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MACRA: Breaking Down the Proposed Rule
Introductions Cindi Kincade Vice President, Consulting Solutions Lindsey Lanning Healthcare Informatics Coordinator Kathy Thompson Managing Consultant
MACRA: Breaking Down the Proposed Rule
Today s Webinar Overview of MACRA and the Quality Payment Program MIPS Quality Resource Use Clinical Improvement Activities Advancing Care Information MIPS Scoring and Payment Adjustments APMs How You Can Prepare
Latest News Possible Meaningful Use Changes for 2016 Hospital Outpatient Prospective Payment Proposed Rule released first week of July Proposes 90- day reporting period Proposed to change how measures are calculated Proposed to allow a hardship exemption for MU portion (ACI) if this is your first year of MIPS and have never done MU before All participants must do Modified Stage 2 in 2017 (Stage 3 not optional) Possible MACRA Delay Acting Administrator Andy Slavitt told the Senate Finance Committee Wednesday the agency would consider delaying the implementation of MACRA set to launch on January 1, 2017
MACRA Overview
MACRA Overview On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide.
Payment Prior to MACRA Medicare payment prior to MACRA was the Fee-for-Service (FFS) payment system, where clinicians are paid based on volume of services, not value. Each year, Congress passed temporary doc fixes to avert cuts in reimbursement. If MACRA did not repeal the Sustainable Growth Rate in 2015 there would have been a 21% cut in Medicare payments to clinicians.
Quality Payment Program The Quality Payment Program is part of a broader push towards value and quality. In January 2015, the Department of Health and Human Services announced new goals for value-based payments and APMs in Medicare. MACRA is the first step in achieving these goals, for which we are ahead of schedule and have already surpassed Goal 1 of 30% this year.
Quality Payment Program Overview The Quality Payment Program is a unified framework that includes two paths: Merit-Based Incentive Program (MIPS) Advanced Alternative Payment Models (APMs) Repeals Sustainable Growth Rate Formula Combines Meaningful Use, Physician Quality Reporting System, and Valuebased Modifier into the new Merit-based Incentive Payment System (MIPS)
MIPS vs. APM Participation The majority of practitioners will be subject to MIPS in 2017 versus APMs
Merit-Based Incentive Program
MIPS Overview The first performance period for MIPS would be from January 1, 2017 through December 31, 2017. MIPS combines the requirements of the Physician Quality Reporting System, the Value Modifier Program, and the Medicare EHR Incentive Program into a single, improved reporting program. Therefore, the last performance period for these separate reporting programs would be January 1, 2016 through December 31, 2016 The first payment year for MIPS will be 2019, based on the first performance period of 2017 MIPS aims to provide flexibility in choosing activities and measures that are most relevant to a practice and their scope of work The major components of MIPS includes: Eligibility Performance Categories Data Submission Payment Adjustments
Eligibility Eligible Professionals are now called MIPS Eligible Clinicians MIPS Eligible Clinicians are the Medicare Part B eligible clinicians affected by MIPS
Who is NOT Eligible? Also Note: MIPS does not apply to Medicaid. If you are a clinician who bills under both Medicare Part B and Medicaid and are ABOVE the low patient volume threshold then you will have to dual report or you will see penalties from Medicare.
MIPS Categories MIPS allows Medicare clinicians to be paid for providing high quality, efficient care through success in four performance categories: Cost/ Resource Use (formerly VM) Quality (formerly PQRS) Clinical Practice Improvement Activities (new) Advancing Care Information (formerly MU)
MIPS Categories: Quality
Key Changes from PQRS Requirements PQRS required 9 measures across 3 domains, whereas MIPS quality requires 6 measures with no domain specification Scoring Performance on measures and credit received will be put towards an overall score instead of a pass/fail methodology CAHPS CAHPS is no longer required for groups of 100 or more ECs, however bonus points can be earned for reporting CAHPS
Reporting There are about 250 total measures and 189 of them are ambulatory measures. NextGen supports: 55 with EHR reporting 95 with registry reporting 11 ambulatory cross cutting measures 10 outcomes measures NextGen also currently supports some specialty measure sets
Quality Category Takeaways Quality will count as 50% of your MIPS score in 2017 MIPS Quality Measures must be captured January 1, 2017- December 31, 2017 and submitted to CMS by March 30, 2018 Submission standards depend on size of group, specialty, and if you are reporting individually An EC s score will be based on performance, and the EC is not required to report data it is collected automatically
MIPS Categories: Cost
Cost measures: Cost Measures Total per capita cost for all attributed beneficiaries Medicare spending per beneficiary (MSPB) Additional episode-based measures Removes current total per capita cost measures for four condition-specific groups (COPD, CHF, CAD and DM)
Other Key Changes from VM Value Modifier Minimum 125 cases to be reliably measured Measure is adjusted for inpatient DRG and other factors with a separate adjustment applied for specialty composition of group practice No episodes used for payment Proposed MIPS Cost Category Proposed to reduce the number of cases to 20 Removed the specialty adjustment and modified the way individual cases are aggregated for a single score 41 proposed clinical episodes TIN attribution Individual TIN/NPI and group TIN levels for attribution
Reporting If an EC is assessed in all other MIPS categories as an individual EC they are monitored by NPI/TIN rather than just TIN and are measured based on cases specific to their practice, rather than all cases attributed to the group TIN If an EC is participating in group reporting they will be monitored using the group TIN under which they report
Cost Category Takeaways Resource Use or cost is 10% of the MIPS score in year one The category score will be calculated based on Part B claims, which means there is no reporting or attestation required All resource use measures are weighed equally, and there is no minimum number of measures required
MIPS Categories: Clinical Practice Improvement Activities
Subcategories
CPIA Reporting In year 1, all MIPS eligible clinicians or groups must designate a yes/no response for activities on a CPIA inventory For third party submission MIPS ECs or groups will tell their health IT vendor (QCDR or qualified registry) which CPIAs have been performed and they will submit on their behalf
CPIA Category Takeaways CPIA is 15% of the MIPS score in year one Certified PCMH gives full credit, participating in an APM gives half credit There are over 90 activities to choose from found in Table H of the proposed rule MIPS ECs need to reach 60 pts Some activities count for 10 points others 20 points CPIA activities must take place over at least a 90-day period during the performance year Partial credit will be awarded if total points < 60 Fewer activities are required for small, rural, HPSA, and non-patient facing providers
Certified PCMH Must be a Certified PCMH Recognized certifying bodies: The Accreditation Association for Ambulatory Health Care (AAAHC) The National Committee for Quality Assurance (NCQA) PCMH recognition The Joint Commission Designation The Utilization Review Accreditation Commission (URAC)
MIPS Categories: Advancing Care Information
ACI Scoring The overall ACI score is made up of a base score and a performance score for a maximum of 100 points A Security Risk Analysis must be performed in order to receive ANY credit if it is not you will automatically receive a 0
Base Score The Base Score is 50 percentage points of the total advancing care information category To receive the base score, ECs must provide the numerator/denominator or yes/no for each objective and measure ECs would be required to report on six objectives and their measures for the base score, the objectives are:
Base Score Models Base Score Models based on what version of CEHRT one is using Modified Primary and Alternate Proposals Intended for eligible clinicians still using 2014 Edition CEHRT in 2017 Follows the modified Stage 2 objectives/measure Option is for 2017 only The difference between the primary and alternative proposals is the inclusion of CPOE and CDS
Performance Score The performance score accounts for 80 percentage points towards the total Advancing Care Information category score ECs select the measures that best fit their practice from the following objectives:
MU v ACI Past Requirements for the Medicare EHR Incentive Program One-size-fits-all every object reported and weighed equally Requires across-the-board levels of achievement or thresholds, regardless of practice or experience Measurement emphasizing process Disjointed and redundant with other Medicare reporting programs No exemptions for reporting New Proposal for Advancing Care Information Category Customizable clinicians can choose which categories to emphasize in their scoring Flexible. Allows for diverse reporting that matches clinician s practice and experience. Measurement emphasizing patient engagement and interoperability Aligned with other Medicare reporting programs. No need to report redundant quality measures. Exemptions for reporting for clinicians in: Advanced alternative payment models First year with Medicare Have low Medicare volumes
Hardship and Exclusions No more exclusions By excluding from MIPS those clinicians who do not exceed the low-volume threshold we believe exclusions for most of the individual advancing care information measures are no longer necessary. The additional flexibility afforded by the proposed advancing care information performance category scoring methodology eliminates required thresholds for measures and allows MIPS eligible clinicians to focus on, and therefore report higher numbers for, measures that are more relevant to their practice. There is a hardship exemption offered to MIPS ECs facing a significant hardship If 2017 was the first year they would have attested to MU, they can file a hardship exemption for only the ACI portion if the proposed rule is finalized without change.
MIPS Timeline 2017: 1 st Performance Period July 2017: 1st Feedback report 2018: Analysis and Scoring January- February: Reporting and Data Collection July: 2 nd Feedback Report July: Targeted Review Based on 2017 MIPS Performance 2019: 1 st MIPS Payment Adjustments in effect
Reporting Options Eligible Clinicians can participate in MIPS as an individual or as a group A group, as defined by taxpayer identification number (TIN), would be assessed as a group practice across all four MIPS performance categories Note: If a PA, NP, or other eligible clinician bills under another EC s NPI, then that PA/NP/etc. would not be subject to MIPS
MIPS Data Submission- All Categories
MIPS Scoring and Payment Adjustment
Scoring Breakdown A single MIPS composite performance score will factor in performance in the 4 weighted performance categories on a 0-100 point scale. The MIPS Composite Performance Score (CPS) will be compared to the MIPS performance threshold to determine the adjustment percentage the EC will receive
Overview of MIPS Categories Scoring
Quality Scoring
Cost Scoring
CPIA Scoring
ACI Scoring
Scoring Steps
Payment Adjustments Table provided by NextGen Healthcare
Adjustment Breakdown
Payment Adjustment Changes Important change: Payment adjustment exclusion for the specialty codes listed below has been removed: Anesthesiology (05) Diagnostic Radiology (30) Interventional Radiology (94) Nuclear Medicine (36) Pathology (22) These are now included
Important Points All eligible clinicians above the performance threshold will be eligible to receive positive payment adjustment There is no requirement that a certain number of ECs must receive a negative adjustment Benchmarks will be known in advance However to get incentives you must submit data, if not you will get 0 performance and a negative adjustment
Alternative Payment Models
Advanced APM Eligible APM entities participate in eligible APMs that: Require the use of certified EHR technology, Provide for payment for covered professional services based on quality measures comparable to measures under the MIPS performance category, and Bear financial risk for monetary losses under the APM that are in excess of a nominal amount or are medical homes expanded under the Center for Medicare and Medicaid Innovation
Advanced APM Models The list of models included in the proposed rule as Advanced APMs are: Comprehensive ESRD Care Model Comprehensive Primary Care Plus (CPC+) Medicare Shared Savings Program- Track 2 and Track 3 Next Generation ACO Model Oncology Care Model Two- Sided Risk Arrangement (available in 2018) Other payer APMs will be available in 2019 Commercial payer ACOs
Qualifying APM Providers Under MACRA, qualifying APM participants are eligible for incentive payments In the years 2019 to 2024, providers qualifying for the APM track will receive a 5% annual lump-sum bonus on MPFS payments Providers must meet increasing thresholds for the percentage of their revenue they receive through eligible APMs For instance in 2019-2020: 25% of Medicare revenue must be received through eligible APMs Qualifying Providers (QPs) are excluded from MIPS
APM Scoring Standard
MACRA Timeline
Key Takeaways The Quality Payment Program changes the way Medicare pays clinicians and offers financial incentives for providing high value care Medicare Part B clinicians will participate in the MIPS, unless they are in their 1 st year of Part B participation, become QPs through participation in Advanced APMs, or have a low volume of patients Payment adjustments and bonuses will begin in 2019 The final rule is expected by November 1, 2016 MACRA makes NO CHNAGES to 2016 Meaningful Use
How will this affect me?
Preparing for Success
Preparation Questions: Quality Did you successfully report PQRS? Did you focus on your CQMs and did you align them with your PQRS measures? How are you reporting? What measures are you reporting on? Do they match any offered under the MIPS Quality category?
Preparation Questions: Resource Use How did you do on VM? Do you know what VM is? Are you seeing a payment adjustment? Do you know if you are seeing a payment adjustment? Do you know how to review your QRURs? Enterprise Identity and Management System (EIDM) account required to access QRURs at https://portal.cms.gov
Preparation Questions: ACI Did you successfully report Meaningful Use in 2015 or previous years? Did you take advantage of the hardship in 2015 rather than attest? Are you prepared for a full year of attestation in 2016? Have you recently ran your HQM reports? Are there any measures you are close to not passing? After running HQM reports would you pass MIPS ACI category today?
Preparation Questions: CPIA Have you looked at Table H in the proposed rule? Are you currently participating in any activities listed right now? Are you a PCMH? Are you thinking about being a PCMH?
By failing to prepare, you are preparing to fail. - Benjamin Franklin
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Questions Lindsey Lanning Healthcare Informatics Coordinator llanning@itentive.com 224-220-5621 Kathy Thompson Managing Consultant kthompson@itentive.com 224-220-5531 Cindi Kincade Vice President, Client Solutions ckincade@itentive.com 224-220-5575
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