Brown, Cynthia_Cynthia.pdf · 7/19/17 1 Cynthia Brown VP, Government Affairs QPP Requirements for 2017 and Proposed Changes for 2018 2017 AAMSE Annual Conference July 28, 2017

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Cynthia Brown VP, Government Affairs

QPP Requirements for 2017 and Proposed Changes for 2018

2017 AAMSE Annual Conference July 28, 2017

© 2017 American Medical Association. All rights reserved.

Some general observations •  QPP created by MACRA is complex

•  More than a “replacement for the SGR”

•  Most of the “new” requirements are really revisions to the legacy FFS programs •  Impacts of legacy programs not universally experienced or understood

•  One goal of MACRA was to simplify administrative processes for physicians •  Many improvements in effect now

•  Additional improvements proposed for 2018

•  CMS has noted its aim is participation, not penalties

•  There is more work to do •  Improving the practice environment is a high priority for the AMA

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MACRA established two Medicare paths for physicians •  MACRA was designed to offer physicians a

choice between two payment pathways:

•  A modified fee-for-service model (MIPS)

•  New payment models that reduce costs of care and/or support high-value services not typically covered under the Medicare fee schedule (APMs)

•  In the beginning, most are expected to participate in MIPS

•  CMS named the physician payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA) law the Quality Payment Program (QPP)

APMs

MIPS

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QPP eligibility •  Eligible clinicians include:

•  Physicians

•  Physician Assistants

•  Nurse practitioners

•  Certified Registered Nurse Anesthetists

•  Clinical Nurse Specialists

•  Exempt clinicians include:

•  Those in first year billing Medicare

•  Participants in qualifying advanced APMs

•  Those meeting a low-volume threshold

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Reasonforexclusion No.TIN/NPIsremaininga7erexclusion(2018es=mates)

AllMedicarecliniciansbillingPartB

1,548,022

MIPSineligibletypes -233,289

Newlyenrolled -81,954

Lowvolume -585,560

QualifyingAPMparLcipants

-74,920

EligibleclinicianswhocanreportunderMIPS

572,299(37%)


Low-volume threshold exemption •  2018 proposal: Clinicians with annual Medicare allowed charges of $90,000 or less, or 200 or

fewer Medicare patients exempt from QPP •  Threshold increased from 2017 levels of $30,000/ 100 patients

•  Eligibility calculated by CMS •  Based on 12-month historical data (previous September-August)

•  Includes Part B drug costs, but not Part D

•  Visit www.qpp.cms.gov, enter your NPI to check eligibility for the current year

•  Low-volume physicians who are members of a group that exceeds the threshold must still participate in MIPS

•  Exempted physicians receive annual fee schedule updates, but no bonuses or penalties

•  CMS considering a MIPS opt-in provision beginning in 2019 performance year for those below just one low-volume threshold criterion (to become eligible for bonuses)

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www.qpp.cms.gov

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Accommodations for small practices

Ineffectfor2017

• PickyourpacetransiLon• Low-volumethreshold$30K/100paLents

• ReducedIAreporLng• $100millioningrantsfortechnicalassistanceviaQIOsandregionalhealthimprovementcollaboraLves

Proposedfor2018

• Low-volumethresholdraisedto$90K/200paLents

• ReducedIAreporLngconLnued• TechnicalassistancegrantsconLnued

• Virtualgroupscreated• ACIhardshipexempLonforsmallpracLces

• BonuspointsaddedtofinalscoreforsmallpracLces

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CMSesLmates81.2%ofEPsinpracLcesof1-15willexperienceposiLveorneutraladjustmentsin2020

Merit-based Incentive Payment System (MIPS)

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MIPS components and proposed scoring weights

QualityReporLng(wasPQRS)60%

Cost(wasValue-basedModifier)0%

AdvancingCareInformaLon

(wasMU)25%ImprovementAcLviLes15%

MIPS

MIPS aims:

•  Align 3 current independent programs

•  Add 4th component to promote improvement and innovation

•  Provide more flexibility and choice of measures

•  Retain a fee-for-service payment option

2018 Proposed Rule:

•  Would postpone original plan to reduce Quality component to 50% and increase Cost component to 10%.

•  For 2019 (2021 adjustments) weights will be 30% for Quality, 30% for Cost, 25% for ACI, 15% for Improvement Activities

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MIPS Quality component

LegacyPQRS

• 9measures• Pass/failapproach• 2%penalLes,nobonuses• Measuresfallacrossspecificdomains

• Onecrosscuangmeasurerequired

2017Quality

• 6measures(oronespecialtyset)

• ParLalcreditallowed• Flexibilityinmeasurechoice• Nodomainsorcross-cuangmeasuresrequired

• BonusesforelectronicreporLng

• 50%thresholdforsuccessfulmeasurereporLng

2018Proposal

• 2017modificaLonsretained• Completenessthresholdtoberaisedto60%in2019

• Newandmodifiedspecialtymeasuresetsavailable

• Crosscuangmeasuresremovedfrommostsets(exceptIM,FM,Ped)

• FavorablescoringforsmallpracLces

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MIPS ACI requirements LegacyMeaningfulUse

• 100%scorerequiredonallmeasures

• Includedredundantqualitymeasures

• IncludedproblemaLcCPOE,CDSmeasures

• Full-yearreporLng(althoughtwicereducedinQ4)

2017ACI

• Pass/failreplacedwithbaseandperformancescoring

• 4basemeasuresrequired,parLalcreditallowedforperformancemeasures

• Fewermeasures;noCPOE,CDC,orclinicalqualitymeasures

• Performancescorethresholdseliminated

• 90dayreporLng• BonusesavailableforregistryreporLnganduseofCEHRTinIA

2018Proposal

• 2017improvementsretained• Willnotrequireupdatesto2015CEHRTin2018

• MayreportmodifiedMUstage2measuresinsteadofadvancingtonewstage3measures

• ACIperformancescoreweightedat0%forASC-basedclinicians

• IncreasedopportuniLesforbonuspoints

• HardshipexempLoncreatedforsmallpracLces

• NewhardshipexempLonforhospital-basedcliniciansforperformancecategory

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MIPS Cost component (calculated by CMS via claims)

Legacyvalue-basedmodifier

• Includedbothqualityandresource-usemeasures

• Doublejeopardy;PQRSfailurecountedagaininpenaltycalculaLons

• PoorriskadjustmentpenalizedthosetreaLngsickestpaLents

• Nostatutorylimitsonpenaltyrisk

2017Cost

• Focussolelyoncost• Double-jeopardyeliminated• 10episodegroupsfinalized,othersbeingtestedandrefined

• PlanstorefineairibuLonmethods

• PartDdrugsnotincludedincalculaLon

• 0%MIPScomponentweighin2017;reportsontotalcostspercapitaandMedicarespendingperbeneficiaryprovidedFYIonly

2018Proposal

• 2017improvementsmaintained

• Maintaining0%weightfor2018

• 10episodegroupstobereplacedwithmeasuresdevelopedwithmoreclinicalinput

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MIPS Improvement Activities (no legacy program)

2017IAs

• IntendedtogivecreditforpracLceinnovaLonsthatimproveaccessandquality

• Over90acLviLesacross8categories• Norequiredcategories• 40pointsneededforlargerpracLces(2-4acLviLes)

• 1-2acLviLesrequiredforgroupsof15orless,ruralandHPSApracLces,non-paLentfacingspecialists(mostphysiciansfallintothesecategories)

• ParLcipaLoninMIPSAPMsandcerLfiedPCMHsearnfullscorein2017

2018proposed

• About20moreacLviLesbeingproposed,includingNDPPreferrals

• CPC+addedtotheMIPSAPMmodelsthatearnfullscorein2018

• 50%ofpracLcesiteswithinaTINmustberecognizedasPCMHstoreceivefullIAcredit

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MIPS reporting period requirements

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2017

• 90-fullreporLngforallcomponents• MinimalreporLngunderPickYourPaceprovidesexempLonfrompenalLes• MaximumbonusesandpenalLes+4%/-4%,plusannualupdate• ExcepLonalperformancebonusesupto10%possible• Paymentadjustmentstakeeffectin2019

2018proposal

• 12-monthreporLngforQualitycomponent• Costcomponentcalculatedover12monthsforinformaLononly• 90-dayreporLngforACIandIA• MaximumbonusesandpenalLes+5%/-5%,plusannualupdate• ExcepLonalperformancebonusesupto10%possible• Paymentadjustmentstakeeffectin2020


Pick Your Pace: 2017 transitional performance reporting options • ReportsomedataatanypointinCY2017todemonstratecapability• 1qualitymeasure,or1improvementacLvity,or4requiredACImeasures• NominimumreporLngperiod• NonegaLveadjustmentin2019

MIPSTesLng

• SubmitparLalMIPSdataforatleast90consecuLvedays• 1+qualitymeasure,or1+improvementacLviLes,or4requiredACImeasures• NonegaLveadjustmentin2019• PotenLalforsomeposiLveadjustment(<4%)in2019

ParLalMIPSreporLng

• MeetallreporLngrequirementsforatleast90consecuLvedays• NonegaLveadjustmentin2019• MaximumopportunityforposiLve2019adjustment(<4%)• ExcepLonalperformerseligibleforaddiLonalposiLveadjustment(upto10%)

FullMIPSreporLng

• NoMIPSreporLngrequirements(APMshavetheirownreporLngrequirements)• Eligiblefor5%advancedAPMparLcipaLonincenLvein2019

AdvancedAPM

parLcipaLon

TheonlyphysicianswhowillexperiencenegaLvepaymentadjustments(-4%)in2019arethosewhoreportnodatain2017

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Performance thresholds and payment adjustments

2017

• Thresholdforbonuses/cutssetat3points

• PotenLaladjustmentsin2019+/-4%

• ThresholdforexcepLonalbonussetat70points

• AddiLonalperformancethresholdstartsat0.5andgoesupto10%

2018proposal

• Thresholdforbonuses/cutswouldbe15points• RecommendaLonsbeingsoughtonhigherorlowerthreshold

• PotenLaladjustmentsin2020+/-5%

• ThresholdforexcepLonalbonusremains70points

• ComplexpaLentbonus1-3points

• SmallpracLcebonus5points

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15pointexamplesfromCMS:•  ReportallImprovement

AcLviLes•  MeetACIbasescoreand

report1qualitymeasurethatmeetsdatacompletenesscriteria

•  MeetACIbasescoreandonemediumweightedImprovementAcLvity

•  Submit6qualitymeasuresthatmeetdatacompletenesscriteria


Bonus points

Currentlyavailable

• Upto5%ACIbonusforreporLngtooneormoreaddiLonalpublichealthandclinicaldataregistries

• Upto10%ACIforreporLngcertainImprovementAcLviLesviaCEHRT

• AddiLonalQualitypointsfor:(1)electronicreporLng;(2)reporLngonCG-CAHPSsurveymeasure;(3)addiLonaloutcomeorhighprioritymeasure

Proposedfor2018

• ForcomplexpaLents,upto3pointsavailablebasedonHierarchicalCondiLonsCategory(HCC)riskscore

• ConsideringwhethertobasecomplexpaLentadjustmentondualeligiblesinsteadorinaddiLon

• SmallpracLcebonusof5pointsaddedtofinalscoreforpracLcesof15orfewer

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2019 and 2020 penalty risks compared

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Legacyprograms

Poten=aladjustments

PQRS -2%

MU -5%

VBM -4%ormore*

Totalpenaltyrisk

-11%ormore*

BonuspotenLal(VBMonly)

Unknown(budgetneutral)*

MIPSfactors 2019scoring 2020proposal

Qualitymeasurement 60%ofscore Nochange

AdvancingCareInfo. 25%ofscore Nochange

Cost 0%ofscore Nochange

ImprovementAcLviLes

15%ofscore Nochange

Totalpenaltyrisk Maxof-4% Maxof-5%

BonuspotenLal Maxof4%,pluspotenLal10%forhighperformers

Maxof5%,pluspotenLal10%forhighperformers;bonuspointsavailableforcomplexpaLents,smallpracLces

*VBM 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.

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New proposal: Improvement scoring for Quality and Cost •  MACRA calls for rewarding improvement as well as overall score

•  Second year of QPP provides first opportunity

•  For Quality: proposal would base improvement scoring on rate of improvement in your total Quality score

•  Greater improvement results in more points; lower performance in transition year could produce highest improvement score

•  Up to 10 points available

•  For Cost: proposal would base score on statistically significant changes at the measure level

•  Proposal would continue to weight cost at 0% in 2018; comments sought on methodology only

•  In neither category could improvement score raise total over 100%

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New proposal: Virtual Groups •  Must include at least 2 solo and small group (<10) clinicians

•  No restrictions on locations or specialties or number of TINs that may participate

•  MIPS Virtual Group Identifiers will be created by CMS; individual clinicians identified through combination of VGI, TIN, and NPI

•  All practices in virtual groups must be eligible for MIPS •  A participating group may include a clinician who is not eligible (e.g., does not meet LVT), but group as a

whole must be eligible

•  All eligible clinicians under the TIN would be included in the virtual group

•  Requirements •  Formal written agreement between each virtual group member (model agreement being developed)

•  Must elect by December 1 prior to performance year

•  For 2018, propose allowing election prior to final rule, in mid-September

•  May only participate in one virtual group during a performance period

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Potential advantages of virtual groups •  Share burden of MIPS reporting

•  Combine credit for MIPS categories like Improvement Activities

•  Combine patient counts in quality reporting for more reliable sample sizes

•  Maintaining independence

•  Take advantage of group reporting options

•  But non-patient facing MIPS clinician and small practice, rural area, and HPSA designation would not apply

•  CMS will provide technical assistance

•  Challenges:

•  IT infrastructure lacking

•  Different EHR systems

•  Workflow and staff training changes

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New facility-based measurement proposal

•  Voluntary options for facility-based clinicians who have at least 75% of their covered provisional services provided in hospital inpatient or emergency department setting

•  Scoring based on Hospital Value Based Purchasing Program

•  For group option, 75% of eligible clinicians must beet eligibility criteria as individuals

•  Scores derived using data at facility where clinician treats highest number of Medicare patients

•  CMS seeking comments on-opt in vs. opt-out process

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Alternative Payment Models (APMs)

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APMs participation options as outlined by CMS

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•  “Advanced” APMs have greatest risks and offer potential for greatest rewards

•  Qualified Medical Homes have different risk structure but otherwise will be treated as Advanced APMs

•  MIPS APMs receive favorable MIPS scoring

•  Physician-focused APMs are under development

AdvancedAPMs

andQualifiedMedicalHomes

MIPSAPMs

Physician-focused

APMsTBD

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CMS criteria for Advanced APMs •  50% of participants must use certified EHR technology

•  Must report and at least partially base clinician payments on quality measures comparable to MIPS

•  Bear “more than nominal risk” for monetary losses

•  Defined as the lesser of 8% of total Medicare revenues or 3% of total Medicare expenditures

•  2018 proposal would extend standard for 2 more years

•  Primary Care Medical Home models with < 50 clinicians have different standards (2.5%-5% total Medicare revenues increased over time)

•  2018 proposed rule would allow Round 1 CPC+ practices to exceed 50 clinicians

•  2018 risk reduced to 2% of total Medicare revenues; delays increase to 5% by one year

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AdvancedAPMs

EHRuse

QualityRepor=ng

FinancialRisk


MACRA incentives for Advanced APM participation

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Modeldesign• APMshavesharedsavings,flexiblepaymentbundlesandotherdesirablefeatures

Bonuses• In2019-2024,5%bonuspaymentsmadetophysiciansparLcipaLnginAdvancedAPMs

Higherupdates• Annualbaselinepaymentupdateswillbehigher(0.75%)forAdvancedAPMparLcipantsthanforMIPSparLcipants(0.25%)starLng2026

MIPSexempLon• AdvancedAPMparLcipantsdonothavetoparLcipateinMIPS(modelsincludetheirownEHRuseandqualityreporLngrequirements)


2017 Advanced APMs

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ComprehensiveESRDCareModel

(AporLonof37ESCOswillqualify)

ComprehensivePrimaryCarePlus

(2,893pracLces)

MedicareSharedSavingsTrack2(6ACOs,1%oftotal)

MedicareSharedSavingsTrack3(36ACOs,8%oftotal)

NextGeneraLonACOModel(currently45)

OncologyCareModelTrack2(AporLonof190pracLcesqualify)

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Proposed All-Payer APM combination option •  Available beginning 2019 performance year

•  Option only for clinicians who fail to become qualified APM participants under the Medicare only APM pathway

•  Payers must submit applications to CMS, beginning for performance year 2019 •  Medicaid, Medicare Advantage, and CMMI multi-payer models may submit arrangements; will be

expanded to commercial payers and other non-Medicare/Medicaid plans in future years

•  Model requirements similar to Medicare advanced APMs

•  50% of clinicians must use CEHRT and clinician payments based on quality measures similar to MIPS.

•  Must be a Medicaid Medical Home model similar to a Medicare expanded PCMH model or require participants to bear more than nominal financial risk.

•  Qualifying All-Payer participant determination period will differ, January 1through through June 30 (vs. August 31 for Medicare APM determinations)

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MIPS APMs Criteria

• APMenLtyparLcipatesinamodelunderanagreementwithCMS• EnLtyincludesatleastoneMIPSeligibleclinicianonaparLcipantlist• PaymentincenLvesbasedonperformanceoncostandqualitymeasures(eitheronenLtyorindividualclinicianlevel)

2017qualifiedmodels• MSSPTrack1counts

AdvancedAPMbenefitsdonotapply• MustparLcipateinMIPStoreceiveanyfavorablepaymentadjustments• Donotqualifyfor5%APMbonuspayments2019-2024• Noteligibleforhigherbaselineannualupdatesbeginning2026

Otherbenefits• 2017MIPSAPMsreceivefullImprovementAcLviLescredit(couldvaryinfutureyears)• ModelshavesimplifiedMIPSreporLng• APM-specificrewards(e.g.,sharedsavings,guaranteedpayments)• EligibleforannualMIPSbonuses,whichconLnueindefinitely(vs.6yearsfor5%APMbonuses)

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Physician-focused payment model proposals

•  11-member Physician-Focused Payment Model advisory committee created to review stakeholder APM proposals, make recommendations to HHS Secretary

•  11 proposals submitted to PTAC, of which 3 were reviewed at April meeting:

1.  Project Sonar submitted by the Illinois Gastroenterology Group and SonarMD, LLC

2.  The COPD and Asthma Monitoring Project submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group Inc. of Sacramento, CA

3.  The ACS-Brandeis Advanced APM submitted by the American College of Surgeons

•  17 additional Letters of Intent submitted with future proposals expected

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Resources

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AMA resources on quality payment program

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www.ama-assn.org/MACRAorwww.ama-assn.org/qpp-reporLng

Linksandtabsto:•  10StepMIPSAcLonPlan•  PickYourPacevideoandinstrucLons•  DetailedinfoonMIPSandAPMs•  STEPSForwardmodules•  AMAPaymentModelEvaluator•  PodcastsfromReachMD•  Linkstospecialtyandstatesociety

MACRAresources•  Linktoqpp.cms.gov•  OtherMACRAresources,links,and

newsstories,aswellasAMAcommentsandrecommendaLons


Resources on www.ama-assn.org/qpp-reporting

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VideodemoforminimalreporLngunder2017PickYourPace•  Step-by-stepguide

onreporLngonequalitymeasureviaclaims

•  PDFofstepsavailable

•  Sampleclaimformincluded

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Documents

Brown, Cynthia_Cynthia.pdf · 7/19/17 1 Cynthia Brown VP, Government Affairs QPP Requirements for 2017 and Proposed Changes for 2018 2017 AAMSE Annual Conference July 28, 2017