2017 Proposed Rule MIPS Composite Performance Score Resource Use Performance Category
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1 Starting at Noon EDT 8/22/ Proposed Rule MIPS Composite Performance Score Resource Use Performance Category Dr. Dan Mingle Register for Webinars or Access Recordings
2 Agenda Context - Review Evolution from PQRS to QPP MIPS Adjustment Factor MIPS Composite Performance Score Details of the Resource Use Performance Category Watch for Future Webinars Alternate Payment Mechanisms 8/24/ Mingle Analytics 2
3 Networking Opportunities Florida Bones Society, Manalapan, FL, Sept 16 19: Speaking HBMA Revenue Cycle Conference, Atlanta, GA, Sept 21 23: Speaking NH/VT HFMA Fall Conference, Manchester, VT, Sept 28: Speaking CAPG Annual Conference, Washington, DC, Sept 28 30: Attending HIMSS Big Data Conference, Boston, MA, Oct 24 25: Attending Maine Health Management Coalition / Maine Medical Association, Annual Conference, Portland, ME: Attending AMBA Annual Conference, Las Vegas, NV, October 27 28: Attending MGMA Annual Conference, San Francisco, CA, October 30 Nov 2: Attending 8/24/ Mingle Analytics 3
4 MACRA Medicare Access and CHIP Reauthorization Act of 2015 Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive 8/24/ Mingle Analytics 4
5 Proposed Rule for QPP Published May 9, 2016 Final Rule to be Published by November 1 Annually 8/24/ Mingle Analytics 5
6 Introducing Medicare s New Quality Payment Program 8/24/ Mingle Analytics 6
7 Physician Quality Reporting System (PQRS) Quality Payment Program(QPP) Value Based Modifier (VBM or VM) Quality Tiering Medicare EHR Incentive Program (aka: meaningful use) Merit-Based Incentive Payment System (MIPS) Eligible Clinicians Virtual Groups Alternate Payment Mechanisms (APM) APM Type APM Entity Advanced APM Qualified Providers (QP) Partial QP Split TIN 2016 Last Reporting Year March 31, 2017 Last Submission Due 2018 Last Payment Adjustments Applied 2017 First Reporting Year March 31, 2018 First Submission Due 2019 First Payment Adjustments Applied 8/24/ Mingle Analytics 7
8 $$$ Fee For Service Volume Based Payment $ Value Based Purchasing Quality / Cost Revenues Increasingly at Risk $50B Medicare Revenue will be at risk by 2022 Program Year Reporting (Service Year) Adjustment Expected Physician Average ± 4% ± $4, ± 5% ± $5, ± 7% ± $7, ± 9% ± $9,000 CMS 2013 PQRS Experience Report 8/24/ Mingle Analytics
9 Estimated Impact in 2019 Program Applies to Negative Adjustments Positive Adjustments MIPS Adjustments 687k to 747k providers $833m $833m Exceptional Performance Payments $500m Advanced APM Incentives 30k 90k Providers $146m - $429m 8/24/ Mingle Analytics 9
10 PQRS Timeline 2016 Q Q Q Q Q Q2 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2015 Submissions Providers: Provide Care Document Care Accumulate Data GPRO 2016 Self Nomination Due Monitor Extractions, Data Exchange, and Performance. Remediate Problems Full Year Data Set 2016 Submissions Submission Portal Opens EHR & QCDR QRDA Due GPRO Web Interface Due 2015 Feedback Reports and QRUR Available Apply for Informal Review Submission Portal Opens EHR & QCDR QRDA Due GPRO Web Interface Due Registry & QCDR XML Due 2017 Penalty Notices Registry & QCDR XML Due MIPS Begins PQRS Ends
11 Quality Tiering How it was done 5% 90% 5% Low Quality Avg Quality High Quality 0 +2x% +4x% -2% 0 +2x% -4% -2% 0 Low Cost Avg Cost High Cost 5% 90% 5% 8/24/ Mingle Analytics 11
12 Conceptual Model of MIPS Year Reporting Year From the CMS Proposed Rule 2019 Payment or Program Year 8/24/ Mingle Analytics 12
13 Conceptual Model of MIPS Year 1 Pmt Year 2017 Reporting Year Adj Factor 2019 ± 4% 2020 ± 5% 2021 ± 7% 2022 ± 9% From the CMS Proposed Rule 2019 Payment or Program Year 8/24/ Mingle Analytics 13
14 Conceptual Model of MIPS Year 1 Pmt Year 2017 Reporting Year Adj Factor 2019 ± 4% 2020 ± 5% 2021 ± 7% 2022 ± 9% From the CMS Proposed Rule 2019 Payment or Program Year Quality Cost ACI CPIA /24/ Mingle Analytics 14
15 Conceptual Model of MIPS Year 1 Pmt Year 2017 Reporting Year Adj Factor 2019 ± 4% 2020 ± 5% 2021 ± 7% 2022 ± 9% From the CMS Proposed Rule 2019 Payment or Program Year Quality Cost ACI CPIA /24/ Mingle Analytics 15
16 Each Performance Category must be submitted with a Single Mechanism Medicare Encourages Groups and Individuals to use the same Vendor for 3 Performance Categories Resource Use is the one Performance Category that Requires no Submission 8/24/ Mingle Analytics 16
17 Submission Mechanisms Mechanism Resource Use Quality Advancing Care Information Clinical Practice Improvement Activities Attestation Ind Grp Ind Grp Qualified Registry Ind Grp Ind Grp Ind Grp Qualified Clinical Data Registry (QCDR) Electronic Health Record / Data Submission Vendor Ind Grp Ind Grp Ind Grp Ind Grp Ind Grp Ind Grp Web Interface Grp 25 Grp 25 Grp 25 Survey Vendor Grp 2 Administrative Claims Ind Grp Select Measures Maybe 8/24/ Mingle Analytics 17
18 Proposed Components of the Resource Use Performance Category Total Costs per Capita for All Attributed Beneficiaries Medicare Spending per Beneficiary (MSPB) Episode Based Measures (New) 31 Method A Measures 7 Method B Measures 8/24/ Mingle Analytics 18
19 Resource Use Dynamics Performance Period 2 Calendar years Prior to Payment Period Claims Data Run-out 60-day floor (March 1) 90-day goal (March 31) Partial Year Practitioners evaluated for all available data Subject to low-volume thresholds 8/24/ Mingle Analytics 19
20 MIPS Excluded Clinicians Newly Medicare-enrolled eligible clinicians Qualifying APM Participants (QPs) Certain Partial Qualifying APM Participants (Partial QPs), Clinicians that fall under the low-volume threshold Individual or Group with $10,000 Allowable Charges AND 100 unique Medicare Beneficiaries 8/24/ Mingle Analytics 20
21 Resource Use Exclusions Will not apply to Shared Savings Plan and Next Gen ACO Model Participants Distribute weight evenly between ACI & CPIA All other APM 0% Quality Quality reporting will be specific to the APM type 0% Resource Use Resource Use analysis will be specific to the APM type 25% CPIA 75% ACI 8/24/ Mingle Analytics 21
22 Adjustments Geographic Payment Rate Beneficiary Risk (HCC Codes) Specialty Adjustment applied only to Total per Capita Costs Measure 8/24/ Mingle Analytics 22
23 Plans to Develop Additional Episode Measures Additional Patient Condition Groups Patient Relationship Categories Risk Adjustment on Socio-Economic Status Include Part D Costs 8/24/ Mingle Analytics 23
24 Change from VBM Track Resource Use by Group (TIN) AND Individual (NPI) For the MSPB measure Eliminate Specialty adjustment (Risk Adjustment appears to be adequate Drop case minimum from 125 to 20 8/24/ Mingle Analytics 24
25 Attribution Methodology Total Per Capita Cost 1. When there is at least one Primary Care Provider Visit Attribute to the TIN with the Plurality of PC visit codes by PCPs 2. When there is no Primary Care Provider Visit Attribute to the TIN with the Plurality of PC visit codes by Specialists Medicare Spending per Beneficiary Attribute to the TIN providing the Plurality of MC Part B charges during the hospitalization 8/24/ Mingle Analytics 25
26 Episode Groupers 8/24/ Mingle Analytics 26
27 Proposed Method A Episode Measures Breast Mastectomy for Breast Cancer Cardiovascular Acute Myocardial Infarction (AMI) without PCI/CABG Abdominal Aortic Aneurysm Thoracic Aortic Aneurysm Aortic/Mitral Valve Surgery Atrial Fibrillation (AFib)/Flutter, Acute Exacerbation Atrial Fibrillation (AFib)/Flutter, Chronic Ischemic Heart Disease (IHD), Chronic Pacemaker Percutaneous Cardiovascular Intervention (PCI) 8/24/ Mingle Analytics 27
28 Proposed Method A Episode Measures Cerebrovascular Ischemic Stroke Carotid Endarterectomy Gastrointestinal Cholecystitis Clostridium difficile Colitis Diverticulitis of Colon Genitourinary Prostatectomy for Prostate Cancer Infectious Disease Kidney and Urinary Tract Infection (UTI) 8/24/ Mingle Analytics 28
29 Proposed Method A Episode Measures Metabolic Osteoporosis Neurology Parkinson Disease Musculoskeletal Rheumatoid Arthritis Hip/Femur Fracture or Dislocation Treatment, Inpatient (IP)-Based Hip Replacement or Repair Knee Arthroplasty (Replacement) Spinal Fusion 8/24/ Mingle Analytics 29
30 Proposed Method A Episode Measures Respiratory Asthma/Chronic Obstructive Pulmonary Disease (COPD), Acute Exacerbation Asthma/Chronic Obstructive Pulmonary Disease (COPD), Chronic Pneumonia, Community Acquired, Inpatient (IP)-Based Pneumonia, Community Acquired, Outpatient (OP)-Based Pulmonary Embolism, Acute Upper Respiratory Infection, Acute, Simple Vascular Deep Venous Thrombosis of Extremity, NOS, Acute 8/24/ Mingle Analytics 30
31 Proposed Method B Episode Measures Gastrointestinal Cholecystectomy and Common Duct Exploration Colonoscopy and Biopsy Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Infectious Disease Kidney and Urinary Tract Infection (UTI) Ophthalmology Lens and Cataract Procedures Musculoskeletal Hip Replacement or Repair Knee Arthroplasty (Replacement) 8/24/ Mingle Analytics 31
32 Scoring the Resource Use Performance Category 8/24/ Mingle Analytics 32
33 Resource Use Scoring Basics Score Each Measure on a 10 point scale Compare to Measure-Specific Performance Period Benchmarks Consider Improvement Scoring after the First Year 20 case minimum to be included in Benchmark Composite Score is a Straight Average of All Calculated Standardized Components that have a 20 case Minimum 8/24/ Mingle Analytics 33
34 Converting Resource Use to a Standard Score Analysis by CMS Resource Use expressed as $ Value Output to Practices and the Public Resource Use Expressed as a Normalized Score $xxx /24/ Mingle Analytics 34
35 Converting a Performance Rate to a Standard Score Benchmark Decile Hypothetical Resource Use Scored 1 $100, $75,893-$99, $69,003-$75, $56,009-$69, $50,300-$56, $34,544-$50, $27,900-$34, $21,656-$27, $15,001-$21, $1,000-$15, ($56008 $50300)/10 = $571 Every $571 increments 0.1 Score Performance Score $56,008 to $55, $55,436 to $54, $54,865 to $54, $54,294 to $53, $53,723 to $53, $53,152 to $52, $52,582 to $52, $52,010 to $51, $51,439 to $50, $50,868 to $56, /24/ Mingle Analytics 35
36 Measure Type Cases 1 2 Medicare Spending Per Beneficiary Total Per Capita Costs Performance $ Median Points Total Possible 20 $15,000 $13, $12,000 $10, Episode 1 22 $15,000 $18, Episode 2 10 $11,000 $9,000 Below Case Threshold 5 Episode 3 45 $7,000 $10, Total Points NA Hypothetical Scoring Example 8/24/ Mingle Analytics 36
37 Measure Type Cases 1 2 Medicare Spending Per Beneficiary Total Per Capita Costs Performance $ Median Points Total Possible 20 $15,000 $13, $12,000 $10, Episode 1 22 $15,000 $18, Episode 2 10 $11,000 $9,000 Below Case Threshold 5 Episode 3 45 $7,000 $10, Total Points NA Resource Use Measures Scored Total Possible Points = 40 8/24/ Mingle Analytics 37
38 Measure Type Cases 1 2 Medicare Spending Per Beneficiary Total Per Capita Costs Performance $ Median Points Total Possible 20 $15,000 $13, $12,000 $10, Episode 1 22 $15,000 $18, Episode 2 10 $11,000 $9,000 Below Case Threshold 5 Episode 3 45 $7,000 $10, Total Points NA Actual Total Score = /24/ Mingle Analytics 38
39 Measure Type Cases 1 2 Medicare Spending Per Beneficiary Total Per Capita Costs Performance $ Median Points Total Possible 20 $15,000 $13, $12,000 $10, Episode 1 22 $15,000 $18, Episode 2 10 $11,000 $9,000 Below Case Threshold 5 Episode 3 45 $7,000 $10, Total Points NA Possible 40 Total Points = 55.8% Max Resource Use Category Score for 2017 = % of 10 = 5.6 8/24/ Mingle Analytics 39
40 Conceptual Model of MIPS Year 1 Pmt Year 2017 Reporting Year Adj Factor 2019 ± 4% 2020 ± 5% 2021 ± 7% 2022 ± 9% From the CMS Proposed Rule 2019 Payment or Program Year Quality Cost ACI CPIA In our Example: Resource Use (Cost) = 5.6 8/24/ Mingle Analytics 40
41 Pulling it All Together From the CMS Proposed Rule Component Presented Quality 7/13/ of 50 Cost ACI CPIA Composite Performance 8/24/ Mingle Analytics 41
42 Pulling it All Together From the CMS Proposed Rule Component Presented Quality 7/13/ of 50 Cost ACI 7/28/ of 25 CPIA Composite Performance 8/24/ Mingle Analytics 42
43 Pulling it All Together From the CMS Proposed Rule Component Presented Quality 7/13/ of 50 Cost ACI 7/28/ of 25 CPIA 8/4/ of 15 Composite Performance 8/24/ Mingle Analytics 43
44 Pulling it All Together From the CMS Proposed Rule Component Presented Quality 7/13/ of 50 Cost 8/24/ of 10 ACI 7/28/ of 25 CPIA 8/4/ of 15 Composite Performance 8/24/ Mingle Analytics 44
45 Pulling it All Together From the CMS Proposed Rule Component Presented Quality 7/13/ of 50 Cost 8/24/ of 10 ACI 7/28/ of 25 CPIA 8/4/ of 15 Composite Performance /24/ Mingle Analytics 45
46 Pulling it All Together From the CMS Proposed Rule Component Presented Quality 7/13/ of 50 Cost 8/24/ of 10 ACI 7/28/ of 25 CPIA 8/4/ of 15 Composite Performance /24/ Mingle Analytics 46
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