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MIPS Deep DiveAlexis Isabelle

Senior Manager Quality Performance

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Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at:http://downloads.cms.gov/files/TR2013.pdf;

Projected Medicare Fee-for-service Payment Cuts per the ACA

2014 2015 2016 2017 2018 2019 2020

Projected number of Medicare beneficiaries

54M 56M 57M 59M 61M 63M 64M

-14B -21B -25B -32B -42B -53B -64B

Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf

FFS versus FFV

Eliminates incentive to increase volume Eliminates incentive to provide high-cost services over equally effective low-cost servicesQuality-based incentives Shared risk Emphasizes the role of primary care providers Encourages coordination of care

Fees billed per units of serviceIncome maximized through volumeNo penalty for poor quality Providers lose money if they reduce unnecessary services

Volume

Driven Health

Care

Value-

BasedHealth

Care Co

stQualit

y

Fee-for-service Value-based payments

• Medicare Access and CHIP Reauthorization Act (MACRA) signed into law April 16th, 2015

• Repealed the flawed sustainable growth rate (SGR) formula

• Extends Children’s Health Insurance Program (CHIP) for two years

• New two-track Medicare physician payment system emphasizing value-based payment models

Landmark legislation alters howMedicare reimburses physicians

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APMACIAPM Entity

Eligible Clinician

MIPS

QPAdvanced APM

CPIAQPPPartial

QPCPS

PQRS

CPIA

MU

VM

MACRA

CHIP

ACI

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QPP

APMMIPS Merit-based Incentive

Payment Systemcombination of MU, PQRs, VM, and new CPIA

Alternative Payment Model

Quality Payment Programthe overarching name that covers MIPS and APM tracks

CPS MIPS composite performance score

MIPS Deep Dive

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MU PQRS VMMIPSMerit-Based Incentive Payment

System

Consolidates three existing programs, adds in additional performance category

APMAlternative Payment Models

Incentive payments available to qualified and eligible APM

1

2

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MIPS Eligibility – Years 1 and 2

• Physicians (MD/DO and DMD/DDS)• PAs• NPs• Clinical nurse specialists• CRNs• Anesthetists• Groups (defined by TIN) that include

such clinicians

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MIPS Eligibility – Years 3+

• Physical or occupational therapists• Speech-language pathologists,• Audiologists,• Nurse midwives• Clinical social workers• Clinical psychologists• Dietitians/Nutritional professionals

Everyone reports MIPS

in 2017.

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Three clinician groups not subject to MIPS

ExclusionsECs can volunteer to reporting but won’t receive any money

Has not submitted claims under any

group prior to performance

period

Qualifyingparticipants (QPs)

Partial qualifying participants who opt not to report

MIPS

<$10k in Medicare billing

AND≤ 100 Part B

enrolled beneficiaries

Newly enrolled Medicare clinicians

APM participantsLow threshold

NOTE: MIPS does not apply to hospitals or facilities

Four performance categories

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Category weight varies over time

2019 2020 2021+

25 25 25

15 15 1510 15 30

50 45 30

Four Categories That Determine MIPS Score Relative Weight Over Time

Quality

Resource UseClinical practice

improvement activities (CPIA)

Advancing Care Information (ACI)

Quality1

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Quality(currently PQRS)

1• 6 measure selection• 1 cross-cutting measure and 1 outcome

measure, or another high priority measure if outcome is unavailable

• Select from individual measures or a specialty measure set

• Population measures automatically calculated

• Providers and groups measured and graded against the performance of their peers

ACI(Advancing Care

Information) 2

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Advancing Care Information(currently EHR Incentive or MU)

2• Scoring based on key measures of patient

engagement and information exchange• Flexible scoring for all measures to promote

care coordination for better patient outcomes

• Points are awarded based on performance; only the highest performers will be able to earn full credit

CPIA(Clinical practice

improvement activities)3

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Clinical practiceimprovement activities

3New category

• Minimum selection of one CPIA activity (from 90+ proposed activities) with additional credit for more activities

• Full credit for patient-centered medical home (PCMH)

• Minimum of half credit for APM participation• Activities are weighted as High or Medium

weight with corresponding points

Resource Use4

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Resource Use(currently VM)

4• Medicare claims; no reporting• Minimum thresholds of 20 patients/cases• Adjusted for geographic payment, beneficiary risk factors

Total per capita cost measure (part A+B across VM chronic conditions for COPD, CHF, CAD, DM) as seen in VM with slight modification• Expanded list of primary care services to include TCM, CCM• Excluded SNF

MSPB measure as seen in VM with slight modifications

Episode-based measures (41 across specialties)*

1

2

3

MIPS has different set of “rules” and scoring going forward

Weighting of Cost & Quality categories will change over time with Quality declining and Cost increasing (from 10% to 30% by 2019)

Source: CMS

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Category Weight(Year 1) Scoring

Quality 50%

• Each measure 1-10 points compared to historical benchmark

• 0 points for a measure that is not reported• Bonus for reporting outcomes, patient experience,

appropriate use, patient safety and EHR reporting• Measures are averaged to get a score for the category

Advancing Care

Information (ACI)

25%

• Base score of 50 percentage points achieved by reporting at least one use case for each available measure

• Performance score of up to 80 percentage points• Public Health Reporting bonus point• Total cap of 100 percentage points available

Clinical practice

improvement activities

(CPIA)

15%• Each activity worth 10 points; double weight for “high”

value activities; sum of activity points compared to a target

Resource Use 10% • Similar to quality

Composite performance score calculation

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A single MIPS composite performance score will factor in performance in 4 weighted performance

categories on a 0-100 point scale

Quality Resource UseCPIAACI

MIPS Composite Performance Score (CPS)

Payment adjustment scale has more complexity, less middle ground

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Demonstrative onlyMIPS Budget-neutral program, 2019 payment based on 2017 performanceCPS Threshold has not yet been releasedCMS estimates only 0.3% of providers will have a score exactly equal to the CPS threshold

Provider payment adjustmentBased on distance from CPS Threshold score

(Example) CPS Threshold -

60Lowest

quartile or non

reporters get flat

4% downward adjustmen

t0 10 20 30 40 50 60 70 80 90 100

14

12

10

8

6

4

2

0

-2

-4

-6

All providers with <60 CPS receives

downward adjustment

All providers with

>60 CPS receive an upward adjustment

Payment Adjustment (%) Payment Adjustment (%) (high performers)

-1% +1%

Payment adjustment will increase over time

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30%

20%

10%

0%

-10%

Paym

ent A

djus

tmen

t

-4%4%

12%

2019

-5%

5%

15%

2020

-7%

7%

21%

2021

-9%

9%

27%

2022

High performers eligible

for additional incentive

Budget neutrality adjustment: Scaling factor up to 3x may be applied to upward adjustment to ensure payout pool equals penalty pool

Non-reporting

groups given lowest score

Preparing for 2017

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2019

Fast timeline for clinicians to follow

MACRA Implementation Timeline

2016 2017 20182019

TodayFinal Rule

Released

Providers may not be certain which track they

will fall into when reporting in 2017

Not much time for many

providers to get

involved in QPP

Performance period

Providers notified of track

assignmentPayment

adjustment

Based on

Merit Based Incentive Payment

System (MIPS)

Advanced Alternative Payment

Models (APM)

Preparing Performing Reporting Payment

StartsJanuary 1st, 2017

Source: CMS

Payment adjustments vary with differentsizes of clinician groups

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Solo 2-9 10-24 25-99 100 or more Overall0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

87.00%69.90%

59.40%44.90%

18.30%

45.50%

12.90%29.80%

40.30%54.50%

81.30%

54.10%

CMS Estimated Penalties and Bonuses in 2017,By Practice Size

Percent likely to be penalized Percent likely to receive bonus

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Historically, our clients perform better.

Meaningful Use Stage 2 attestation

% of HCPs avoidingPQRS penalties in 2015

NATIONAL AVERAGE

60%ATHENAHEALTH

CLIENTS

93.6%NATIONAL AVERAGE

33%ATHENAHEALTH

CLIENTS

98.2%MU and PQRS Client

Guarantee

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Currently estimating our clients’ performance in real-time

athenaNet provider performance on Meaningful Use Stage 2 measure: Use Secure Electronic Messaging

NETWORK WIDE CHANGES:1. NEW FUNCTION: Now easier for practices to

register patients to the patient portal.2. FUNCTION UPDATE: Now easier for providers

to send patients secure messages through the patient portal.

100%

90%

80%

70%

OCT. 2014 NOV. 2014 DEC. 2014

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We will take on your busy work

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We will make sense of the 200 measures and choose which are right for

you

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Thank You

Glossary of Terms

ACI

Advanced APM

APM

Advanced Care Information, formerly known as Meaningful Use

Alternative Payment Model

Alternative Payment Model which CMS has designated “eligible”

APM Entity

CPS

CPIA

EC

The TIN(s) participating in an APM or Advanced APM

Clinical Practice Improvement Activities

MIPS composite performance score

Eligible Clinician, the new definition of professionals who fall under this category under MACRA

MIPS

QPP

QP

Partial QP

Merit Based Incentive Payment System, the combination of MU, PQRS, VM and new CPIA

Qualifying APM Participant

Quality Payment Program, the overarching name that covers MIPS and APM tracks

Partial Qualifying APM participants