe Accountable Care Organizations (ACOs). ACOs are evaluated for payments on the basis ofquality care and the cost factors associated in achieving their quality goals

Post-MACRA implementation, all clinicians will receive payments as per the MIPS (Merit basedincentive payments) and Advanced APMs (Advanced alternative payment models). ACO’s canregister as APM entities and are eligible to receive payments under Advanced APMs

There is a third category of APM entities which participate in Advanced APMs models but do notmeet the threshold of payments and patients set by CMS. Such entities fall into a category that isstraddling the line between APM and the MIPS track, called MIPS APM (partially qualifying APMparticipants). This document discusses about the reporting, scoring and payments for the MIPSAPM entities

Who would benefit?

Providers willing to learn about changes post the final rule for 2nd year of MACRA - 2018

Providers reporting as ACOs and looking for payment adjustments for 2019 onwards

Providers who have decided to take the ACO path

Providers still deciding or considering to take a suitable path post MACRA reform

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Overview & Threshold Criteria for Advanced APMs

Steps to Register as an ACO

Scoring Criteria for MIPS APM Entities

Reporting Timelines and Requirements for MIPS APM Entities

Payment Adjustments for MIPS APM Entities

Key Takeaways

References

Agenda

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ACO Tracks Eligible for MIPS APMs

Medicare Shared Savings Program (MSSP)

• MSSP Track 1 (One sided risk) *

• MSSP Track 2 (Two-sided risk) **

• MSSP Track 3 (Two-sided risk) **

Next Generation Accountable Care Organization (NGACO) **

Comprehensive Primary Care Plus (CPC+) initiative **

Oncology Care Model (OCM- one and two sided risk arrangement) **

Comprehensive ESRD Care (CEC) Model (LDO arrangement) **

Comprehensive ESRD Care (CEC) Model (non LDO one and two-sided risk arrangement) **

MIPS APM Overview

Eligible Clinicians (ECs) in APMs not meeting patient and payment thresholds become a part of MIPS APM subset

ECs in MIPS APMs are scored using the APM Scoring Standard

Under the APM scoring standard, ECs are subject to the MIPS reporting requirements and payment adjustments

Using the APM Scoring Standard, one final score for the APM entity is calculated and applied to all ECs within the APM entity

ECs in MIPS APMs are not eligible for the annual AAPM 5% lump-sum bonus payment

One-sided risk model (Track 1) is subject to MIPS reporting requirements while two-sided risk model (Track 2 & 3) and other AAPMs will be subject to Advanced APM reporting requirement (if threshold is met)

* Alternative Payment Models (APMs)

** Advanced Alternative Payment Models (AAPMs)

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Threshold Criteria for Advanced APMs

ACOs have to meet the following thresholds to be eligible for payments under Advanced APMs, those which do not fulfill this criteria become a part of MIPS APM

Payment Threshold Patient Threshold

The collective Part B payment for services provided to attributed beneficiaries should be at least 25% of all the services provided to attribute-eligible beneficiary.

The collective number of patients who receive services delivered should be at least 20% of all the patients who are attribute-eligible and received services.

Payment Year 2019 2020 2021 2022 2023 2024+

QP Payment Threshold 25% 25% 50% 50% 75% 75%

QP Patient Count Threshold 20% 20% 35% 35% 50% 50%

Threshold increases every two years until 2023 and remains flat afterwards. ACOs not qualifying these thresholds will become a part of MIPS APM entities.

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Steps to Register as an ACO

Register as MSSP Track 1 ACO

For 3 years report on 31 ACO Measures

Apply for 3 years extension

Continue as MSSP Track 1 for 3 more years

Face applicable penalty as per

MIPS

Unable to successfully submit 31 ACO Measures

3 Years2018 2024

Upgrade ACO Track (APM’s/AAPM’s)

Can move to advance ACO track after 1 year of successful reporting or can be in one track for maximum period of 3 years.

3 Years

2021

Registering as an ACO

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In 2018 CMS aligned weighting of scores across all MIPS APMs

MSSP tracks and Next Gen ACO can report the same quality measures that is part of PQRS quality measure set

A cumulative score will be calculated for all providers reporting as a group under these tracks which will help all physicians to receive equal reimbursement

Category.

Year 2017 Year 2018

MSSP Tracks & Next Gen ACO

Other MIPS APMs All MIPS APMs

Quality 50% 0% 50%

Cost 0% 0% 0%

Advancing Care Information

30% 25% 30%

ImprovementActivities

20% 75% 20%

MIPS APM Scoring: Transition Year 1 (2017) & Year 2 (2018)

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Performance Category

MIPS MIPS – APM

Year 2017 2018 2019 2017 2018 2019

Quality 60% 50% 30% 50 50Not

defined

Cost 0 10% 30% 0 0 0

Advancing Care Information

15% 25% 25% 30 30Not

defined

Improvements Activities

25% 15% 15% 20 20Not

defined

Benefit to MIPS APM over MIPS Scoring Standard

CMS scores clinicians and groups on four categories: Quality, Cost, Advancing Care Information (ACI) and Improvement Activities (IA). Each performance category is assigned a weightage which cumulatively comes to 100%.

*

* As per CMS MIPS APM entities will not be scored on cost measures for 2018 and future years hence reduced burden of reporting these measures.

Payment for performance years 2017,2018 and 2019 will be done in the year 2019,2020,2021 respectively.

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Data Gathering& Integration

Measure Computation

Measure Validation

Measure Submission

Final date forApplication

1st Jan 2018 Mid 2018 31st Dec 2018

Mid Jan 2019

Mid Feb 2019

31st Mar 2019

Reporting EndsPerformance Period31st July2017

31st May2017

Final date forNOIA

MIPS APM Reporting timelines

ACOs following MIPS APM Reporting Standard must report for full year: 1st Jan to 31st Dec 2018

The reporting for 2018 ends by 31st March 2019

CMS is yet to publish the dates for those providers who want to register as ACOs for 2019

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ACO NQF Domain Measure Title Reporting Method

ACO-1 NQF 005Patient / Care Giver Experience

CAHPS: Getting Timely Care, Appointments, and Information

Survey


CAHPS: How Well your Providers Communicate

Survey


CAHPS: Patients’ Rating of Provider Survey

ACO-4 N/APatient / Care Giver Experience

CAHPS: Access to Specialists Survey


CAHPS: Health Promotion and Education

Survey


CAHPS: Shared Decision Making Survey


CAHPS: Health Status/Functional status

Survey


CAHPS: Stewardship of Patient Resources

Survey

Reporting MIPS APM Survey Measures

Providers reporting PQRS CAHPS measures can report the same measures for MSSP Tracks and Next Gen ACOs MIPS APM reporting.

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ACO PQRS NQF Domain Measure TitleData Submission Method

ACO-12 PQRS 46 NQF 009CC / PatientSafety

Medication Reconciliation Post Discharge

Web Interface

ACO-13 PQRS 154 NQF 0101CC / PatientSafety

Falls: Screening for Future fall Risk Web Interface

ACO-14 PQRS 110 NQF 0041Preventive Health

Preventive Care and Screening: Influenza Immunization

Web Interface


Pneumonia Vaccination Status for Older Adults

Web Interface


Preventive Care and Screening: Body Mass Index Screening and Follow-Up

Web Interface


Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Web Interface


Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan

Web Interface

Reporting MIPS APM Web Interface Measures (1/2)

Providers reporting PQRS measures can report the same web interface measures under MSSP Tracks and Next Gen ACOs reporting.

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ACO PQRS NQF Domain Measure TitleData Submission Method


Colorectal Cancer Screening Web Interface


Breast Cancer Screening Web Interface

ACO-42 PQRS 438 N/APreventive Health

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Web Interface

ACO-40 PQRS 411 NQF 0710At Risk Population

Depression Remission at 12 Months

Web Interface


Diabetes: Hemoglobin A1c Poor Control

Web Interface


Diabetes Eye Exam Web Interface


Controlling High Blood Pressure Web Interface


Ischemic Vascular Disease: Use of Aspirin of another Antithrombotic

Web Interface

Reporting MIPS APM Web Interface Measures (2/2)

Providers reporting PQRS measures can report the same web interface measures under MSSP Tracks and Next Gen ACOs reporting.

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Reporting MIPS APM Meaningful Use & Claim Measures

ACO Domain Measure Title Method of data Submission

ACO-8 CC / Patient Safety Risk-Standardized, All Condition Readmission Claims

ACO-35 CC / Patient SafetySkilled Nursing Facility 30-Day All-Cause Readmission Measures (SNFRM)

Claims

ACO-36 CC / Patient SafetyAll-Cause Unplanned Admissions for Patients with Diabetes

Claims

ACO-37 CC / Patient SafetyAll-Cause Unplanned Admissions for Patients with Heart Failure

Claims

ACO-38 CC / Patient SafetyAll-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

Claims

ACO-43 CC / Patient SafetyAcute Composite (AHRQ Prevention Quality Indicator [PQI] #91)

Claims

ACO-44 CC / Patient Safety Use of Imaging Studies for Low Back Pain Claims

ACO- 11 CC / Patient Safety Use of Certified EHR TechnologyMeaningful Use Certified EHR(QPP)

ACOs do not need to collect or submit additional data aside from normal billing activities. The CMS ACO Program Analysis Contractor (ACO PAC) will coordinate with CMS to obtain the necessary Medicare claims files and calculate the rates for these measures for each ACO.

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Exceptional performers receive additional positive adjustment factor up to $500M available each year from 2019 to 2024

For instance, a Provider is reporting as MSSP track 1 ACO with a revenue of approximately 100 million. For the consecutive years 2019 to 2022 payments will be calculated at 4%, 5%,7%,9% respectively as per the Composite Performance Score (CPS) received by the ACOs

The CPS is the weighted sum of the points in four performance categories that determine the payment adjustments ranging from 0-100 points. 3 points being the minimum to avoid any penalties and up to 100 points to receive the maximum payment adjustment.

Payment Adjustments for MIPS APM Entities

*

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Key Takeaways

A path towards ACOs is beneficial as it is a move providers towards greater accountability and improved quality of care. MIPS APM scoring has clear benefits. It’s a win-win situation for both patients and providers

ACOs have additional benefits in MIPS scoring category with zero weightage on resource use measures (i.e. costs). There is greater overall weight to the quality category in which ACOs are expected to perform very well

No additional reporting requirements for claim measures. CMS will collect the information from ACOs and report these measures

ACOs that are MIPS APM entities will directly receive half of the total points for Clinical Practice Improvement Activities and also have the benefit to gain rest of the points by additional reporting

Advantages for specialists practices is that ACOs refer patients to specialists they know to support high quality and coordinated care so specialists participating in an ACO may increase their referral base

Two-sided ACOs that meet the QP thresholds (who are not MIPS APM) would earn a 5 percent bonus annually from 2019 through 2024. This bonus is in addition to the shared savings ACOs can earn through MSSP or the Next Generation ACO model, and the shared savings rate for these ACOs is greater than that available to track 1 ACOs

ACOs with IT infrastructure have a huge benefit over others who don’t, as they are able to manage, track and have easy access to quality data to support their findings. ACOs can leverage IT capabilities to identify gaps , fix the areas causing revenue loss and improve quality of patient care

Participating in an advanced track will be an opportunity for providers to be a part of innovative ways of healthcare delivery

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References

http://www.aafp.org/practice-management/payment/medicare-payment/mips-apms.html

http://healthcareblog.pyapc.com/2017/05/articles/accountable-care-organizations/the-intersection-of-mips-and-mssp-how-the-apm-scoring-standard-works/

https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf

https://naacos.memberclicks.net/naacos-comments-letter-on-macra-final-rule

http://www.aafp.org/practice-management/payment/medicare-payment/mips-apms.html

http://healthcareblog.pyapc.com/2017/05/articles/accountable-care-organizations/the-intersection-of-mips-and-mssp-how-the-apm-scoring-standard-works/

https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf

https://naacos.memberclicks.net/naacos-comments-letter-on-macra-final-rule

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Thank You

Authors:

Sonu Abraham

Healthcare Business Analyst

Vinod Chavan

Healthcare Consultant

[email protected]

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