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2/25/2019
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MACRA, MIPS & APMSDR. ELISABETH VOLPERT DNP, APRN, FNP-C
FIRST THING IS FIRST
• I Have No Disclosures
OBJECTIVES
• Explain the definition and purpose of value-based reimbursement:
• The Medicare Access and CHIP Reauthorization Act (MACRA)
• Merit-Based Incentive Payments System (MIPS)
• Alternative payment models (APMs)
• Explain who value-based reimbursement applies to.
• Explain the 2019 updates.
• Explain how to increase reimbursement by meeting benchmarks.
• Clinical workflows shown to aid providers in achieving benchmarks.
• Explain alternative office visits that can increase reimbursement, improve outcomes and achieve
benchmarks.
TERMS
• APM – Alternative payment models
• CMS – Centers for Medicare and Medicaid Services
• EHR – Electronic Health Record
• MACRA - Medicare Access and CHIP Reauthorization Act
• MIPS - Merit-Based Incentive Payments System
• MU – Meaningful Use
• PFS – Physician Fee Schedule
• PQRS - Physician Quality Reporting System
• QP - Qualifying APM Participant
• SGR – Sustainable Growth Rate
• VM - Value-Based Payment Modifier
A STROLL DOWN MEMORY LANE
• Late 1950’s 75% Americans had private insurance• AMA was against national health insurance
• 1965 Medicare Part A &B• Fear physicians would decline to see pt with this coverage
• Development of fee for service
• 1973 HMO• Fee for service, increase procedures and decrease preventative care
• 1997 Sustainable Growth Rate (SGR)• Restrict Medicare Part B
• April 16,2015 MACRA • CMS named the physician payment system created by MACRA the Quality Payment Program (QPP)
CMS’ Program History. Centers for Medicare and Medicaid Services. June 2018. https://www.cms.gov/About-CMS/Agency-Information/History/index.html
A STROLL DOWN MEMORY LANE
• 2015- The Medicare Access and CHIP Reauthorization Act terminated the Sustainable Growth
Rate (SGR) formula.
• If SGR would have continued it would have resulted in significant payment reductions for clinicians
participating in Medicare. CMS’ Program History. Centers for Medicare and Medicaid Services. June 2018. https://www.cms.gov/About-CMS/Agency-Information/History/index.html
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MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT (MACRA)
• The Department of Health & Human Services established a goal to convert from fee-for-
service Medicare payments to value-based payment models.
• A form of reimbursement that links payments for care to the quality of care provided.
• Incentivizes providers with rewards providers for both efficiency and effectiveness of care.
MACRA. Centers for Medicare and Medicaid Services. September 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
SO WHAT IS MACRA?
• Quality Payment Program that:
• repeals the SGF
• changes the way that Medicare rewards clinicians for value over volume
• streamlines multiple quality programs under the new MIPS
• gives bonus payments for participation in eligible APMs
MACRA. Centers for Medicare and Medicaid Services. September 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
MACRA’S GOAL
• CMS Center for Clinical Standards and Quality Director, Kate Goodrich, MD, stated MACRA’s goal:
“To have a single, unified program with flexibility. The new Merit-Based Incentive Payment System
(MIPS) will offer that flexibility and not be a one-size fits all program. The new rule will reimburse
physicians based on four factors.”
MACRA GOALS
• Improve patient outcomes and reduce overall costs the healthcare system.
• Expect in 2019 to:
• Reduce administrative costs by $87 million
• $843 million over the next 10 years
• Save 21 million clinician hours
CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-
what-you-need-know
MACRA REQUIRES CMS TO IMPLEMENT AN INCENTIVE PROGRAM
• MIPS
• a performance-based payment adjustment
through MIPS
• Most participate
• Reduce costs of care and/or support
high-value services
• Not typically covered under the Medicare
fee schedule (APMs)
• APMs
• earn a Medicare incentive payment for
sufficiently participating in an innovative
payment model
MACRA. Centers for Medicare and Medicaid Services. September 2018.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-
MIPS-and-APMs.html
WHO CAN PARTICIPATE IN QUALITY PAYMENT PROGRAMS
• Nurse Practitioners
• Some Physicians
• Physician Assistants
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetists
• Physical Therapist
• Occupational Therapist
• Speech Therapist
• Audiologist
• Clinical psychologist
• Registered dietitian or nutritional professionals
CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-
final-2019-mips-rules-are-here-what-you-need-know
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WHO IS IN
Bill more than $90,000 a year in allowed charges for covered professional services.
Provide care to 200 of fewer Medicare beneficiaries a year
Provide 200 or fewer covered professional services under the PFS
Low-volume threshold criteria. CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-
know
WHO IS OUT
• If you do not exceed all three you are excluded from MIPS. • You have the opportunity to “opt-in” if you meet or exceed one or two of the low-volume threshold
criteria.
or or
CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-know
Enrolled in Medicare for the first time in 2018
Participate in an APM and a QP
Participate in an APM and are a Partial QP
AM I IN OR OUT?
• To verify if you’re eligible to participate in MIPS, enter your 10-digit National Provider
Identifier in the status tool at:
https://qpp.cms.gov/participation-lookup
MIPS EHR incentive
Program
VM
PQRSMIPS
4 MIPS AREAS
• Quality (45%)
• Promoting Interoperability (25%)
• Cost (15%)
• Improvement activities (15%)
MACRA Basics Merit-based Incentive Payment System (MIPS). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/mips.html
MIPS PERFORMANCE MEASURES
• Quality• 6 measures to submit.
Example: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
• 12 months
• Promoting Interoperability• Example: Electronic prescribing, MU
• 90 days
• Cost• No submission required
• 12 month
• Clinical practice improvement activities • Example: Care coordination
• 90 days MACRA Basics Merit-based Incentive Payment System (MIPS). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-
management/payment/medicare-payment/mips.html
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QUALITY MEASURES
• Quality Payment Program website
https://qpp.cms.gov/mips/explore-measures/quality-measures
• Changes for 2019
• 8 new quality measures
• 26 measures removed
MIPS REPORTING
• January 1, 2019 to December 31, 2019
• Submit March 31, 2020
• Feedback July 2020
• Adjustment January 1, 2021
SCORE
0-----10-----20-----30-----40-----50-----60-----70-----80-----90-----100
78.72
MACRA Basics Merit-based Incentive Payment System (MIPS). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/mips.html
HOW MUCH IS PAYMENT ADJUSTED
• 2019 +/- 4%
• 2020 +/- 5%
• 2021 +/- 7%
• 2022 +/- 9%
MACRA Basics Merit-based Incentive Payment System (MIPS). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/mips.html
APM
• Another payment model to replace fee-for- services
• Larger organizations - have the infrastructure and resources to implement change
• To qualify as an eligible Advanced APM:
• Use of certified EHR technology
• Base payment must be based on quality measures (comparable to MIPS)
• There also needs to be financial risk
• or operate as a medical home (meeting CMS criteria)
MACRA Basics Advanced Alternative Payment Models (AAPMs). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/aapms.html
QUALIFYING APM PARTICIPANTS
• Clinicians meeting the criteria for this track are excluded from MIPS.
• Receive a lump sum bonus payment of 5% 2019-2024
• Receive a high fee schedule
MACRA Basics Advanced Alternative Payment Models (AAPMs). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/aapms.html
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PARTIAL QUALIFYING APM PARTICIPANTS
• Meet a reduced threshold
• Participants can choose whether or not to participate in MIPS
MACRA Basics Advanced Alternative Payment Models (AAPMs). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/aapms.html
WHO IS IN FOR APMS
• Organizations that are automatically qualified to APMs:
• Comprehensive ESRD Care Model
• Medicare Shared Savings Program -Track 2 and 3
• Next Generation ACO Model
• Comprehensive Primary Care Plus (CPC+):
• Oncology Care Model Two-Sided Risk Arrangement
MACRA Basics Advanced Alternative Payment Models (AAPMs). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/aapms.html
SUMMING UP SO FAR
• MACRA
• MIPS vs APM
• More types of clinicians will need to report
• Opt-in and opt-out
• New measures
• Increase in penalties for clinicians who do not report or fail to meet minimum threshold (30 points)
• Increase payment adjustments
SO WHY?
WHAT IS NEXT
• New Value-Based Bundled Payment Model
• Announced in January 2018, and will be from October 1, 2018 through December 31, 2023.
• Participants can earn additional payments
• Bundled payments for additional clinical episodes
• outpatient episodes
• Preliminary target prices
• The amount CMS will pay for episodes of care under the model
• Participants assume risk for patients’ healthcare costs
• If ALL expenditures for a beneficiary’s episode of care are less than a spending target
• If the expenditures exceed the target price, the participant must repay money to Medicare
CMS Announces Participants in New Value-Based Bundled Payment Model. Centers for Medicare and Medicaid Services.
October 2018. https://www.cms.gov/newsroom/press-releases/cms-announces-participants-new-value-based-bundled-
payment-model
HOW DO I SUCCEED
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HOW CAN WE IMPROVE OUTCOMES
• Controlled High Blood pressure
• Proper assessment
• Logs
• Shorter follow up
HOW CAN WE IMPROVE OUTCOMES
• Hemoglobin A1C Control (<9%)
• Chart audit
• Shorter follow up
• Portal or telephone messages
HOW CAN WE IMPROVE OUTCOMES
• Colorectal Cancer Screening & Breast Cancer Screening
• Chart audit
• Cologuard and FIT
• Permanent deferral
HOW CAN WE IMPROVE OUTCOMES
• Influenza Immunization & Pneumonia Vaccination
• Chart audit
• Patient immunization cards in exam rooms
• Permanent deferral
HOW CAN WE IMPROVE OUTCOMES
• Diabetic Eye Exam
• Falls Screening
• BMI Screening and Follow Up
HOW MANY CLICKS ARE TOO MANY?
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DOES IT REALLY MATTER?
• Payment is there!
• Linked to NPI
REFERENCES
CMS’ Program History. Centers for Medicare and Medicaid Services. June 2018. https://www.cms.gov/About-CMS/Agency-Information/History/index.html
MACRA. Centers for Medicare and Medicaid Services. September 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
CMS Final 2019 MIPS Rules Are Here - What You Need to Know. Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-know
Mdinteractive. November 2018. https://mdinteractive.com/mips-blog/cms-final-2019-mips-rules-are-here-what-you-need-know
MACRA Basics Merit-based Incentive Payment System (MIPS). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/mips.html
MACRA Basics Advanced Alternative Payment Models (AAPMs). American Academy of Family Physicians. February 2019. https://www.aafp.org/practice-management/payment/medicare-payment/aapms.html
CMS Announces Participants in New Value-Based Bundled Payment Model. Centers for Medicare and Medicaid Services. October 2018. https://www.cms.gov/newsroom/press-releases/cms-announces-participants-new-value-based-bundled-payment-model
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