American College of Physicians   Internal Medicine Meeting 2017 San Diego, CA MIPS or APM: Making the Most of Medicare Payment Faculty Moderator: Walter J. Gorski Disclosure: Has no relationship with any entity producing, marketing, re‐ selling, or distributing health care goods or services consumed by, or used  on, patients. Panelist(s): Robert M. McLean, MD, FACP Disclosure: Has no relationship with any entity producing, marketing, re‐ selling, or distributing health care goods or services consumed by, or used  on, patients. Ashby  Wolfe, MD, MPP, MPH Disclosure: Has no relationship with any entity producing, marketing, re‐ selling, or distributing health care goods or services consumed by, or used  on, patients. Posted Date:  March 21, 2017 ©2017 American College of Physicians. All rights reserved. Reproduction of Internal Medicine Meeting 2017 presentations, or print or electronic material  associated with presentations, is prohibited without written permission from the ACP. Any use of program content, the name of a speaker and/or program title, or the name of ACP without the written consent of ACP is prohibited. For  purposes of the preceding sentence, “program content” includes, but is not limited to, oral presentations, audiovisual materials used by speakers,  program handouts, and/or summaries of the same. This rule applies before, after, and during the meeting. American College of Physicians   Internal Medicine Meeting 2017 San Diego, CA MIPS or APM: Making the Most of Medicare Payment Clinical questions to be addressed: 1.What are the essential features of the merit‐based incentive programs and alterative payment models?  How will physicians know which option is best for their practice? 2.What changes do physicians need to make in their practice to succeed under these new models?  3.What resources can help physicians succeed now and in the post‐MACRA (Medicare Access and CHIP  Reauthorization Act) world? Posted Date:  March 21, 2017 ©2017 American College of Physicians. All rights reserved. Reproduction of Internal Medicine Meeting 2017 presentations, or print or electronic material  associated with presentations, is prohibited without written permission from the ACP. Any use of program content, the name of a speaker and/or program title, or the name of ACP without the written consent of ACP is prohibited. For  purposes of the preceding sentence, “program content” includes, but is not limited to, oral presentations, audiovisual materials used by speakers,  program handouts, and/or summaries of the same. This rule applies before, after, and during the meeting. Quality Payment Program Quality Payment Program Getting Started with the Quality Payment Program: An Overview of MIPS and APMs Ashby Wolfe, MD, MPP, MPH Chief Medical Officer, Region IX Centers for Medicare and Medicaid Services Presentation to the American College of Physicians April 1, 2017 2 Quality Payment Program Quality Payment Program CMS OFFICES Disclaimer This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. . Quality Payment Program Quality Payment Program Better Care, Smarter Spending, Healthier People Focus Areas Test and edžpand alternative payment models ƒ ƒ Accountable Care Incentives ƒ Care Delivery The CMS Innovation Center Focus Areas Description Promote value-based payment systems – Test new alternative payment models – Increase linkage of Medicaid, Medicare FFS, and other payments to value Bring proven payment models to scale ƒ Bundled payment models വ Pioneer ACO Model വ Medicare Shared Savings Program (housed in Center for Medicare) വ Advance Payment ACO Model വ Comprehensive ERSD Care Initiative വ Eedžt 'eneration ACK Pay Providers ƒ Encourage the integration and coordination of services ƒ Improve population health ƒ Promote patient engagement through shared decision making വ Bundled Payment for Care Improvement Models 1-4 വ Kncology Care Model വ Comprehensive Care for Joint Replacement (proposed) ƒ Initiatives Focused on the Medicaid population വ വ വ വ ƒ Primary Care Transformation വ Comprehensive Primary Care Initiative (CPC) വ Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration വ Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration വ Independence at Home Demonstration വ Graduate Nurse Education Demonstration വ Home Health Value Based Purchasing (proposed) Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicaid Innovation Accelerator Program ƒ Dual Eligible (Medicare-Medicaid Enrollees) വ Financial Alignment Initiative വ Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents ƒ Kther വ Medicare Care Choices വ Medicare Advantage Value-Based Insurance Design model Support providers and states to improve the delivery of care ƒ Learning and Diffusion Information ƒ ƒ Create transparency on cost and quality information Bring electronic health information to the point of care for meaningful use Source: Burwell SM. Setting Value-Based Payment 'oals ൞ HHS Efforts to Improve h.S. Health Care. EE:M ϮϬϭϱ :an Ϯϲ͖ published online first. Deliver Care വ Partnership for Patients വ Transforming Clinical Practice വ Community-Based Care Transitions ƒ Health Care Innovation Awards Distribute Information ƒ State Innovation Models Initiative വ SIM Round 1 വ SIM Round 2 വ Maryland All-Payer Model ƒ Million Hearts Cardiovascular Risk Reduction Model Increase information available for effective informed decision-making by consumers and providers ƒ Information to providers in CMMI models ƒ Shared decision-making required by many models Quality Payment Program Quality Payment Program Origins of the Quality Payment Program: MACRA • Bipartisan Legislation: the “Medicare Access and CHIP Reauthorization Act,” 2015 • Increases focus on quality of care delivered – Clear intent that outcomes needed to be rewarded, not number of services – Shifts payments away from number of services to overall work of clinicians Medicare Payments Prior to MACRA Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. d patient-centric health care system • Moving toward • Services provided Medicare Fee Schedule Adjustments Physician Quality Reporting Program (PQRS) Value-Based Payment Modifier Final payment to clinician Replaces Sustainable inable Growth Rate (SGR) S'R ELIMIEATED BY MACRA Medicare EHR Incentive Program 7 Quality Payment Program Quality Payment Program The Quality Payment Program MACRA changes how Medicare pays clinicians. • 8 The Quality Payment Program policy will reform Medicare Part B payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system The Quality Payment Program policy will: • Reform Medicare Part B payments for more than 600,000 clinicians • Improve care across the entire health care delivery system Clinicians have two tracks to choose from: Adjustments Services provided Medicare Fee Schedule Final payment to clinician 9 Quality Payment Program 5 Quality Payment Program Discussion Structure Part I: MIPS Basics What Do I Need to Know? • Part 1: What do I need to know about MIPS? • Part 2: What do I need to know about APMs? • Part 3: How do I prepare for and participate in The Quality Payment Program? 11 12 Quality Payment Program Quality Payment Program What is the Merit-based Incentive Payment System? What is the Merit-based Incentive Payment System? Combines legacy programs into single, improved reporting program A visualization of how the legacy programs streamline into the MIPS performance categories: Physician Quality Reporting System (PQRS) Participating in… Value-Based Payment Modifier (VM) Medicare EHR Incentive Program (EHR) Is similar to reporting on… PQRS Quality Cost Legacy Program Phase Out Last Performance Period PQRS Payment End VM 2016 2018 EHR Advancing Care Information 13 Quality Payment Program Quality Payment Program What Is MIPS? MIPS for First-Time Reporters https://qpp.cms.gov Performance Categories: Improvement Activities Quality • • 14 Advancing Care Information Cost You Have Asked: “What if I do not have any previous reporting experience?” MIPS Performance Score CMS has provided options that may reduce participation burden to first time reporters by: Reporting standards align with Alternative Payment Models when possible Adjusting the low-volume threshold to exclude more individual clinicians and groups Many measures align with those being used by private insurers Allowing clinicians to pick their pace of participation for Transition Year 2017 by lowering the performance threshold to avoid a negative adjustment Clinicians will be reimbursed under Medicare Part B based on this Performance Score 15 Quality Payment Program 16 Quality Payment Program When Does the Merit-based Incentive Payment System Officially Begin? Performance year submit Feedback available 2017 March 31, 2018 Feedback January 1, 2019 Performance Year Data Submission • CMS provides performance feedback after the data is submitted. • Clinicians will receive feedback before the start of the payment year. • MIPS payment adjustments are prospectively applied to each claim begin January 1, 2019. • Performance period opens January 1, 2017. • Closes December 31, 2017. • Clinicians care for patients and record data during the year. • Deadline for submitting data is March 31, 2018. • Clinicians are encouraged to submit data early. MIPS Eligibility What Do I Need to Know? adjustment Payment Adjustment 17 18 Quality Payment Program Quality Payment Program Exempt Example Eligible Clinicians: Dr. “B.” is: • An eligible clinician • Billed $100,000 in Medicare Part B charges • Saw 80 patients Dr. B. would be EXEMPT from MIPS due to seeing less than 100 patients. 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. BILLING > $30,000 AND > 100 These clinicians include: Physicians Physician Assistants Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetists Remember: To be eligible BILLING $100,000 + BILLING > $30,000 80 = EXEMPT From MIPS AND > 100 19 20 Quality Payment Program Quality Payment Program Who is Exempt from MIPS? Eligibility for Clinicians in Specific Facilities Clinicians who are: • Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) o Newly-enrolled in Medicare Below the low-volume threshold • Enrolled in Medicare for the first time during the performance period (exempt until following performance year) • Medicare Part B allowed charges less than or equal to $30,000 a year OR • See 100 or fewer Medicare Part B patients a year Significantly participating in Advanced APMs Eligible clinicians billing under the RHC or FQHC payment methodologies are not subject to the MIPS payment adjustment. However… • Receive 25% of their Medicare payments OR • See 20% of their Medicare patients through an Advanced APM o Eligible clinicians in a RHC or FQHC billing under the Physician Fee Schedule (PFS) are required to participate in MIPS and are subject to a payment adjustment. 15 Quality Payment Program 22 Quality Payment Program Eligibility for Non-Patient Facing Clinicians • Non-patient facing clinicians are eligible to participate in MIPS as long as they exceed the low-volume threshold, are not newly enrolled, and are not a Qualifying APM Participant (QP) or Partial QP that elects not to report data to MIPS • The non-patient facing MIPS-eligible clinician threshold for individual MIPS-eligible clinicians is < 100 patient facing encounters in a designated period • A group is non-patient facing if > 75% of NPIs billing under the group’s TIN during a performance period are labeled as non-patient facing • There are more flexible reporting requirements for non-patient facing clinicians 23 MIPS Performance Categories What Do I Need to Know? 24 Quality Payment Program Quality Payment Program What are the Performance Category Weights? MIPS Performance Category: Quality Weights assigned to each category based on a 1 to 100 point scale • 60% of Final Score in 2017 • 270+ measures available Transition Year Weights— 25% o You select 6 individual measures • 1 must be an Outcome measure OR • High-priority measure Į Quality Cost Improvement Activities Advancing Care Information 60% 0% 15% 25% o • Defined as outcome measures, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination. You may also select specialty-specific set of measures Keep in mind: Replaces PQRS and Quality portion of the Value Modifier Note: These are defaults weights; the weights can be adjusted in certain circumstances Provides for an easier transition for those who have reporting experience due to familiarity 25 26 Quality Payment Program Quality Payment Program MIPS Performance Category: Cost MIPS Performance Category: Improvement Activities • No reporting requirement; 0% of Final Score in 2017 • Clinicians assessed on Medicare claims data • CMS will still provide feedback on how you performed in this category in 2017, but it will not affect your 2019 payments. • Keep in mind: Uses measures previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR) • 15% of Final Score in 2017 • Attest to participation in activities that improve clinical practice Į Only the scoring is different • Examples: Shared decision making, patient safety, coordinating care, increasing access Clinicians choose from 90+ activities under 9 subcategories: 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 27 28 Quality Payment Program Quality Payment Program MIPS Performance Category: Advancing Care Information MIPS Performance Category: Advancing Care Information • 25% of Final Score in 2017 • Promotes patient engagement and the electronic exchange of information using certified EHR technology • Ends and replaces the Medicare EHR Incentive Program (also known as Medicare Meaningful Use) • Greater flexibility in choosing measures • In 2017, there are 2 measure sets for reporting to choose from based on EHR edition: Advancing Care Information Objectives and Measures 2017 Advancing Care Information Transition Objectives and Measures 29 30 Quality Payment Program Quality Payment Program Advancing Care Information: Flexibility CMS will automatically reweight the Advancing Care Information performance category to zero for Hospitalbased MIPS clinicians, clinicians who lack of Faceto-Face Patient Interaction, NP, PA, CRNAs and CNS • Reporting is optional although if clinicians choose to report, they will be scored. A clinician can apply to have their performance category score weighted to zero and the 25% will be assigned to the Quality category for the following reasons: 1. Insufficient internet connectivity 2. Extreme and uncontrollable circumstances 3. Lack of control over the availability of CEHRT MIPS Participation What Do I Need to Know? 31 32 Quality Payment Program Quality Payment Program Pick Your Pace for Participation for the Transition Year MIPS: Choosing to Test for 2017 Participate in an Advanced Alternative Payment Model MIPS Test • Submit minimum amount of 2017 data to Medicare • Avoid a downward adjustment • Gain familiarity with the program Full Year Partial Year Minimum Amount of Data • Some practices may choose to participate in an Advanced Alternative Payment Model in 2017 • Submit some data after January 1, 2017 • Neutral payment adjustment Note: Clinicians do not need to tell CMS which option they intend to pursue. • Report for 90-day period after January 1, 2017 • Fully participate starting January 1, 2017 • Neutral or positive payment adjustment • Positive payment adjustment 1 OR Quality Measure 1 OR Improvement Activity Not participating in the Quality Payment Program for the Transition Year will result in a negative 4% payment adjustment. 33 4 or 5* Required Advancing Care Information Measures *Depending on CEHRT edition Quality Payment Program Quality Payment Program MIPS: Partial Participation for 2017 MIPS: Full Participation for 2017 • Submit 90 days of 2017 data to Medicare • Submit a full year of 2017 data to Medicare • May earn a positive payment adjustment • May earn a positive payment adjustment • Best way to earn largest payment adjustment is to submit data on all MIPS performance categories “So what?” - If you’re not ready on January 1, you can start anytime between January 1 and October 2 23 Key Takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted. Need to send performance data by March 31, 2018 24 25 Quality Payment Program Quality Payment Program Submission Methods Individual • • • Qualified Clinical Data Registry (QCDR) Qualified Registry EHR Claims Improvement Activities • • • • QCDR Qualified Registry EHR Attestation Advancing Care Information • • • • QCDR Qualified Registry EHR Attestation • MIPS Reporting What Do I Need to Know? Quality QCDR Qualified Registry EHR Administrative Claims CMS Web Interface CAHPS for MIPS Survey QCDR Qualified Registry EHR CMS Web Interface Attestation • • • • • QCDR Qualified Registry EHR Attestation CMS Web Interface *Must be reported via a CMS approved survey vendor together with another submission method for all other Quality measures. 37 Quality Payment Program Group • • • • • • • • • • • 38 Quality Payment Program Transition Year 2017 Part II: APM Basics What Do I Need to Know? Final Score >70 points Payment Adjustment x x 4-69 points 3 points 0 points x Positive adjustment Eligible for exceptional performance bonus—minimum of additional 0.5% x Positive adjustment Not eligible for exceptional performance bonus x Neutral payment adjustment x Negative payment adjustment of -4% 0 points = does not participate x 39 40 Quality Payment Program Quality Payment Program Alternative Payment Models (APMs) Advanced APMs Must Meet Certain Criteria • • • A payment approach that provides added incentives to clinicians to provide high-quality and costefficient care. Advanced APMs are a Subset of APMs The APM: APMs Can apply to a specific condition, care episode or population. May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs. To be an Advanced APM, the following three requirements must be met. Requires participants to use certified EHR technology; Advanced APMs 41 Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk. 42 Quality Payment Program Quality Payment Program Advanced APMs in 2017 For the 2017 performance year, the following models are Advanced APMs: Comprehensive End Stage Renal Disease Care Model (Two-Sided Risk Arrangements) Comprehensive Primary Care Plus (CPC+) Shared Savings Program Track 2 Shared Savings Program Track 3 Next Generation ACO Model Oncology Care Model (Two-Sided Risk Arrangement) What is the benefit of participating in an Advanced APM? The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements as needed. 43 44 Quality Payment Program Quality Payment Program Advanced Alternative Payment Models Qualifying APM Participant (QP) Clinicians who participate significantly in Advanced APMs can: • Receive greater rewards for taking on some risk related to patient outcomes. Qualifying APM Participants (QPs) are clinicians who have a certain % of Part B payments for professional services or patients furnished Part B professional services through an Advanced APM Entity. + Advanced APMs Advanced APMspecific rewards 5% lump sum incentive “So what?” - It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs. Beginning in 2021, this threshold % may be reached through a combination of Medicare and other nonMedicare payer arrangements, such as private payers and Medicaid. 45 Quality Payment Program 46 Quality Payment Program How do Eligible Clinicians become Qualifying APM Participants? Part III: Checklist for Preparing and Participating in MIPS 9 The Threshold Score is compared to the corresponding QP threshold table and CMS takes the better result. Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements) Performance Year 2017 2018 2019 2020 2021 2022 and later Percentage of Payments through an Advanced APM Percentage of Patients through an Advanced APM 47 48 Quality Payment Program Quality Payment Program Preparing and Participating in MIPS: A Checklist ‰ Determine Your Eligibility ‰ Determine your eligibility and understand the requirements. ‰ Choose whether you want to submit data as an individual or as a part of a group. ‰ Choose your submission method and verify its capabilities. ‰ Verify your EHR vendor or registry’s capabilities before your chosen reporting period. ‰ Prepare to participate by reviewing practice readiness, ability to report, and the Pick Your Pace options. ‰ Choose your measures. Visit qpp.cms.gov for valuable resources on measure selection and remember to review your current billing codes and Quality Resource Use Report to help identify measures that best suit your practice. ‰ Verify the information you need to report successfully. ‰ Care for your patients and record the data. ‰ Submit your data by March 2018. How Do I Do This? 1. 2. Calculate your annual patient count and billing amount for the 2017 transition year. • Review your claims for service provided between September 1, 2015 and August 31, 2016, and where CMS processed the claim by November 4, 2016. • Did you bill more than $30,000 AND provide care for more than 100 Medicare patients a year? o Yes: You’re eligible. o No: You’re exempt. CMS will provide additional guidance on eligibility in Winter/Early Spring 2017. 49 50 Quality Payment Program Quality Payment Program ‰ Prepare to Participate ‰ Choose Your Measures/Activities How Do I Do This? 1. Consider your practice readiness. • 2. 3. How Do I Do This? 1. Go to qpp.cms.gov. Have you previously participated in a quality reporting program? Evaluate your ability to report. 2. Click on the • What is your data submission method? • Are you prepared to begin reporting data between January 1, 2018 and March 31, 2018? Review the Pick Your Pace options for Transition Year 2017. • Test • Partial Year • Full Year tab at the top of the page. 3. Select the performance category of interest. 4. Review the individual Quality and Advancing Care Information measures as well as Improvement Activities. 51 Quality Payment Program 52 Quality Payment Program Website: https://qpp.cms.gov https://qpp.cms.gov Quality Payment Program Quality Payment Program Technical Support Available to Clinicians Integrated Technical Assistance Program NEXT STEPS Į Where can I go to get help? Į Full-service, expert help • Quality Payment Program Service Center • Quality Innovation Network/Quality Improvement Organizations • Quality Payment Program — Small, Underserved, and Rural Support • Transforming Clinical Practice Initiative • APM Learning Networks Self-service • QPP Online Portal https://qpp.cms.gov/education 55 Quality Payment Program All support is FREE to clinicians Quality Payment Program Quality Payment Program: How to get help https://qpp.cms.gov Ashby Wolfe, MD, MPP, MPH Chief Medical Officer, Region IX Centers for Medicare and Medicaid Services 57 ashby.wolfe1@cms.hhs.gov 56