You Down with QPP? Daniel Collins Director of Finance Orlando Health Physician Enterprise

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1 You Down with QPP? Daniel Collins Director of Finance Orlando Health Physician Enterprise

2 Why Was the QPP created? Source:

3 What is QPP? Quality Payment Program Created from bi-partisan legislation named MACRA (Medicare Access CHIP and Reauthorization Act) in Approved 92 to 8 in the Senate. Approved 392 to 37 in the House. 3-in-1 Approach PQRS, VM, MU QPP

4 Who Does It Apply To? MD s ARNP s & PA s DO s Clinical Nurse Spec Medicare Part B Reimbursement 2017 Low-Volume Threshold: - $30,000 Billed or Patients Seen

5 Timeline Source: Page 4

6 2 Step Music Ciara & Missy Elliott 1, 2 Step Unk 2 Step Remixed by T Pain Dave Matthews Band Two Step Brad Paisley Wrapped Around History The Original Two-Step John Phillip Souza - "Washington Post March" in Now used in both country-western and hip-hop dancing

7 2 Different Tracks Merit Based Incentive Payment System 4 Weighted Categories: 1) Quality 2) Advancing Care Information 3) Continuing Practice Improvement Activities (NEW) 4) Cost Limited Risk Advanced Alternative Payment Model 3 Criteria: 1) Use certified EHR Technology 2) Base payments on quality measures comparable to the MIPS Quality category. 3) Bear financial risk for monetary losses Examples: MSSP Tracks 2 & 3 Next Generation ACO CPC Plus

8 Participation Estimates Participation Type 48.1% 14.4% 32.5% Not Eligible Type of Clinician Low-Volume Clinician Advanced APM 5% MIPS Source: MACRA: Final Rule; Vizient Southeast; Page 18

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10 MIPS Quality Select Six (6) Individual Measures (> 270 measures) One (1) Measure = Outcome Measure Reduced from a required nine (9) measures for PQRS Mandatory All-Cause Readmission Population Based Measure CMS will choose six best scoring measures if report more than the required number of measures. All-Payer Data Required (change from only Medicare) Data Completeness 50% of denominator for measure Extra Credit Receive bonus for each measure reported using CEHRT (up to 10%) Receive bonus for each Additional High Priority Measure (up to 5%)

11 MIPS ACI Applies to all clinicians, instead of only physicians (under MU) No longer all-or-nothing measure threshold reporting; clinicians are scored on participation and performance 5 Required Performance Measures: Security Risk Analysis E-Prescribing Provide Patient Access Send Summary of Care Request/Accept Summary of Care Additional credit for submitting up to 9 measures

12 MIPS CPIA Brand NEW value category introduced by MIPS Minimum selection of one (1) CPIA activity required, with additional scoring for more activities 93 eligible activities Automatic full credit for PCMH; ½ credit for APM participation with opportunities for full credit Most activities have medium weight 10 points Some activities have high weight 20 points Max credit obtained by achieving 40 points

13 MIPS Cost CMS calculates based on claims submitted NO reporting requirements for providers. Feedback provided for 2017 Performance Period on 10 episodebased measures. Episode measures will change in future years and may be utilized in scoring. Weighting was originally intended to gradually increase for cost and decrease for quality. UPDATE: For 2018, CMS has increased the weight from 0% to 10%. 2 Measures in 2018 Performance Period Total per Capita Costs for all attributed beneficiaries Medicare Spending per Beneficiary.

14 Quality 6 individual quality measures; Score = 48 All-Cause Readmission measure = 8.5 All measures submitted using CEHRT = 5 Final Score = 61.5/70 X 60% = 52.7 ACI All 5 measures submitted; Base Score = 50 Scoring of 5 Measures = 33 Final Score = 83/100 X 25% = Cost No Required Reporting 2 Measures Weighted for 2018 Final Score = 0/0 X 0% = 0 CPIA 1 High-Weight Activity Reported = 20 1 Medium-Weight Activity Reported = 10 Final Score = 30/40 X 15% = Total Composite Performance Score (CPS) CPS over 70 are eligible for the exceptional performance adjustment ($500M pool) CPS = 84.7

15 MIPS Weighting Changes Source:

16 Small Practices will Lose Source: MACRA.pdf

17 MIPS in Hip Hop Trivia Macklemore ICE-T Pitbull Snoop Dogg

18 Advanced APMs New approaches to paying for medical care through Medicare that incentivizes quality & value. QPP does NOT change how current APM s function. It only creates extra incentives! Incentives for Participation: 1) Do not have to participate in MIPS 2) 5% lump sum payment adjustment bonus in payment years ) Higher fee schedule updates starting in MUCH HIGHER DOWNSIDE RISK to Clinicians Requires significant infrastructure

19 Advanced APMs Criteria 1) Certified EHR Technology At least 50% of eligible clinicians must use CEHRT Increases to 75% after Year 1 (2017) A penalty or reward may be assigned based on the degree of CEHRT usage among clinicians. 2) Base Payment on MIPS Comparable Quality Measures No minimum number of measures Must have at least one (1) outcome measure 3) Clinicians Bear Risk for Monetary Losses Certain magnitude required > 8% of the average estimated Parts A and B revenue of the participating APM entity

20 Qualified Participants (QPs) Payment Amount Method 25% of Medicare Part B payments received through the Advanced APM Patient Count Method 20% of patients receiving Medicare Part B professional services received through the Advanced APM *Only QP s are eligible for Incentives from participation in an Advanced APM

21 Late-Comers August 31, 2017 Last snapshot date to qualify in an Advanced APM as a QP. If a provider joins an Advanced APM after this date, they will have to report separately via the MIPS route. Issue will only occur in CY17 reporting, an additional 12/31 snapshot is added in future years.

22 Advanced APM Examples Shared Savings Programs (Tracks 2 & 3) ACO Track 1+ Model Next Generation ACO Comprehensive ESRD Care Comprehensive Primary Care Plus Oncology Care Model (two sided risk track, available 2018) * NOT MSSP Track 1 (no downside risk)

23 Source: Slide 30

24 Finish The Lyric Shawty had them Apple Bottom Jeans, Boots with the. "To the To the Everything you own in the box to the. Fur In The Ayer Nelly Left Irreplaceable - Beyonce

25 Finish The Lyric And still I see no. Can t a brother get a little peace? It s war on the streets and a war in the Middle East. Changes Changes 2Pac

26 2017 to 2018 Final Rule Changes 2017 Low Volume Threshold $30K or 100 Part B patients Virtual Groups Not a submission option Quality Data Completeness 50% (if not met, 3 points) 2018 Low Volume Threshold $90K or 200 Part B patients Virtual Groups Can be made up of solo practitioners and groups of 10 or fewer eligible clinicians Quality Data Completeness 60% (if not met, 1 point)

27 2017 to 2018 Final Rule Changes 2017 Category Weights Quality = 60% ACI = 25% CPIA = 15% Cost = 0% Improvement Scoring for Quality & Cost None 2018 Category Weights Quality = 50% ACI = 25% CPIA = 15% Cost = 10% Improvement Scoring for Quality & Cost Quality = up to 10 points Cost = up to 1 point

28 2017 to 2018 Final Rule Changes 2017 Performance Threshold 3 points Example: 1 Quality Measure submission (does not need to meet data completeness) Performance Period 90 days to be eligible for positive payment adjustment 2018 Performance Threshold 15 points Example: 5 Quality Measure submissions that meet data completeness requirement Performance Period Full year to be eligible for positive payment adjustment

29 MIPS Elimination? MedPAC is looking to eliminate the MIPS track of the QPP and replace with a voluntary value program Focus on population-based measures from claims data or surveys. Eliminate reporting burden of MIPS Withhold 2% of Medicare payment for all providers Join voluntary value program or Advanced APM or forfeit amount

30 MIPS Elimination? March 2018 October 2017 MedPAC publicizes draft recommendations to repeal MIPS December 2017 MedPAC finalized its proposed recommendation to repeal MIPS January 2018 MedPAC voted 14-2 to get rid of MIPS and replace with the Voluntary Value Program (VPP). MedPAC will present its proposal to Congress.

31 Orlando Health Medical Group Case Study

32 OHMG Initial Strategy 1) Form a QPP Core Group with Key Stakeholders/Decision Makers Meet monthly 2) Gather Past Quality and Resource Use Reports (QRURs) 3) Choose a Third Party Vendor to perform data submission to CMS 4) Educate physicians, practice management, and executive admin

33 OHMG Structure OHMG Specialist TINs Primary Care TINs Large Specialist TIN Oncology Specialist TIN Small Specialist TIN Small PCP TIN Large PCP TIN Small PCP TIN 400 Physicians 50 Physicians 10 Physicians 10 Physicians 100 Physicians 10 Physicians

34 OHMG Specialists TINs 1) Large Specialist TIN Lower Quality Scores on QRUR 2) Oncology Specialist TIN Higher Quality Scores on QRUR 3) Small Specialist TIN Smaller physician entity of only 10 providers

35 OHMG Specialists TINs Large Specialist TIN Oncology Specialist TIN 2015 Annual Quality and Resource Use Reports

36 OHMG Specialists Strategy Combine the Oncology Specialist TIN into the Large Specialist TIN Report Oncology quality metrics that received perfect scores under PQRS The TIN combination is effective 10/1/17. 6 month lead time to communicate to Managed Care payers & CMS, Accounting, Legal, Regulatory, Providers, Billing Office, Foundation, and HR. Allows for 90 consecutive day reporting

37 OHMG Primary Care TINs 1) Participates in an MSSP ACO MSSP Track 1 ACO (non-advanced ACO) 2) Gained Patient Centered Medical Home status Full credit for Continuing Practice Improvement Activities category 3) Top performing MSSP ACO s in the country in

38 OHMG Primary Care Strategy 2019 No longer will be able to participate in MSSP Track 1. Considering MSSP Track 3 or Next Generation ACO Combine specialist TINs into MSSP Track 3 or Next Generation ACO. May increase PMPM cost based on patient attribution to providers PCP attribution trumps Specialist Reduces reporting burden

39 OHMG Primary Care Strategy Receive 0.75% Fee Schedule increases in 2026 and beyond Take advantage of +5% Advanced APM bonus for all Provider TINs.

40 Resources CMS Quality Payment Program Education Website Join the Transforming Clinical Practice Initiative 140,000 clinician practices over the next four years Designed to support sharing, adapting, and further developing quality improvement strategies along with adherence to the Quality Payment Program Quality Payment Program Service Center M-F from 8 AM - 8 PM Dan Collins, Director of Finance - OHMG Daniel.Collins@orlandohealth.com (321)

41 YOU DOWN WITH QPP?

42 Questions?