A PRIMER FOR PRIMARY CARE

MACRA / MIPS Transition to value-based payment in Medicare A PRIMER FOR PRIMARY CARE Robert Resnik MD MBA

Source: CMS

What does MACRA Accomplish? Repeals the Sustainable Growth Rate (SGR) Formula Changes the way that Medicare rewards clinicians for value over volume Streamlines multiple quality programs under the new Merit-Based Incentive Payments System (MIPS) Provides bonus payments for participation in eligible alternative payment models (APMs)

Source: CMS

Source: CMS

Composite Performance Score (CPS) MIPS defines four categories of eligible clinician performance These categories determine a MIPS composite performance score (CPS) of up to 100 points Relative weights CY2017 performance year and associated CY2019 payment year Quality (50%) Advancing Care Information (ACI, renamed from Meaningful Use) (25%) Clinical Practice Improvement Activities (CPIA) (15%) Resource Use (10%)

MIPS PERFORMANCE MEASURES 2019 2020 2021 Quality 50% 45% 30% Advancing Care 25% 25% 25% Resource Use 10% 15% 30% Clinical Practice Improvement 15% 15% 15% Quality PQRS Resource Use Value based payment modifier ADVANCING CARE EHR Incentive Clinical Practice Improvement Care Coordination, Population management, Expand Access, patient safety, beneficiary engagement

Source: CMS Billing up to $10,000 Treating up to 100 patients

Source: CMS

Source: CMS

Source: CMS

Source: CMS

Nominal Financial Risk A threshold to trigger losses no greater than 4% Shared losses become APM responsibility when exceeding expected expenditures from 0% to 4%. Example Expected spending threshold is $10,000,000 APM responsible for losses once spending exceeds $10,000,000 or responsibility for losses triggered once spending exceeds up to $400,000 APM responsible for all losses over $400,000 or 4% of threshold If APM does not start paying back losses say until 5% or after exceeding the target threshold by $500,000 then not considered nominal risk

Nominal Financial Loss Loss sharing of at least 30% APM must be responsible for losses of at least 30% or greater If total losses are $1 million the APM must be responsible for $300,000 or more It total losses are $ 1million and the APM is only responsible for $250,000 (25%) then APM does not qualify Maximum possible loss is at least 4% If total losses are $10,000,000 APM must be responsible for $400,000 or more in losses to be a qualified APM

Source: CMS

Comprehensive Primary Care Plus The Comprehensive Primary Care Plus (CPC+) program qualifies as an Advanced APM under the MACRA proposed rule. This program does not meet risk criteria but does meet the or standard to qualify as a Medical Home Model

Source: CMS

MACRA milestones 2016 Last performance year for PQRS, meaningful use, and VBPM Proposed rule outlining MIPS and APM criteria expected in the spring 2017 First performance measurement year for MIPS 2018 Separate PQRS, meaningful use, and VBPM programs / penalties sunset on Dec. 31 2019 First MIPS payment adjustments applied, maximum +4% (phases up to + 9% in 2022) First APM performance assessed, 5% bonus payments made to qualifying participants

2019 (first year) penalty risks compared Prior Law 2019 adjustments PQRS -2% MU -5% VBPM Total penalty risk Bonus potential (VBPM only) -4% or more* -11% or more* Unknown (budget neutral)* *VBPM was in effect for 3 years before MACRA passed, and penalty risk was increased in each of these years; there were no ceilings or floors on penalties and bonuses, only a budget neutrality requirement. MIPS factors Quality measurement MU Resource use Clinical improvement activities 2019 scoring 50% of score 25% of score 10% of score 15% of score Total penalty risk Max of -4% Bonus potential Max of 4%, plus potential 10% for high performers

MIPS Financial Impacts MACRA defines two types of financial impacts for clinicians participating in MIPS: A small, annual inflationary adjustment to the Part B fee schedule The inflationary adjustment is an annual +0.5% increase for the payment years CY2016 to CY2019, which is the first payment year for MIPS under the QPP. The inflationary adjustment resumes in CY2026 and thereafter, where MIPS eligible clinicians will receive a +0.25% annual adjustment

MIPS Financial Impacts MIPS payment adjustments (incentives or penalties) based on the MIPS 100-point Composite Performance Score (CPS) The potential MIPS incentives and penalties via payment adjustments are much more substantial than the inflationary adjustments The calculated CPS could result in incentives reaching 37% of Medicare Part B payments by the fourth year of the program, while maximum penalties grow to 9%:

COMPOSITE PERFORMANCE SCORE (CPS) Each performance category is scored separately Each as a percentage of maximum possible performance within that category Category-level scores are weighted by the appropriate category weight Weights are then summed to produce the CPS. 1. Quality (50%) 2. Advancing Care Information (ACI, renamed from Meaningful Use) (25%) 3. Clinical Practice Improvement Activities (CPIA) (15%) 4. Resource Use (10%)

Penalties and Incentives Program Performance Year Medicare Part B Payment Adjustment Year Maximum -% Medicare Part B Payment Adjustment Maximum +% Medicare Part B Payment Adjustment PQRS/VBM 2016 2018-4% penalty +4%*X incentive MIPS 2017 2019-4% penalty +4%*X incentive MIPS 2018 2020-5% penalty +5%*X incentive MIPS 2019 2021-7% penalty +7%*X incentive MIPS 2020 2022-9% penalty +9%*X incentive CMS budget-neutral program: Incentive offset by penalties For MIPS, x capped at 3.0 plus a 10% "exceptional performance bonus" For Performance Year 2020, up to 9% x 3.0 + 10% = 37% bonus

MIPS Adjustment Example for Year 2017 If a clinician has a CPS of zero, the penalty assessed is 4%, the maximum penalty. If a clinician earns a CPS of 100 points, then the incentive is 4%*X (adjustment multiplier) X is a budget-neutrality factor CMS calculates to set the total MIPS incentive pool in dollars equal to the total MIPS penalties Keeps the program budget neutral.

Source: CMS

Source: CMS

Performance Threshold Each performance year corresponds to a payment year For 2017 the performance year corresponds to a payment year of 2019 Each performance year CMS sets a performance threshold (PT) This is the number of points at which a provider earning PT points receives 0% adjustment to their Medicare Part B payments. Every incremental point above the PT results in progressively more incentives Each point the CPS is below the threshold, the clinician is assessed a proportional penalty until a floor (for 2017-4%) is reached. Very few eligible clinicians will experience a zero payment adjustment Essentially, every CPS point translates directly into higher or lower reimbursement

The performance threshold is determined annually as the mean or median of the MIPS scores for all eligible providers in a prior period For the initial two payment years (2019 and 2020), the PT will be based on historical MIPS scores For payments in 2019 and 2020 the PT will be determined by a combination of historical performance on measures and activities related to PQRS, MU, VBM, and possibly other factors as determined by CMS.

MIPS TRACK EXTRA BONUS CMS has set aside about $500 million for the first six years of the program to reward exceptional performers in the MIPS track. CMS has defined these providers are in the 25 th percentile of possible composite performance scores (CPS)compared to the normal performance threshold.

Exceptional Performance Bonus - Example Normal performance threshold =64 Range above the performance threshold would be 65-100. 25th percentile of those possible values would be (¼ * (100-64) Exceptional Performance Threshold = (.25*64) + 64 = 73. Providers with CPS 73 or > eligible for a bonus from the $500 million pool. Sliding scale is used based on score to determine percentage of bonus Providers at 73 = factor of 0.5 percent Providers at 100 = factor of 10 percent maximum additional adjustment factor. CMS will announce the exceptional performance threshold and normal performance threshold prior to the performance period.

Budget Neutrality X Factor Theoretically, the budget-neutrality X factor could reach a cappedvalued of 3.0 This will happen should there be many more clinicians penalized than receiving incentives in a given year For the CY2017 performance year, the base adjustment could reach as high as 4% x 3.0 = 12%, This will result in an even higher maximum incentive of 12% base + 10% exceptional performance bonus = 22%. Similarly, the maximum possible incentive for the CY2020 performance year could reach 9% x 3.0 + 10% = 37%.

MIPS Adjustment/Bonuses 32 Based on composite performance score EPs may receive an upward, downward or no payment adjustment Exceptional Performers see significant opportunities for additional bonuses/adjustments on top of traditional MIPS incentives Available in 2019 through 2024

CPS Scores in lowest ¼ or 0-25% percentile always receive the maximum negative adjustment for 2017 (-4%) CPS Scores in lowest 25-49 percentile receive graduated reduction between maximum negative and zero for 2017 ( 0 to -4 %) CPS Scores between 51-74 percentile >0% <=2% for each point above performance threshold CPS Scores at or above 75% or top 25% graded adjustment between approx. >2% to 4% plus bonus performance graded from 0.5(close to 75% to 10% at 100%. Can max out at 4%+10% or 14% for 2019 Remember budget neutrality factor can increase up to 3X or 3 x4% + 10% =22%

What is the MACRA impact on fees? RVU relative value unit Medicare physician fee schedule factor MIPS adjustment factor

Medicare physician fee schedule factor Each year this factor is updated 2015 it was 35.9335 2016 it is 35.8279 Misvalued codes = -.77% RVU budget neutrality = -.02% Annual MACRA update =.50% none in 2020-25 Overall this resulted in -0.29% change Starting 2026 (.25%) for MIPS and.75% for APM

Source: CMS

Source: CMS

Source: CMS

COMPOSITE PERFORMANCE SCORE (CPS)

Individual vs. Group Rating MIPS clinicians can choose to be rated as an individual-clinician basis Or as a group of clinicians (defined by a tax ID) The choice applies across all performance categories. CPS could be significantly impacted depending upon whether that clinician is rated individually or inherits the CPS earned by an entire group. MIPS clinicians in Medicare ACOs must be rated as a group MIPS clinicians do not have the choice to be rated as individuals

Quality Initial weight is 50% MIPS essentially adopts the quality measures and reporting methods from the PQRS and VBM programs. Although there are some changes to the PQRS reporting methods for the most part the quality reporting methods remain the same. For the registry, EHR, and qualified clinical data registry (QCDR) reporting methods, a clinician must typically select a minimum of six PQRS measures These can be across any combination of quality domains 1. one measure is a cross-domain-cutting measure 2. one measure is an outcome measure

Key Changes from Current Program (PQRS): Reduced from 9 measures to 6 measures No domain requirement Emphasis on outcome measurement

Clinician or group picks PQRS 6 measures CMS calculates Two additional measures for individual clinicians or groups <10 Three additional (for groups with 10+ clinicians) population These are (claims-based) quality measures Each PQRS and population quality measure is assigned a possible 10 quality points. Groups < 10 providers have maximum 80 quality points available Groups >= 10 providers have maximum 90 quality points available Each measure earns up to 10 points Points are calculated based upon the percentile-basis performance of that measure relative to national peer benchmarks

PQRS Examples #1. Diabetes: Hemoglobin A1c Poor Control #5. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) #6. Coronary Artery Disease (CAD): Antiplatelet Therapy #7. Coronary Artery Disease (CAD): Beta-Blocker Therapy Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) #8. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) #39. Screening for Osteoporosis for Women Aged 65-85 Years of Age #41. Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older #48. Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older #50. Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older #52. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy

If the Quality measure has a 69% measure rate then that measure would earn 8 out of 10 possible points. Decile Sample Quality Measure Benchmarks Possible Points Decile 1 0-6.9% 1.0-1.9 Decile 2 7.0-15.9% 2.0-2.9 Decile 3 16.0-22.9% 3.0-3.9 Decile 4 23.0-35.9% 4.0-4.9 Decile 5 36.0-40.9% 5.0-5.9 Decile 6 41.0-61.9% 6.0-6.9 Decile 7 62.0-68.9% 7.0-7.9 Decile 8 69.0-78.9% 8.0-8.9 Decile 9 79.0-84.9% 9.0-9.9 Decile 10 85.0-100% 10

Example For an individual provider or group < 10 Add together the total points for each of the eight quality categories If each of the eight measures earned eight points each Total points = 8 x 8 = 64 out of possible 80 64/80 = 80% For 2017 Performance Year Quality has weight of 50% 50% x 80% x 100 = 40 points added to overall CPS

MIPS grants bonus points for certain quality reporting activities. 1. Two bonus points for reporting each extra outcome measure beyond the one required 2. Two bonus points for reporting the patient experience measure (CAHPS for MIPS survey counts as one patient experience measure) 3. One bonus point for reporting each extra high priority measure The total bonus points are capped at 5% (of the denominator of the quality score) Example 5% of 80 = 4 max bonus points in the previous example

Example Assume four bonus points were earned Quality score would increase to (64+4)/80 = 85% Quality weighted at 50% results in 42.5 CPS points (40 pt w/o bonus) Bonus points are not counted in the quality score denominator It is possible to get a quality score of greater than 100% If > 100% the quality score is truncated back down to 100%.

Advancing Care Information (ACI) Initial weight 25% MIPS has renamed MU to ACI No longer all-or-nothing compliance program Now a continuous scoring system MU measure rates are compared to benchmarks just like with quality MU program may have low compliance threshold Provider scoring 15% given same credit at another scoring 90% Under the ACI scoring system the provider scoring 15% will receive 2/10 points Provider scoring 90% will receive 10/10 So a historically high MU achiever may end up having a low ACI score if MU performance rates do not improve.

Source:CMS

The ACI category defines 131 ACI performance points that can be earned: Base Score: 50 points for reporting either a non-zero numerator or a yes, as applies, for selected measures from the MU Modified Stage 2 or MU Stage 3 measure sets Performance Score: Up to 80 points for performance on eight measures per the decile scoring scale Bonus Point: Up to 1 bonus point for reporting to an additional public health registry The ACI percentage score is calculated by dividing the number of ACI points by 100 The percentage is capped at 100% if more than 100 ACI points be earned For example, 80 ACI points equates to 80% ACI performance score Weighted score for CPS = 80% (ACI performance) x 25% (ACI category weight) x 100 = 20 CPS points contributed by ACI.

Source:CMS

Source:CMS

Clinical Practice Improvement Activities (CPIA) Maximum points in CPIA category is 60 Report any combination of medium-weight activities (worth 10 points each) and/or high-weight activities (worth 20 points) each If a clinician is non-patient-facing, a small practice with 15 or fewer professionals, a practice in a rural area, or a practice in a geographic Health Professional Shortage Area (HPSA), then all activities are worth 30 points each - 2 Activities = 60 points If a clinician participates in an APM, the clinician earns 30 points and can earn additional points as described above If a clinician is in certain medical home models, the clinician automatically earns the full 60 points

Patient Centered Medical Home A patient-centered medical home will be recognized if it is: A nationally recognized accredited patient-centered medical home A Medicaid Medical Home Model Medical Home Model. The NCQA Patient-Centered Specialty Recognition will also be recognized, which qualifies as a comparable specialty practice. Nationally recognized accredited patient-centered medical homes are recognized if they are accredited by: (1) The Accreditation Association for Ambulatory Health Care (2) The National Committee for Quality Assurance (NCQA) PCMH recognition (3) The Joint Commission Designation (4) The Utilization Review Accreditation Commission (URAC)

CPIA CATEGORIES Expanded Practice Access: expanded practice hours telehealth services participation in models designed to improve access to services Population Management: participation in chronic care management programs participation in rural and Indian Health Services programs participation in community programs with other stakeholders to address population health Use Qualified Clinical Data Registry (QCDR) to track population outcomes Care coordination: Use of a QCDR to share information timely communication and follow up participation in various CMS models designed to improve care coordination implementation of care coordination training implementation of plans to handle transitions of care active referral management

CPIA CATEGORIES Beneficiary Engagement: Use of EHR to document patient-reported outcomes Providing enhanced patient portals Participation in a QCDR that promotes the use of patient engagement tools Use of QCDR patient experience data to inform efforts to improve beneficiary engagement Patient Safety and Practice Assessment Use of QCDR data for ongoing practice assessments and patient safety improvements Use of tools such as the Surgical Risk Calculator Achieving Health Equity: Seeing new and follow-up Medicaid patients in a timely manner Use of QCDR for demonstrating performance of processes for screening for social determinants Emergency Response and Preparedness: Participation in disaster medical teams or participation in domestic International humanitarian volunteer work Integrated Behavioral and Mental Health: Tobacco intervention and smoking cessation efforts Integration with mental health services

Source: CMS

There are currently 90 activities listed in the proposed ruling. Each activity is given a weight of either medium or high. CPIAs are weighted as high based on alignment with CMS national priorities Quality Innovation Network-Quality Improvement Organization (QIN/QIO) Comprehensive Primary Care Initiative An activity identified as a public health priority (such as emphasis on anticoagulation management or utilization of prescription drug monitoring programs).

Some examples of high-weighted activities (20 points) include: Beneficiary Engagement: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan. Access 24/7 practice access, with access to patient medical record; provision of same-day or next-day access to providers Patient Safety and Practice Assessment: Consultation of Prescription Drug Monitoring Program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days.

Examples of medium-weighted activities (10 points) include: Care Coordination: Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: Participate in a Health Information Exchange Use structured referral notes. Population Management: Participation in research that identifies interventions, tools, or processes that can improve a targeted patient population. Care plan : Engaging patients and family caregivers in developing a care plan and care priorities, documented in an EHR Initially, these activities must be conducted for a full 90 days during the performance year. A full list of proposed activities can be found on page 946 of the MACRA proposed rule.

Calculating the CPIA % score The CPIA percentage score is calculated by dividing the total CPIA points by 60. For example, 45 points would yield a 45/60 = 75% CPIA performance score CPIA is weighted at 15% 75% x 15% x 100 = 11.25 points

Resource Use - Weight Year 1-10% MIPS rates clinicians for Resource Use (Medicare costs of attributed patients) will be based on 40+ cost measures to account for differences among specialties. No separate reporting requirements for clinicians Measures are calculated based on claims collected by CMS. Measures can earn up to 10 points each on a percentile benchmark scale The percentage score is then multiplied by the Resource Use category weight (10% for the CY2017 performance year) to deliver the CPS points contributed. If provider earns eight points on each of two included cost measures. Resource Use points = (8+8)/20 x 10% x 100 = 8 CPS points.

Source: CMS

Example of Calculating a CPS (COMPOSITE PERFORMANCE SCORE) Assuming that the numerical examples used for the four categories as described above all apply to the same clinician, we can calculate a total CPS from the components: Quality = (56 of 80 points) x 50% weight x 100 = 35 CPS points ACI = (50 of 100 points) x 25% weight x 100 = 12.5 CPS points CPIA = (40 of 60 points) x 15% weight x 100 = 10 CPS points Resource Use = (14 of 20 points) x 10% weight x 100 = 7 CPS points Total CPS points = 35 + 12.5 + 10 + 7 = 64.5

MIPS will publish each eligible clinician s annual Composite Performance Score (CPS) and scores for each MIPS performance category within approximately 12 months after the end of the relevant performance year. Consumers will be able to see their providers rated on a scale of 0 to 100 and how their providers compare to peers nationally. This raises the level of transparency while releasing more specific data

MIPS APM Clinicians MIPS eligible clinician also participating in an APM and meeting certain additional requirements There are some special rules governing MIPS data submission for such a clinician. The MIPS Quality category may not require a separate data submission if the APM is already collecting quality data for CMS to analyze

MIPS APM clinician? Participation in an Alternative payment model (APM) APM includes only these payment models run by CMS (not by commercial payers): CMS Innovation Center Model (other than a Health Care Innovation Award) Medicare Shared Savings Program (MSSP ACOs) Demonstration under the Health Care Quality Demonstration Program Demonstration required by federal law The MIPS APM concept provides some relief to those APM clinicians who otherwise would be subject to the full range of MIPS requirements in addition to their APM obligations

Medicare Shared Savings Program MSSP Accountable care organization (ACOs) Track 1 (one-sided, incentive-only) Tracks 2 and 3 (two-sided) of MSSP All MSSP Tracks meet the criteria for MIPS APM entities. Track 1 is deemed non-advanced APM s Each provider MSSP Track 1 is subject to MIPS The ACO s MIP s eligible clinicians get some preferential treatment on scoring and data submission

What are the benefits of being a MIPS APM clinician? MIPS APM clinician benefits from special rules governing MIPS scoring and data submission These are designed to grant performance credit and reduce reporting burdens for APM MIPS eligible clinicians An APM provider who meets either the first-year-clinician or low-volume MIPS exemption is not subject to MIPS at all.

The rating of MIPS APM clinicians is based on the rating for their entire APM entity not the individual provider This is similar to how MIPS enables multiple clinicians billing through the same tax ID (TIN) to be rated for MIPS as a group There are some differences however: A MIPS APM entity may comprise of only a single MIPS eligible clinician (solo practice TIN in MSSP) MIPS normally requires at least two clinicians to be within a group of clinicians rated for MIPS as a group.

These providers do not inherit the MIPS performance of the entity as for MIPS normally, all clinicians billing through a TIN and choosing to be rated for MIPS as a group will inherit the MIPS composite performance score (CPS) earned by the group. A MIPS APM entity may be comprised of more than one unique participating TIN (ACO) MIPS normally has only one TIN is allowed per group of clinicians rated for MIPS as a group. A MIPS APM entity may include a participating TIN which contains clinicians billing through that TIN who do not participate in the MIPS APM entity

MIPS APM vs ADVANCED APM Different criteria to determine whether an APM is a MIPS APM vs an Advanced APM An Advanced APM may not include MIPS eligible clinicians on its participation list and, thereby, would not be deemed a MIPS APM

CMS requires reporting certain performance categories on an individual clinician basis For a MIPS APM CMS sums the associated measure values submitted for individual clinicians to derive the MIPS APM entity s group CPS. The entity s CPS becomes the MIPS eligible CPS as long as they are listed on the entity s list of participating clinicians as of December 31st of the performance year

Source: CMS

Medicare Shared Savings Program (MSSP) ACOs Quality: 50% weight - Requires group data submission via CMS Web Interface for the ACO s TIN (submitted on behalf of the entire ACO, not at the level of each TIN participating in the ACO) Resource Use: 0% weight (weight redistributed to CPIA and ACI categories as below) - Already evaluated by MSSP, so set to zero weight for MIPS. CPIA: 20% weight - Requires group data submission via allowed data submission methods for each TIN participating in the ACO. (15% weight for MIPS provider) The ACO s score is calculated as the average across TINs weighted by the number of MIPS eligible clinicians in each TIN. Any ACO participant TIN that is also deemed a patient-centered medical home or comparable specialty practice will receive the highest potential CPIA score. All other ACO participants TINs will receive a minimum of half the highest potential CPIA score. Advancing Care Information (ACI): 30% weight - Requires group data submission via allowed data submission methods for each TIN participating in the ACO, and the ACO s score is calculated as the average across TINs weighted by the number of MIPS eligible clinicians in each TIN. (25% MIPS)

It is important to understand ramifications of reduction of the MIPS Resource Use weight to 0% in all of the MIPS APM types Don t have to report in one category but now makes performance in each of other categories more important. Really consolidated to 3 categories

Next Generation ACOs Same as MSSP Quality (50% weight) Resource Use (0% weight) CPIA (20% weight) ACI (30% weight) Exception is that performance data for each MIPS eligible clinician, rather than for each ACO participant TIN, must be submitted to CMS. CMS averages all of the MIPS eligible clinician scores for each category to derive the category score for the ACO entity.

Clinicians that qualify currently to meet the requirements for the APM track cannot opt out of the APM track and into the MIPS track.

Notification of Track Officially providers may not know which track they fall into until 2018 when awaiting approval for the ADVANCED APM track So for performance year 2017 with payments in 2019 this could create some reporting issues. This could create some issues for Advanced APM s

Partial Qualifying APM Participants. APM organizations that participate in Advanced APM models, but have less than the required percentage of revenue at risk or patient counts 2019-2020 APM must have at least 20% but less than 25% of their Medicare payments tied to APM 2019-2020 APM must have at least 10% of their eligible Medicare patients tied to APM but not greater than 20% 2023 and beyond at least 50% but less than 75% of Medicare payments tied to APM 2023 and beyond must have at least 35% but less than 50% of Medicare patients tied to APM Partial APM do not qualify for APM Track Don t qualify for 5% bonus pay Can opt-in to MIPS and be judged just like other MIPS participants. If opt-out will not receive any payment adjustments for the year

Summary Previous year track does not dictate the next performance year track Each year providers will have a new opportunity to qualify for the APM track. By default any provider not on the APM track is assigned the MIPS track unless they are a first year Medicare provider or low volume Medicare provider. CMS has estimated that over 90%+ of providers will fall into MIPS track CMS has an estimate of 8-10% will be in the APM track

Quality - Summary Similar to PQRS Some measure will be claims based and calculated by CMS At present there will still be over 200 measures to choose from With over 80% of these being specific to specialists Providers only have to report on 6 measures vs current 9 measures under PQRS Bonus points for reporting on more than 6 measures Bonus points for using certified EMR technology

Cost /Resource Use- Summary Similar to Value Based Payment Modifier (VBPM) No changes to measures still on Part A and Part B with focus on per-capita cost for all beneficiaries and Medicare spending per beneficiary Expanded from 4 episode cost measures to over 40

Advanced Care Summary Builds on Meaningful Use Focus on expanding use of EMR Can report as group or individual NO longer all or nothing can get partial credit No longer requires reporting on clinical decision support and computerized clinical orders entry

Clinical Practice Improvement Activity- Summary New category that rewards physicians for practice improvement activities 90 activities in 9 categories Weighting Medium or High with associated point value difference Expanded Practice Access Beneficiary Engagement Achieving health equity Population Management Patient Safety

Reporting Requirements- Summary Providers can submit performance data as an individual, a group, or an APM entity. Must report same way across all four categories. If provider reports through an APM they must do so for all categories.

Part D Prescription Drugs MIPS only includes Part A and Part B (which includes some drug costs). There is a provision to include Part D in the future CMS is currently evaluating this option

Adding New Provider in Performance Year Payment adjustments are assigned at the level of the individual provider this is by TIN/NPI combination. New providers payments are based on prior-year performance at previous practice MIPS ties payment adjustments to the MIPS performance for the preceding 2 years. Providers practicing in multiple TIN s during performance year will receive a weighted score across all TIN s Provider joining in 2019 would be paid on their performance from 2017. Providers hired could bring in a positive or negative adjustment based on their previous performance

Medicare Advantage and MIPS For Performance years through 2019 there is no credit for MA patients Starting in 2021 (based on the 2019 performance year), CMS will allow providers to use other payer data to meet qualification for the Advanced APM model including Medicare Advantage Not all downside risk Medicare Advantage plans will qualify clinicians for the APM track in 2021. Consideration will also be given to the commercial alternative payment model must meet the same criteria that CMS uses to assess CMS-run APMs. CMS has also considered that full capitation risk arrangements would meet this Other Payer Advanced APM financial risk criterion.

APM MIPS ( MSSP Track 1) Get composite score of group Still have to do some TIN/Individual reporting No guaranteed bonus Get some preferential scoring but if PCMH get higher score Only rated on three categories rather than 4 in MIPS not Resource Use as this is evaluated by MSSP Dependent more on performance of group in fewer categories Have potential bonus if MSSP generates savings

Advanced APM No MIPS Get 5% bonus and elevated payments starting 2025 (0.75% increase over 0.25%) Have potential for savings and losses At some point improving cost becomes difficult and may lead to losses or dropping out of program Many ACO s have not generated savings.

MIPS SCORES and PATIENT RISK Risk adjustment included in both the quality and resource use categories. Quality category outcomes measures typically have risk adjustment embedded in their calculation. Resource use category will utilize risk adjustment standards from the VBPM. This will be adjusted for clinical factors and demographics. There was also be risk adjustment for Medicare spending per beneficiary (MSPB) measure. The possibility will exist that CMS may introduce risk adjustment for socioeconomic status on quality measured and resources use.

Initial Performance Threshold for 2019 There will be a proposed to pre-set the Performance Threshold (PT) using historical provider performance This will be derived from the current physician pay-forperformance programs. For 2019 CMS will use 2014 and 2015 PQRS, VBPM, and MU data to determine the PT CMS will make this performance threshold available prior to 2017 for 2019 payments

MIPS is a revenue neutral program Winners = Losers This is similar to the Value-Based Payment Modifier

Maximum Payments 2019-12% (including bonus 4% max) 2020-15% (including bonus 5% max) 2021-21% (including bonus 7% max) 2022-27% (including bonus 9% max) Budget neutrality adjustment 10% exceptional performance payout 3 X upward multiplier Ensure payout = penalties

MIPS Conversion Factor- Summary Each year provider gets MIPS payment adjustment factor + or - % Based on Composite Performance score from 0-100 CMS will set a performance threshold (PT). Providers scoring above the PT will receive a bonus in the way of a positive MIPS adjustment factor Providers scoring below the PT will be subject to a penalty, or negative MIPS adjustment factor. MIPS payment adjustments will change every year. Not cumulative if -2% in 2019 and -4% in 2020 the overall factor in 2020 will still be -4% There will always be a two year lag in performance and payment

5 things to do now to prepare for the January 2017 start of MIPS Make sure all providers in your TIN understand MIPS and MACRA Estimate your MIPS score using your current MU, PQRS and VBM scores Optimize MU & PQRS/VBM Quality to maximize the MIPS score (comprise 75% of the CY2017 MIPS score) Evaluate staff, resources and organizational structure Identify CY2016 deadlines impacting CY2017 MIPS, e.g. Medicare Shared Savings Program Track 2/3 ACO or NCQA PCMH application deadlines to gain MIPS exemptions or points

APM entities anticipating having MIPS APM clinicians preparation 1. Determine whether your APM entity qualifies as a MIPS APM entity according to the eligibility rules. 2. Estimate the number of MIPS eligible clinicians in the MIPS APM entity 3. Estimate the MISP eligible clinicians Medicare Part B annual payments at risk under MIPS 4. This will help determine the amount of exposure your entity has to the MIPS APM scoring and data submission rules. 5. Estimate the MIPS composite performance score (CPS) for your MIPS APM entity 6. Begin to optimize the MIPS categories with performance gaps or high weightings

GOOD LUCK Questions rresnik@mindspring.com