Fall Summit | October 18-20 | Orlando, FL

Therese Mulvey, MD, Massachusetts General Hospital, ASCO MACRA Task Force

MACRA MIPS Update

MACRA: Where are we now?

Therese Mulvey, MD FASCO

Director Quality, Safety and Value

MGH Cancer Center and Affiliated Networks

Disclosure Information 2017 AACI/CCAF Annual Meeting

Dr. Therese Mulvey

I have no financial relationships to disclose.

– and –

I will not discuss off label use and/or investigational use in my presentation.

At this time, there are four manifestations of value based-payment:

1. Penalties and rewards on FFS payments for performance indicators (MIPs)

2. Shared savings programs (APMs including Next Gen ACO and MSSP)

3. Bundles (Ortho and Cardiac)

4. Full capitation (Medicare Advantage, NHP, etc.)

Why MACRA?? Align incentives.

4

4 ways to contain healthcare spending:

1. Reducing payments to docs

2. Increasing consumer cost – share

3. Rationing services

4. Giving providers incentives to be more efficient – VALUE-BASED PAYMENT

6

MACRA replaces uncertainty of SGR with Value-Based Payment → Quality Payment Program (QPP)

• In 2015, Congress passed MACRA, which repeals the Medicare Sustainable

Growth Rate (SGR) and creates the Quality Payment Program (QPP).

Merit-based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMs)

• Combines existing quality programs (PQRS, Value Based Modifier, Medicare EHR Incentive Program) plus newly added ‘Improvement Activities’ into one, budget neutral program.

• 5% annual bonus from 2019-2024 if significant share of Medicare revenue in contracts that include 2-sided payment risk.

• Positive or negative payment adjustment is assessed based on combined score for Quality, Cost, EHR and Improvement Activities.

• E.g. Next Gen ACO • Oncology Payment Model

Eligible clinicians participate in QPP through one of two Medicare payment tracks:

*Neurology, Psychiatry, Hem/Onc, Cardiology, Endocrinology, OB/GYN

Quality Payment Program (QPP)

Merit Based Incentive

Program System

• Measures Quality, use of

CEHRT, Improvement

Activity and Cost

• Peer Comparisons

• Incentives/Penalties

• Publicly Reported

Alternative

Payment Models

• New Payment

Mechanisms

• New Delivery Systems

• Negotiated Incentives

• Automatic Bonus

MIPS

APMs

8

Merit-Based Incentive Payment System (MIPS)

Year 1 – 2017 Performance ( 2019 Payment)

60%

15%

25%

*Cost (Value) 0% in Year I

MIPS

PQRS

MU VBP

Clinical Quality Measures (Formerly PQRS)

Advancing Care Information (Formerly MU)

Improvement Activities (New)

Funnels existing, separate

CMS physician programs into a

single, new program – MIPS.

MIPS shifts the emphasis to

reimbursement to quality based

measures.

Cost is not part of MIPS in

2017.

Will It Affect Me?

9

1st time Part B Participant

Low Volume( $30K ) or

Low Patient Count (100 Patients)

APM Qualified Participant

Medicare Part B

(Physician Services)

25%

60%

15% Advancing Care Information (MU)

Quality (PQRS)

Improvement Activity (New)

0 100

Low Performers -4%

National Median Composite Score

Medicare Provider Composite Score

High Performers +4%

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MIPS Performance Categories

Quality ~PQRS

60% 50% 30% Selection of at least 6 Measures or “specialty measure set (registry)

Resource Use ~Value Modifier

---- 10% 30% Continuation of two measures: total per capita cost & MSPB

Improvement Activities -New

15% 15% 15% Clinicians to engage in at least 4 activities (similar to Leapfrog). Attestation

Advancing Care

Information ~Meaningful Use

25% 25% 25% MU Core objectives reduced to 5 measures

MIPS Composite Performance Score

100% 100% 100%

MIPS Composite Performance Score determines whether clinician receives upward, downward, or neutral payment adjustment

Year 1-2017 2019 payment

Year 2-2018 2020 payment

Year 3-2019 2021 payment Notes:

PREPARING FOR 2018!

What should I be doing today?

2017

-4% Failure to participate in

QPP in 2017 WILL result in

a negative payment

adjustment in 2019

Pick Your Pace

In 2019, my payment

adjustment will be….

A. -4%, I’m not participating this year.

B. Neutral, I’m submitting at least one measure

this year.

C. I’m all in, I might get a positive adjustment.

Let’s get real….

• Pick measures that are measurable electronically

– 50% requirement in 2017….. Eventually 90%

• Think about workflow and documentation as you choose your measures

– Who?

– What?

– When?

– Where?

– How?

Example of MIPS Participation for an Oncologist

ACI (Base Score)

Protect PHI/security risk

analysis

E-prescribing

Provide patient

electronic access

HIE – send/receive

summary of care

Sample Improvement

Activities

Participation in a QCDR (e.g. QOPI)

Participation in MOC IV

Registration/use of PDMP

Engagement of

patient/family/caregivers in

developing care plan

Implementation of medication

management practice

improvements

Implementation of practices /

processes for developing regular

individual care plans

Participation in private payer

improvement activities

Use of decision support and

standard treatment protocols

Telehealth services that expand

access to care

Sample Quality

Measures

Chemotherapy plan

documented

Documentation of current

medications/medication

reconciliation

Advance care plan

Pain intensity quantified

Tobacco use - screening &

cessation counseling

HER2 negative – no HER2

targeted therapies

administered

Metastatic CRC – anti-EGFR

w/KRAS testing

>1 ED visit last 30 days of life

Preparing for 2018

Category 2017 Reporting

Requirements

2018 Reporting

Requirements

Quality Minimal: 1 measure, 1 patient/chart

Partial: 90 days, 50% of all patients

Full: at least 90 days, 50% of all

patients

Full year

60% of all patients

ACI Minimal: base score for 90 days

No performance thresholds used in

scoring

At least 90 days

Potential addition of performance

thresholds for scoring

IA Minimal: 1 activity for 90 days

Full: 2-4 activities for at least 90

days

At least 90 days

2-4 activities

Cost Full year

Calculated automatically by CMS

0% weight in MIPS

Full year

Calculated automatically by CMS

10% weight in MIPS

Improvement

Activity

Achieving

Health Equity

Integrating

Behavioral/Mental

Health

Emergency

Preparedness &

Response

Expanded

Practice Access

Population

Management

Beneficiary

Engagement

Patient Safety &

Practice Assessment

APM

Participation

Care

Coordination

Improvement Activity

Reporting Registry

….. coming soon!

QOPI is a CMS-approved QCDR

• What is a QCDR?

– Qualified Clinical Data Registry

– Collects medical and/or clinical data for patient and

disease tracking to foster improvement of quality of care

– CMS Approved

– Quality Measures

• National Quality Foundation

• MIPS Measures

• ASCO measures approved by CMS

– New for 2017, can also report Practice Improvement and

EHR Technology

QOPI QCDR

• 16 quality measures (13 MIPS approved measures) for

2017 reporting

• Practice Improvement Attestation Reporting

• Advancing Care information Attestation/Reporting

• Electronic submission

– CancerLinQ (18 measures active, 11 QCDR overlap)

• 2017 is a transition year for the QOPI QCDR to become

electronically functional to be able to report at 60% of charts

for 2018

– Both the QOPI QCDR and the practices will be asked to “test”

electronic reporting in 2017 so all will be positioned to report at the

higher volume requirement in 2018

Making Every Activity Count

Improvement Activity:

10 – 20 pts

Advancing Care Information:

Up to 10% +

10% Bonus: IA using CEHRT

Quality Measurement:

3-10 points

Activity:

Chemotherapy

plan

documented in

EHR

Personalized plan for high risk

patients; integrate patient goals,

values, priorities

Patient specific education

Personalized plan for high risk

patients; integrate patient goals,

values, priorities

More Tools & Resources www.asco.org/macra

• New! ASCO MACRA Decision Tree

– How does MACRA affect me?

• Improvement Activities and ASCO Quality Programs

– A crosswalk to help you attest to improvement activities you may

already be doing

• Practice Improvement Library….coming soon

– QOPI, Quality Training Program, Quality Certification Program,

ASCO University

• Webinar series

– Next: “Optimizing Your MIPS Score,” Monday, July 10

ALTERNATIVE PAYMENT

MODELS

Whirlpool Collaborative Participants

Slide per Blase Polite

• Whirlpool willing to encourage AMC use for cancer care for their employees and

families through benefit design

• Whirlpool also willing to consider innovative payment models to compensate for

supportive care services

• What Whirlpool expects

– Employee access within 5 days of inquiry

– Comprehensive care plan developed within 7 days of initial appointment

– Respond within 24 hours to inquiries from community providers

– Second opinion within 5 days of inquiry

– Continuous improvement process focused on 5 metrics of care

Project Description

Slide per Blase Polite

• Why are so many terminal patients dying in the ICU despite their expressed

desire to die at home?

• Why are so few terminally ill patients enrolled in palliative care or hospice when

it is shown to control symptoms and extend survival?

• Why are cancer patients receiving 4th and 5th lines of chemotherapy when not

on clinical trials?

• Why are cancer patients receiving three or more PET scans within twelve

months?

• Why are cancer patients receiving chemotherapy during last 14 days of life?

Red Flag Events: Markers of Low Value Care

Slide per Blase Polite

HHS Goal:

By 2018,

50% of all

Medicare

payments based

on alternative

models

OCM Key Features

• Practice Requirements:

– Six “practice requirements”

• Quality & Performance Metrics:

– 32 preliminary quality and performance improvement

metrics

• Risk Option:

– One-sided risk for first 2 years with option to convert to

two-sided risk thereafter (up side and down sided risk)

• Performance payment looks at ‘all costs’:

– Includes all Medicare Part A, Part B and certain Part D

& added episode of care transformational payments

Six OCM Practice Requirements

1. Patient access 24/7 to clinician who has real time access to practice’s medical record

2. Attestation and use of ONC-certified EMR

3. Utilize data for Continuous Quality Improvement (CQI)

4. Provide core functions of patient navigation

5. Document care plan in accordance with IOM

6. Chemotherapy treatment consistent with nationally recognized clinical guidelines

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Exemption

from MIPS

5% Lump Sum

Bonus

APM Specific

Rewards

Qualifying Physicians

Advanced APM

CMS Recognized Alternative Payment Models (APM)

Pick-Your-Pace for 2017:

APM Participation

Any Advanced APMs in 2017?

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Medicare Shared Savings Program (2 Tracks)

Next Generation ACO

Comprehensive ESRD Care (2 models)

Comprehensive Primary Care Plus

Oncology Care Model (OCM) - two-sided risk

track available in 2017

ASCO Offers Solutions

• Improvement Activity • APM Participation

Certification

• Quality Reporting

Rapid Learning

• Quality Reporting • Advancing Care Information • Improvement Activity • Cost • APM Participation

Reporting

• APM Participation • Improvement Activity

Reimbursement

Transformation • APM Participation

Proposed Rule 2018

0 100

Low Performers -5%

National Median Composite Score

Medicare Provider Composite Score

High Performers +5%

Cost Category is

0% in 2018 • Episode-based

methodology

delayed;

• MSPB and total

per-capita cost

• 2018: more Pick-Your-Pace

– More reporting required, but still not full reporting

• Increasing the low-volume threshold to less than or equal to $90,000 in

Medicare Part B allowed charges (from $30,000) or less than or equal to 200

Medicare Part B patients (from 100 patients)

• Continuing to allow the use of 2014 Edition of CEHRT (Certified Electronic

Health Record Technology), while encouraging the use of 2015 edition of

CEHRT

• Bonus points available for:

– Small practices

– Caring for complex patients

– Using 2015 Edition CEHRT exclusively

• New improvement activity tied to Appropriate Use Criteria

• Year-over-year performance improvement may be considered

• Facility-based scoring available for facility-based clinicians

QPP 2018 Performance Year – MIPS

Virtual Groups (new)

• Generally follows the same rules as MIPS groups

• Allows two or more solo practitioners or groups to form new groups – solo practitioner (individual MIPS eligible clinician who bills under a TIN with no other NPIs billing

under such TIN);

– or a group with 10 or fewer eligible clinicians under the

– one year performance period • Election to participate as a virtual group at the beginning of the performance year

– All MIPS eligible clinicians within a TIN must participate in the virtual group

• No restrictions on geography or specialty

• No restrictions on group size

• CMS will provide model agreement to guide practices

• CMS may use waiver authority to use the APM score instead of the virtual

group score instead of the MIPS score when groups move to APMs

QPP 2018 Performance Year – MIPS

Additional ASCO Support

ED

UC

AT

ION

AN

D R

ES

OU

RC

ES

• Check the ASCO website regularly for new tools and resources

• Webinars

• Fact Sheets

• Quality Improvement library (planned)

• www.asco.org/macra

CO

NS

ULT

ING

& A

DV

OC

AC

Y

• Practice Transformation, Oncology Medical Home readiness

• Readiness for Alternative Payment Models

• Filing Extensive Comments

Proposed Rule 2018

• Addition of Part B and D drugs in risk

• Clinical Trials enrollment

• This is a time of transition

• Changes will be coming by rule as MACRA is law

• CMS administrators are new

For more information….

www.asco.org/macra

www.qpp.cms.gov