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MACRA Jumpstart:Using Free CMS Resources for MIPS Success
Beth Hickerson
Lead Quality Improvement Advisor
June 21, 2017
Value Driven. Health Care. Solutions.
MACRA Jumpstart – Navigating the Quality Payment Program
2Value Driven. Health Care. Solutions.
There are many questions
surrounding MACRA, but the
bottom line is if you participate in
Medicare you will be impacted by
MACRA and the Quality Payment
Program (QPP)
MIPS or APM? Today we’ll help
you determine which track to
participate in
If you’re MIPS eligible, what is
your readiness level?
MACRA Jumpstart – Using Free CMS Resources for MIPS Success
3Value Driven. Health Care. Solutions.
At the close of our MACRA
Jumpstart presentation you
should have a better idea of
which track to participate in and
we will share free CMS
Resources for MIPS support
– QPP Resource Center– www.qppresourcecenter.com
– Medical Advantage Group’s
MACRA Jumpstart– www.medicaladvantagegroup.com/macra
jumpstart/
– qppta@medadvgrp.com
Medicare Access and CHIP Reauthorization Act of 2015
(MACRA)
4Value Driven. Health Care. Solutions.
Repealed the Sustainable Growth
Rate (SGR) methodology
– Supported by organized medicine
– Passed with over 90 percent
support in both the House and
Senate; bi-partisan legislation
Created Quality Payment
Program which moves Medicare
into value-based payments
– Alternative Payment Model (APM)
– Merit-based Incentive Payment
System (MIPS)
Quality Payment Program (QPP)
January 1, 2017 – physicians enter the MIPS track or the APM track
For the first few years of the QPP, majority of clinicians in MIPS
5Value Driven. Health Care. Solutions.
Quality Payment Program
(QPP)
Merit-based Incentive
Payment System (MIPS)
Alternative Payment Model
(APM)
Advanced APM MIPS APM
ALTERNATIVE PAYMENT MODELS (APMS)
What are APMs?
Payment approach that
incentivizes clinicians to
provide high-quality, cost-
effective care
Structured models that
promote coordination and
cooperation among
providers
Full list of 2017 APMs at
https://qpp.cms.gov/docs/
QPP_Advanced_APMs_in
_2017.pdf
7Value Driven. Health Care. Solutions.
APM vs Advanced APM
Alternative Payment
Model
– Participation requirements
unique to each APM model
– Participants must still
report MIPS, but have a
modified scoring system
that takes their APM
activities into account
Advanced Alternative
Payment Model (AAPM)
– More stringent participation
requirements, usually
involve some level of risk
– Qualifying Participants
(QPs) are exempt from
MIPS and receive 0.5%
bonus payment
– Partial Qualifying
Participants (Partial QPs)
can opt out of MIPS without
penalty
8Value Driven. Health Care. Solutions.
Advanced APMs’ Eligibility Criteria
Eligibility criteria
– At least half of the clinicians must use certified electronic health
record technology (CEHRT)
– Report on quality measures comparable to MIPS quality
measures
– Be a medical home model OR require participants to bear more
than a nominal amount of financial risk
– Only medical home that
qualifies for Advanced
APM (AAPM) is CPC+
9Value Driven. Health Care. Solutions.
2017 Advanced APMs
10Value Driven. Health Care. Solutions.
MSSP Track 2 MSSP Track 3
Comprehensive
Primary Care Plus
(CPC+)
Next Generation
ACO
Comprehensive
ESRD Care Model
Oncology Care
Model-Two sided
QPs and Partial QPs for AAPMs
Qualifying Participants (QPs)
– Exempt from MIPS
– Earn an annual lump sum payment of 5 percent of the MPFS
from 2019-2024
CMS predicts that approximately 100% of eligible
clinicians in Advanced APMs will be QPs in performance
year 2017
11Value Driven. Health Care. Solutions.
Performance Year 2017 2018 2019 2020 20212022 and
later
Percentage of Medicare
payments through an
Advanced APM
Percentage of Medicare
patients through an
Advanced APM
25%
20% 35% 35% 50% 50%20%
50% 50% 75% 75%25%
QPs and Partial QPs for AAPMs
Partial Qualifying Participants (Partial QPs)
– Can opt out of MIPS without penalty
– Can report MIPS for possible incentive
12Value Driven. Health Care. Solutions.
Performance Year 2017 2018 2019 2020 20212022 and
later
Percentage of Medicare
payments through an
Advanced APM
Percentage of Medicare
patients through an
Advanced APM
20%
10% 25% 25% 35% 35%10%
40% 40% 50% 50%20%
Future APMs
Current Advanced APMs will reopen to allow more
participants
New models will launch:
13Value Driven. Health Care. Solutions.
MERIT-BASED INCENTIVE PAYMENT SYSTEM
(MIPS)
Categories and Reporting Requirements
Impact on the MPFS
Instead of a 21 percent payment cut
– No increase in MPFS (January – June 2015)
– Increase 0.5 percent (July 2015 – December 2015)
– Increase 0.5 percent per year (2016 – 2019)
– No increase (January 2020 – December 2025)
– 2026 and beyond:
– APM participants –
0.75 percent annual increase
– MIPS participants –
0.25 percent annual increase
15Value Driven. Health Care. Solutions.
0
0.2
0.4
0.6
0.8
201
5
201
6
201
7
201
8
201
9
202
0
202
1
202
2
202
3
202
4
202
5
202
6
202
7
MIPS Impact on Current Programs
– PQRS Quality
– VM Cost
– EHR Advancing
Care
Information
– Improvement Activities is a
new measure in MIPS
16Value Driven. Health Care. Solutions.
CMS legacy programs become measures in
the MIPS program
MIPS Overview
Provides both upside and
downside adjustments to the
MPFS
Maximum adjustments:
– 2019: 4 percent
– 2020: 5 percent
– 2021: 7 percent
– 2022 & beyond: 9 percent
First MIPS performance year-
2017
First MIPS payment year-2019
17Value Driven. Health Care. Solutions.
Threshold
4x% 5x% 7x% 9x%
-4x% -5x% -7x% -9x%
2019 2020 2021 2022
MIPS Eligible Providers
Years 1 and 2 Medicare Part
B clinicians:
Physicians MD, DO
Podiatrists
Optometrists
Chiropractors
Dentists
Physician Assistants
Nurse Practitioners
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Year 3+ Medicare Part B
clinicians:
Occupational Therapists
Physical Therapists
Speech Therapists
Audiologists
Nurse Midwives
Clinical Social Workers
Dietitians
18Value Driven. Health Care. Solutions.
Who is Exempt from MIPS?
3 groups of clinicians:
19Value Driven. Health Care. Solutions.
First year of
Medicare Part B
participation
Below low patient
volume threshold
Qualified
Participants in
ADVANCED
Alternative
Payment Models100 or fewer Part B patients
OR billing no more than
$30k/year
NOTE: MIPS does not apply to hospitals or facilities
MIPS Category Measures Over Time
A score of 0-100 developed for each eligible clinician based
on performance in four categories:
20Value Driven. Health Care. Solutions.
Quality
Advancing Care
Information
Improvement
Activities Cost
Replaces PQRS Replaces MU New (PCMH) Replaces VBM
2017 60% 25% 15% 0%
2018 50% 25% 15% 10%
2019+ 30% 25% 15% 30%
Three MIPS Options to Participate in 2017
To avoid a negative adjustment in 2019, submit to CMS
one of the following in 2017:
21Value Driven. Health Care. Solutions.
1Quality
Measure
1Improvement
Activity
5Required Advancing Care
Information
Measures
OR OR
Reporting
Individual – defined as a single NPI tied to a single TIN
– CEHR
– Registry
– Qualified clinical data registry
Group – must share a common TIN
– CEHR
– Registry
– Qualified clinical data registry
– CMS web interface – must register by June 30, 2017
22Value Driven. Health Care. Solutions.
Quality – 60%
Select 6 measures to
report on from about
300 quality measures
Or select from a set of
specialty specific
measures
Full list of measures at
https://qpp.cms.gov/m
easures/quality
23Value Driven. Health Care. Solutions.
Must report for
at least 90 days
to be eligible for
a positive
adjustment
3-10 points per
measure based
on performance
against a
benchmark
60 possible
points
Bonus points for
high-priority and
EHR reporting
60Points
Advancing Care Information – 25%
24Value Driven. Health Care. Solutions.
Choose between 2 lists of Advancing Care Information
(ACI) Objectives ad Measures
ACI Objectives and Measures 2017 ACI Transition Objectives and
Measures
5 required base measures 4 required base measures
9 optional performance measures 7 optional performance measures
2015 Certified EHR 2014 Certified EHR
Stage 3 Meaningful Use standards Modified Stage 2 Meaningful Use
standards
Advancing Care Information Performance Category Fact Sheet available at
https://qpp.cms.gov/resources/education
Advancing Care Information – 25%
25Value Driven. Health Care. Solutions.
– Security risk analysis
– e-Prescribing
– Provide patient access
– Health Information
Exchange
– 5 percent for public
health/clinical data
registry reporting
– 10 percent for
improvement activity
alignment
– Provide patient access
– Health information
exchange
– View, Download, or
Transmit
– Patient-specific education
– Secure messaging
– Medication Reconciliation
– Immunization Registry
reporting
Required base
score*
Optional performance
score*
Bonus score
50 90 15
*2017 ACI Transition Objectives and Measures
Improvement Activities – 15%
Attest to completing activities
that improve clinical practice
for at least 90 days during the
year
92 activities in 9 categories
Accumulate 40 points for
maximum category scoring
– Medium-weighted activities
(10 points)
– High-weighted activities (20
points)
Points are doubled for small,
rural, and health professional
shortage area practices
26Value Driven. Health Care. Solutions.
1. Expanded
Practice
Access
2. Population
Management
3. Care
Coordination
4. Beneficiary
Engagement
5. Patient
Safety and
Practice
Assessment
6. Participation
in an APM
7. Achieving
Health Equity
8. Integrating
Behavioral and
Mental Health
9. Emergency
Preparedness
and Response
Improvement Activities – 15%
Full credit for clinicians in CPC+, in a PCMH, or in
similar specialist practice
– PCMH certifications for MIPS include: a national program,
a regional or state program, a private payer, or other body
that certifies at least 500 practices
Partial or full credit for participation in an APM
Full list of Improvement Activities, with details on action
required and suggested documentation, available at
https://qpp.cms.gov/resources/education under MIPS
Data Validation Criteria
27Value Driven. Health Care. Solutions.
Cost – 0%
Clinicians are not required to submit cost data to CMS
– CMS assesses clinicians based on Medicare claims data
CMS compares resources used to treat similar care
episodes and clinical condition groups across practices
Cost measures adjusted for geographic payment rates
and beneficiary risk factors
ECs earn a maximum of 10 points per episode cost
measure
28Value Driven. Health Care. Solutions.
MERIT-BASED INCENTIVE PAYMENT SYSTEM
(MIPS)
Scoring and Payment Adjustments
Pick Your Pace Options
Three options to participate in MIPS in 2017:
30Value Driven. Health Care. Solutions.
Don’t submit
Pick Your Pace Options
Four options to participate in MIPS in 2017:
31Value Driven. Health Care. Solutions.
No
Participation
Minimum
Participation
Partial
Participation
Full
Participation
• Report
nothing
• -4% penalty
• Report
1 Quality measure
Or
1 Improvement
Activity
Or
4/5 Required
Advancing Care
Information
measures
• 0% adjustment
• Report more
than minimum
for at least 90
days
• Small incentive
• Report all
categories for at
least 90 days
(preferably one
full year)
• Up to 4%
incentive
• Possible bonus if
≥ 70 points
Scoring Basics
Each provider/practice will receive a final score for
each MIPS category based on performance
Category scores will be calculated (based on category
weighting) to produce a total score between 1-100
32Value Driven. Health Care. Solutions.
Payment Adjustment Basics
CMS will publish a “performance threshold” score at
the start of each year
Each Eligible Clinician’s (EC’s) final score is compared
to the performance threshold score
ECs with a score exactly at threshold will receive no
MIPS adjustment
ECs with a score below threshold will receive a
negative payment adjustment
ECs with a score above threshold will receive a
positive payment adjustment factor
Adjustment percentages are variable based on EC
score compared to threshold score
33Value Driven. Health Care. Solutions.
2017 Final Scores and Adjustments
34Value Driven. Health Care. Solutions.
Final Score Payment Adjustment
≥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 payment adjustment of -4%
– 0 points = does not participate
35
Budget Neutrality
>> Amounts accrued from penalties assessed
against ECs with scores below the threshold will fund
payments for ECs with scores above the threshold
Value Driven. Health Care. Solutions.
Additional Incentive Payments and Support
For 2019-2024, maximum of $500 million per year in
additional incentive payments may be available to
distribute to ECs who have “exceptional performance”
– Final score of 70 or higher qualifies for an additional payment in
2017 (2019 payment year)
– Not budget neutral
Technical support for small and rural practices
– QPP Small, Underserved, and Rural
Support (QPP SURS)
36Value Driven. Health Care. Solutions.
Example of MIPS Negative Adjustment
37Value Driven. Health Care. Solutions.
MPFS
Reimbursement
2017 data/
2019 payment
2018 data/
2020 payment
2019 data/ 2021
payment
2020 data/
2022 payment
Maximum Loss 4% 5% 7% 9%
$50,000 $2,000 $2,500 $3,500 $4,500
$100,000 $4,000 $5,000 $7,000 $9,000
$400,000 $16,000 $20,000 $28,000 $36,000
Example of MIPS Positive Adjustment
38
MPFS
Reimbursement
2017 data/
2019 payment
2018 data/
2020 payment
2019 data/
2021 payment
2020 data/
2022 payment
Plus or Minus 4% 5% 7% 9%
Bonus 10% 10% 10% 10% 10%
$50,000 $7,000 $7,500 $8,500 $9,500
$100,000 $14,000 $15,000 $17,000 $19,000
$400,000 $56,000 $60,000 $68,000 $76,000
Value Driven. Health Care. Solutions.
Physician Compare Website
Shows MIPS composite
scores and individual
performance category
scores
Patients can see health
care providers rated on a
scale of 0 to 100 and
how physician compares
to peers nationally
39Value Driven. Health Care. Solutions.
PREPARING FOR MIPS 2017
Based on your practice’s capabilities
Pick Your Pace - Minimum and Ideal
Good - Submit data on at least one quality measure,
one improvement activity or four advancing care
information transition measures to avoid a 4% negative
adjustment
Better - Submit more than the required data in 1 or
more categories for least 90 days to possibly earn a
modest positive adjustment
Best - Submit full data in all 3 categories for at least 90
days (one full year preferred) to possibly earn the
maximum positive adjustment
41Value Driven. Health Care. Solutions.
If you previously reported PQRS
1. Review the list of 2017 Quality measures to verify that
your previous measures are still available
➢ https://qpp.cms.gov/measures/quality
➢Measures Group reporting is no longer an option!
2. If reporting Quality via Claims, continue adding the
appropriate codes to Medicare claims
3. If reporting Quality via EHR or registry,
➢ review your quality measure reports for accuracy, and
contact your vendor if there are obvious issues
4. Begin improving performance on quality measures
42Value Driven. Health Care. Solutions.
If you previously reported Meaningful Use
1. Review the list of 2017 ACI Transition Objectives and
Measures
➢ https://qpp.cms.gov/measures/aci
2. Print your 2017 Year-to-Date ACI or MU report
3. Verify that you are able to meet all required base
measures (especially the Health Information Exchange
measure)
4. Begin improving on your optional performance
measures
43Value Driven. Health Care. Solutions.
If you do have an EHR & have not reported
1. Choose an improvement activity that you can complete
for 90 days, and begin implementation
➢Review the list at https://qpp.cms.gov/measures/ia
2. Contact your EHR vendor for guidance on MIPS
reporting
➢Do you need a software upgrade?
➢How do you review Quality and ACI reports?
➢How much is MIPS reporting per provider?
44Value Driven. Health Care. Solutions.
If you do not have EHR & have not reported
1. Choose an improvement activity that you can complete
for 90 days, and begin implementation
➢Review the list at https://qpp.cms.gov/measures/ia
2. Begin learning how to submit quality information via
claims
➢Contact your billing company to see if they can assist
➢ Begin educating yourself at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-
Instruments/PQRS/Downloads/2016PQRS_Claims_Codin
gRpgPrinc.pdf
3. Begin exploring EHR options
45Value Driven. Health Care. Solutions.
TYING IT ALL TOGETHER
Start Working on QPP Activities now
Next Steps – Using Free CMS Resources for MIPS Success
47Value Driven. Health Care. Solutions.
Determine your eligibility – MIPS or
APM
If you’re MIPS eligible, and your
practice is under 15 physicians, rural,
or underserved, you likely qualify for
FREE support through the QPP
Resource Center
How to Sign Up: visit the
www.qppresourcecenter.com – click
the “Join Now” button at the top,
answer a few short questions about
your practice and you’re on your way!
Questions: Contact Us - 800.264.7221
or QPPTA@medadvgrp.com
Next Webinar – July 21
48Value Driven. Health Care. Solutions.
Visit Medical Advantage Group’s
MACRA Jumpstart Page:
– www.medicaladvantagegroup.com/mac
rajumpstart/
Register for our July 21 webinar:
– MACRA Jumpstart: Preparing Your
Small Practice for MIPS Success
Beth Hickersonbhickerson@medicaladvantagegroup.com
Value Driven. Health Care. Solutions.
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