Introduction to the Quality Payment Program · MACRA shifts the payment equation from the services that are only one part of the clinician’s job to the overall work of the clinician

Quality Payment Program Train-the-Trainer

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Introduction to the Quality Payment Program

October 20, 2016


Closed Captioned Recording

Please note: A closed captioned recording of this webinar will be available in the next few days.

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Learning Objectives

By the end of this lesson, you will be able to:

• Explain the Quality Payment Program origins and goals

• Communicate role of “collaboration”

• Discuss program:- Changes

- Benefits

- Participation

- Support

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Icebreaker

Describe the Quality Payment Program in one word

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Presenter

The intent of this slide would be to pose the question to engage the learners and create a feeling of ease that we want them to interact with us throughout the training. Based upon your current understanding, what is one word you would use to describe the Quality Payment Program?


Origins of the Quality Payment Program

MACRA

Medicare Access and CHIP Reauthorization Act of 2015

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Presenter

The Quality Payment Program began as a component of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). But first, what is MACRA? Let’s take a moment to quickly review this regulation.



• Bipartisan Legislation

• Replaces Sustainable Growth Rate (SGR)- SGR established in 1997 to control cost of Medicare payments to clinicians

- SGR “doc fixes” would cut >20% of Medicare FFS payments in coming years

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Presenter

MACRA was a bipartisan piece of legislation passed by huge margins in the Senate 92-to-8 and in the House 392-to-37. Congress passed the MACRA legislation to replace the highly flawed Sustainable Growth Rate formula, which ended 13 years of last-minute legislative fixes, also known as “doc fixes,” to statutory requirements that would have reduced fee-for-service Medicare payments to clinicians by more than 20 percent in the coming years. Those who practice medicine and care for our beneficiaries were fearful of these looming reductions in Medicare payments.


Origins of the Quality Payment ProgramMACRA:

• Builds off Affordable Care Act coverage expansions and improvements to access

• Increases focus on quality of care and value of care delivered– Clear intent that outcomes needed to be rewarded, not number of services

– MACRA shifts payment equation from number of services provided to overall work of clinicians

• Moving toward patient-centric health care system– Delivers better care

– Smarter spending

– Healthier people

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Presenter

There was also clear intent that in today’s health care system, we often do not pay clinicians for the best care that they can give. We reward based on the number of services rather than outcomes. We know that much of the good work doctors do is not a test or a prescription, but rather the time it takes to have a conversation with a patient about test results, being available to a patient through telehealth or expanded hours, coordinating medicine and treatments to avoid confusion or errors, and developing care plans. MACRA shifts the payment equation from the services that are only one part of the clinician’s job to the overall work of the clinician. This helps Medicare patients receive better care, and helps doctors afford to take the time to provide that better care.


Quality Payment Program Goals

• Support care improvements by focusing on better patient outcomes, decrease clinician burden, and preservation of independent clinical practice

• Promote adoption of Alternative Payment Models that align with incentives across health care stakeholders

• Advance existing delivery system reform efforts including smooth transition to a new system that promotes high-quality efficient care through unification of CMS “legacy programs”

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MACRA Implementation

Notice of Proposed Rule Making

April 27, 2016

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Presenter

To support these goals, the Department of Health and Human Services issued a Notice of Proposed Rule Making on April 27, 2016 to implement key provisions of the MACRA legislation under the unified framework of the Quality Payment Program.


Passed with bipartisan Congressional support

“So what?”

MACRA components like the Quality Payment Program are not likely to simply “go away”

Solves annual “doc fix” issue with QPP

“So what?”

Without the Quality Payment Program, the SGR would have significantly decreased clinician reimbursement

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Training Tips — Policy Specific

Pays clinicians for delivering best care and for overall work with patients

“So what?”

We are shifting away from a system of paying only for volume to a system that rewards value and outcomes

MACRA

Presenter

Trainers! When we discuss the origins of the Quality Payment Program under MACRA, it is important that we not only convey the following, but make sure that trainers understand the importance and relevance behind this information. In other words, we all need to understand the “so what?” behind the policy. MACRA was passed with bipartisan Congressional support “So what?” — This means its components, which includes the QPP, are not likely to simply “go away” MACRA, specifically the QPP, is a solution to the annual “doc fix” issue “So what?” — Without the QPP, there is the risk of significant clinician reimbursement MACRA is focused on paying clinicians for delivering the best care and for their overall work with the patient “So what?” — We are shifting away from a system of only paying for volume


Training Tips — Creating an Identity Toward a Common Goal

Quality Payment Program = “Collaboration”

Key Point: Policy created with clinicians

Our Role

1. Establish an identity through collaboration

Example: Use unifying terms like we, us, shared

2. Spread the word: We are still listening and here to help

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Presenter

It is also important to communicate that the Quality Payment Program was developed with the input and support of thousands of clinicians, health care professionals, partners, and organizations. We are all working toward a common goal of paying for care that drives improved patient outcomes, and we are all doing this through one program. Therefore, we need to move forward together. The QPP represents “togetherness” The policy was created with clinician input (4,000 comments and 64,000 attendees at outreach sessions) We all need to create an “identity of togetherness” using “we,” “us,” “shared,” “collaborative,” etc. We are all still listening and here to help Encourage clinicians to get involved in the 60-day comment period on the Final Rule Seeking input on virtual groups


Training Tips — Creating an Identity Toward a Common Goal

“So what?” Key Point: We’re all part of the Quality Payment Program

• You• CMS• Our support teams• Clinicians• Patients

We all share a similar goal to improve patient outcomes!

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Presenter

If there is one important message to takeaway it is that we — you, CMS, our support teams, clinicians, patients — are all a part of this program.


Knowledge Check

The Quality Payment Program intends to shift reimbursement from the volume of services

provided toward a payment system that rewards clinicians for their overall work in

delivering the best care for patients.

True or False?

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Presenter

Knowledge Check. Interactive poll: True or False “The Quality Payment Program intends to shift reimbursement from the volume of services provided toward a payment system that rewards clinicians for their overall work in delivering the best care for patients” True


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The Quality Payment Program at a Glance


Quality Payment Program Bedrock

High-quality patient-

centered care

Useful feedbackContinuous improvement

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What Does the Quality Payment Program Do?

Creates Medicare payment methods that promote quality over volume by:

• Repealing SGR formula

• Creating two tracks:- Merit-based Incentive Payment System (MIPS)

- Advanced Alternative Payment Models (Advanced APMs)

• Streamlining legacy programs

• Providing 5% incentive to Advanced APM participants

• Establishing PTAC, the Physician-focused Payment Model Technical Advisory Committee

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Presenter

What does the QPP do? The overarching goal of the program is to create a predictable Medicare payment method that promotes the delivery of quality care instead of the number of services by:� Repealing the Sustainable Growth Rate (SGR) Formula Creating two tracks for clinicians to participate Merit-based Incentive Payment System (MIPS), which may include participation in some Alternative Payment Models (APMs) Advanced Alternative Payment Models (AAPMs) Streamlining the “Legacy Programs” — Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare Electronic Health Records (EHR) Incentive Program — into one reporting program under MIPS Providing a 5% incentive payment for development of and participation in AAPMs through 2024 Encouraging the creation of additional Physician-Focused Payment Models (PFPMs) by establishing a Physician-focused Payment Model Technical Advisory Committee (PTAC). The PTAC is an independent 11 member advisory committee, appointed by the Comptroller General, which will assess physician-focused payment model proposals, and make recommendations to the HHS Secretary for consideration.


Training Tips: Supplemental Information

MIPS• Adjusts payments based on 4 performance categories:

Quality, Cost, Improvement Activities, and Advancing Care Information

• Streamlines legacy programs into single program• “So what?” — Clinicians are familiar with program

elements

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Quality Improvement Activities

Advancing Care

Cost

Presenter

Trainers! It is important for us to add in some additional detail to the key QPP overview points for other trainers: Two tracks for clinicians MIPS: Adjusts clinician payment based on four performance categories — Quality, Cost, Improvement Activities, and Advancing Care Information Streamlines the “Legacy Programs,” i.e. PQRS, VM, and EHR Incentive Program into one program under MIPS The MIPS performance categories are linked to the “Legacy Programs,” i.e. Quality — PQRS, Cost — VM, and ACI is EHR Incentive Program “So what?” — It is important for us to reassure clinicians that if they have previously been participating in one of these programs the change to the QPP will not be a substantial deviation


Training Tips: Supplemental Information

Advanced APMs

Creates incentives to move to Advanced APMs

“So what?” — Provides 5% incentive payment to Qualifying Participants in Advanced APMs until 2024 and in 2026 there is a higher annual increase in the physician fee schedule payments

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Presenter

2. Transitioning to an Advanced Alternative Payment Model is the ultimate goal AAPMs: Clinicians will receive a favorable Physician Fee Schedule update after 2026 of 0.75% for Qualified Professionals and 0.25% for non-Qualified Professionals Also a 5% incentive payment until 2024 — this is the “So what?”


Clinicians

• Streamlines reporting

• Standardizes measures (evidence-based)

• Eliminates duplicative reporting, which allows clinicians to spend more time with patients

• Promotes industry alignment through multi-payer models

• Incentivizes care that focuses on improved quality outcomes

Patients

• Increases access to better care

• Enhances coordination through a patient-centered approach

• Improves results

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How Does the Quality Payment Program Benefit Clinicians and Patients?

Presenter

Clinicians: Streamlines reporting Standardizes measures (evidence-based) Eliminates duplicative reporting, which allows clinicians to spend more time with patient Promotes industry alignment through multi-payer models Incentivizes care that focuses on improved quality outcomes Consumers: Increases access to better care Enhances coordination through a patient-centered approach Improves results


What Is the Quality Payment Program Timeline?

• First Payment Year – 2019– Based on first performance period of 2017

• 2017 Pick Your Pace Options – Four options to help clinicians avoid negative payment adjustments:

1. Test Pace

2. Partial Year

3. Full Year

4. Participate in an Advanced APM

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Presenter

Scenario: “My practice is relatively small, with few resources and reporting mechanisms to fully participate in the first year of the Quality Payment Program. I’m worried my payment will be significantly impacted due to these circumstances. What can I do?” The first payment year for the Quality Payment Program is 2019, based on the first performance period of 2017. The first performance period will allow clinicians to “pick their pace” of participation. Clinicians will have several options that will prevent them from receiving a negative payment adjustment. These include:� Test Pace Partial Year Full Year Participate in an Advanced Alternative Payment Model


Test Pace

• Submit some data after January 1, 2017

• Neutral or small payment adjustment

Partial Year

• Report for 90-day period after January 1, 2017

• Small positive payment adjustment

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Training Tips — Pick Your Pace

Full Year

• Fully participate starting January 1, 2017

• Modest positive payment adjustment

MIPS

Presenter

Trainers! We have an important task to help clinicians understand the differences between the first year reporting options. MIPS Test Pace An effort to help clinicians “experiment” with the program Preparing clinicians for broader reporting in 2018 and 2019 Clinicians must submit some data after January 1, 2017 What does “some” data mean? Eligible for a neutral or small payment adjustment Partial Year Clinicians report for a period of 90-days anytime after January 1, 2017 October 2, 2017 is the last day to begin reporting for the 90-day option Eligible for a small positive payment adjustment Full Year Option is for clinicians/practices that are prepared to fully participate starting on January 1, 2017 Eligible for a modest positive payment adjustment


Training Tips — Pick Your Pace

Advanced APM Participation Requirements• Qualified Advanced APM

• Clinicians must receive enough of their Medicare payments or see enough of their Medicare patients through an Advanced APM to qualify for incentive pay and not participate in the MIPS track

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Presenter

AAPMs Participate in an Advanced Alternative Payment Model Must be a qualified AAPM To be discussed in additional detail during the AAPM training session Clinicians must receive enough of their Medicare payments or see enough of their Medicare patients through an AAPM to qualify for incentive pay and avoid participating in the MIPS track


What Support Is Available to Clinicians? Integrated Technical Assistance Program

- Full-service, expert help• Quality Payment Program Service Center• QIQ-QIOs (Quality Innovation Network — Quality Improvement

Organizations) • QPP-SURS (Quality Payment Program — Small, Underserved, and Rural

Support)• Transforming Clinical Practice Initiative• APM Learning Networks

- Self-service• QPP Online Portal

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Quick Tip: All support is FREE to clinicians

Presenter

Integrated Technical Assistance Program: Full-service QPP Service Center Assistance for clinicians with all Quality Payment Program questions, including program basics and getting started Quality Innovation Networks — Quality Improvement Organizations (QIN-QIOs) For clinicians in larger practices (more than 15 eligible clinicians) Quality Payment Program — Small, Underserved, and Rural Support (QPP-SURS) For clinicians in smaller practices (less than 15 eligible clinicians) Transforming Clinical Practice Initiative Practice Transformation Networks (PTNs) Support and Alignment Networks (SANs) For clinicians interested in practice transformation and eventually transitioning to an APM APM Learning Networks Learning and Action Networks (LANs) available to specific CMMI models aimed at sharing best practices for success Self-service QPP Online Portal Starting point for information on and interaction with the Quality Payment Program


Training Tips – Supplemental Information

For both MIPS and Advanced APMs:

1. No penalties for clinicians who participate in any one of the options

- Only clinicians who do not submit any data receive negative payment adjustment

2. Last day to report 2017 data – March 31, 2018

3. Plenty of support available to clinicians

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Presenter

Three additional points to emphasize: Clinicians will not be penalized if they participate in any one of these options The negative payment adjustment is for clinicians who do not submit any data March 31, 2018 is the last day to report 2017 data There is plenty of support available to clinicians


Lesson Summary

In this lesson, you have learned that:

• The Quality Payment Program:- Repeals SGR formula- Streamlines legacy programs- Creates two tracks for clinicians: MIPS and Advanced APMs

• Pick Your Pace options are available for first performance year

• Support for technical assistance is available to all clinicians

• We must create a unified identity through collaboration for the Quality Payment Program to succeed

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Question & Answer Session

Questions?

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Presenter

What questions do you have for us on the introductory section? We will take a few questions out of the chat box.


Introduction to the Merit-based Incentive Payment System (MIPS)

Part I — Overview

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Learning Objectives


• Identify MIPS performance categories

• Explain eligibility requirements

• Discuss clinician enrollment as:

– Individual

– Group

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What Is MIPS?Combines legacy programs into single, improved reporting program

Legacy Program Phase Out

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2016 2018

Last Performance Period PQRS Payment End

PQRS VM EHR MIPS

Presenter

As we discussed in the introductory section of this training, under the Quality Payment Program there are two tracks for clinicians — MIPS and AAPMs. So what specifically does the Merit-based Incentive Payment System do? MIPS combines the three “Legacy Programs” in which many clinicians have been participating to date into a single, improved reporting program. These programs include: Physician Quality Reporting System (PQRS) Physician Value Modifier (VM) program, and Medicare EHR Incentive Program The last performance period for these three separate reporting programs was January 1, 2016 through December 31, 2016. PQRS payment adjustments will end in 2018.


What Is MIPS?

Performance Categories

• Reporting standards align with Advanced APMs when possible

• Many measures align with those being used by private insurers

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Quality Cost Improvement Activities

Advancing Care Information

Presenter

Within MIPS, each eligible clinician will be assessed under four performance categories, and those four performance categories will constitute a Final Score for each clinician. The four performance categories are Quality, Cost, Improvement Activities, and Advancing Care Information. It is important to note that the reporting standards for MIPS and Advanced APMs are aligned wherever possible, to make it easy for clinicians to move between the different tracks of the Quality Payment Program based on what works for them and their patients. Additionally, and this is important as a trainer to express, many of the measures found under MIPS are also aligned to those being used by private insurers, which helps to reduce the reporting burden on clinicians.


Who Is Eligible for MIPS?

• Medicare Part B clinicians billing more $30,000 and providing care to more than 100 Medicare patients per year.

- Known as “eligible clinicians”

• Voluntary option for all other clinicians not included in transition year

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Physicians Physician Assistants

Nurse Practitioners

Clinical Nurse Specialists

Certified Registered Nurse

Anesthetists

Presenter

MIPS applies to Medicare Part B clinicians, referred to as “eligible clinicians” under the Quality Payment Program. For the first year of the program, eligible clinicians will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. In future years, and based on the discretion of the Secretary, the classification of eligible clinicians may be broadened to include occupational therapists, physical therapists, clinical social workers, dieticians, etc. For the time being, the option is available for these professionals to voluntarily report during the first year to gain some experience under the MIPS program.


Who Is Exempt from MIPS?

• Clinicians who:

- Are newly enrolled in Medicare

- Do not meet thresholds:

• < $30,000 in Medicare charges

OR

• < 100 Medicare patients

- Are significantly participating in an Advanced APM

• MIPS doesn’t apply to hospital-based or facility-based payment programs

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Quick Tip: This means than clinicians with >$30,000 AND >100 Medicare patients would be included unless they met other exclusions.The threshold is measured at the group level for group reporting and individual level for individual reporting.

Presenter

Medicare Part B clinicians may be exempted from reporting through MIPS if they meet any of the following requirements: Are newly enrolled in Medicare Do not meet the appropriate thresholds, i.e. have less than or equal to $30,000 in Medicare charges OR less than or equal to 100 Medicare patients Based on a one-year historical look-back of claims Are significantly participating in an Advanced APM It is important to clarify that MIPS does not apply to hospital-based or facility-based payment programs.


Non-Patient Facing Clinicians• Non-patient facing clinicians are eligible to participate in MIPS as

long as they exceed the low-volume threshold, are not newly enrolled, and are not a qualifying APM participant (QP) or partial QP that elects not to report data to MIPS

• The non-patient facing MIPS-eligible clinician threshold for individual MIPS-eligible clinicians is < 100 patient facing encounters in a designated period

• A group is non-patient facing if > 75% of NPIs billing under the group’s TIN during a performance period are labeled as non-patient facing

• There are special reporting requirements for non-patient facing clinicians

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Presenter


Knowledge Check

Which of following is NOT considered an “eligible clinician” during the initial performance year?

� Physician

� Nurse Practitioner

� Medical Assistant

� Clinical Nurse Specialist

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Presenter

Interactive poll question: “Which of following is NOT considered an “eligible clinician” during the initial performance year?” Physicians Nurse Practitioners Medical Assistants Clinical Nurse Specialists


OPTIONS

Individual Group

How Do Clinicians Participate in MIPS?

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1. Individual – under an NPI number and TIN where they reassign benefits

2. As a Group –a) 2 or more clinicians (NPIs) who have reassigned

their billing rights to a single TIN*b) As a MIPS APM entity

* If clinicians participate as a group, they are assessed as group across all 4 MIPS performance categories

Presenter

Eligible clinicians have two options for participating in MIPS. Individually — meaning that the clinician reports under a unique Tax Identification Number (TIN) and National Provider Identifier (NPI) As a Group (non-virtual) — meaning that the two or more clinicians with a unique NPI have reassigned their billing rights over to a single TIN It is important to note that if clinicians participate as a group, they would be assessed as a group across all four MIPS performance categories.


When Will Clinicians Learn If They Are Eligible for MIPS?

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December 2016

CMS contacts clinicians

Presenter

Clinicians will learn whether they are eligible for MIPS at the end of December.


Is a Clinician Eligible for MIPS and Advanced APMs?

MIPS-APM Option

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Presenter

Scenario: “How does participating in an Alternative Payment Model or an Advanced Alternative Payment Model affect my MIPS eligibility?” Clinicians who participate to a sufficient extent in an Advanced Alternative Payment Model are exempt from the MIPS program and its reporting requirements. Of course, there may be clinicians who are not fully prepared to participate in an Advanced Alternative Payment Model, but may be able to satisfy the requirements of a general Alternative Payment Model. The good news is that there are additional options for these clinicians to help make the move between the components of the Quality Payment Program as easy as possible. Certain APMs that hold participants accountable for the cost and quality of care can be considered MIPS-APMs. CMS will score eligible clinicians in MIPS-APMs under a special MIPS standard (the APM scoring standard) that uses the work that clinicians already do in a MIPS-APM to reduce their MIPS reporting burden. This way, clinicians can focus on the goals of the APM.


MIPS-APM Track for Clinicians — Scoring Standard

• APM scoring standard applies for MIPS-eligible clinicians who are in MIPS-APMs

• A MIPS-APM is an APM that meets the following criteria:

1. Participates as APM under an agreement with CMS

2. Includes at least one MIPS-eligible clinician on APM participation list

3. Bases payment incentives on performance on cost/utilization and quality measures

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Presenter

The APM scoring standard helps alleviate certain duplicative, unnecessary, or competing data submission requirements for MIPS eligible clinicians participating in MIPS-APMs. The APM scoring standard for MIPS eligible clinicians participating in MIPS-APMs eliminates the need for such APM eligible clinicians to submit quality and clinical practice improvement data, for both MIPS and their respective APMs. CMS will look at the performance of a group of MIPS eligible clinicians in an APM Entity and score them collectively as an APM Entity group. The APM scoring standard will be applied to MIPS eligible clinicians participating in MIPS-APMs. The APM scoring standard under MIPS would only be applicable to clinicians participating in MIPS-APMs, which have been defined as APMs that meet the following criteria: APM entities participate in the APM under an agreement with CMS The APM requires that APM entities include at least one MIPS eligible clinician on a Participation List The APM bases payment incentives on performance (either at the APM entity or eligible clinician level) on cost/utilization and quality measures


MIPS-APM Track for Clinicians — Eligibility

Important dates to convey: • March 31

• June 30

• August 31

“So what?”— Clinicians that appear on an APM participation list on any of these dates are eligible for APM scoring standard.

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MAR

31JUN

30AUG

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Presenter

To be scored under the APM scoring standard, eligible clinicians must be identified as participants in an APM Entity group. To do this, CMS review its participation lists on March 31, June 30, and August 31 of each year. If clinicians appear on an APM Entity’s participation list on at least one of those three dates, they will be included in the APM Entity group for purposes of the APM scoring standard. CMS uses the same process for determining APM Entity groups for the APM scoring standard as it does for determining APM Entity groups in Advanced APMs for making Qualifying APM Participant (QP) determinations. CMS will post the list of MIPS-APMs prior to each calendar year. If the APM would have qualified as a MIPS-APM, but the APM is ending before the end of the performance period, then the APM will not appear on this list. CMS will notify clinicians before the start of the performance period if they need to report to MIPS using the MIPS individual or group reporting option to avoid a MIPS negative payment adjustment.


Training Tips — Points to EmphasizeMIPS Sunsets Legacy Programs

• Clinicians have the “know how” and experience for MIPS success

• Exemptions available for those truly in need that would reweight the Advancing Care Information performance category

– Applications must be submitted annually

– Categories of exemption similar to hardship exemptions available under EHR Incentive Program

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Presenter

Trainers! Let’s discuss and review some additional points on the information that we just covered. MIPS will sunset the “Legacy Programs” Make sure that other trainers understand the following takeaways: Experience in these programs will provide clinicians with the “know how” to succeed within the MIPS program For those clinicians who may not have participated in the EHR Incentive Program but are required to participate in MIPS, they are able to apply for a hardship exemption that would reweight the Advancing Care Information performance category to zero These applications must be submitted annually


Training Tips — Points to Emphasize

MIPS Performance Categories

Measures are similar to legacy programs eases clinician burden:

____________________________________________

New category gives clinicians significant flexibility to choose activities

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Quality

Improvement Activities

Advancing Care Information Cost

Presenter

Three of the four performance categories under MIPS, Quality, Cost, and Advancing Care Information, are similar to the reporting requirements found in the “Legacy Programs” “So what?” — This was done to ease clinician reporting burden Improvement Activities is the only new category, but is very flexible in allowing clinicians to choose activities from various focus areas New requirements typically lead to physician fear and anxiety; it is our job to explain the significant flexibility in the Improvement Activities category



MIPS Eligibility• Clinicians need to update their practice information before first

performance year

• Applies to Medicare Part B “eligible clinicians”

• Most clinicians will likely begin in the MIPS program

– Significant amount of support required to help clinicians

– MIPS serves as valuable platform to transition toward an Advanced APM

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Presenter

MIPS applies to Medicare Part B “eligible clinicians” To ensure that clinicians are accurately identified as eligible for the MIPS program, it is vital that they update their practice information prior to the beginning of the performance period each year Most clinicians will likely participate in MIPS during the first few years, however it is important to remind clinicians that the program serves as a platform to participation and success in a general APM and, ultimately, an Advanced APM


Lesson Summary


• MIPS is comprised of four performance categories

• Those participating in MIPS are known as “eligible clinicians”

• Clinicians may report under MIPS individually or as a group through a TIN where they reassign benefits or a MIPS APM entity

• Clinicians will learn of their MIPS eligibility in late December 2016

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Questions?

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Presenter

What questions do you have for us on the MIPS Overview section? We will take questions from the chat box.


Introduction to the Merit-based Incentive Payment System (MIPS)Part II — Performance Category Basics

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Lesson Objectives


• Explain weights assigned to each MIPS performance category for the initial year

• Discuss basics of each performance category, including:- Structure

- Reporting requirements

- Alternative scoring (if available)

• Describe vendor reporting

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First Performance Period

January 1, 2017 through

December 31, 2017

First Payment Year

2019 Based on 2017 performance

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When Does MIPS Officially Begin?

Presenter

The first performance period for MIPS will be from January 1, 2017 through December 31, 2017. Remember, that during the first performance period, eligible clinicians have the “pick your pace” option in determining their level of participation. The first payment year for MIPS, where eligible clinicians will have their payments adjusted, will be in 2019, and will be based on the first performance period of 2017.


What Are the MIPS Performance Categories?

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Cost

Presenter

As we have discussed, there are four performance categories under MIPS. These include Quality, Cost, Improvement Activities, and Advancing Care Information. Clinicians within the MIPS program will be scored on all four of these categories, with the result being a “Final Score.” Quality Cost Improvement Activities Advancing Care Information


How Are MIPS Performance Categories Weighted?Weights assigned to each category based on a 1 to 100 point scale

Transition Year Weights— 25%

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Quality

60%


15%


25%

Cost

0%

NOTE: These are defaults weights; the weights can adjust in certain circumstances

Presenter

There are specific category weights assigned to each of those four categories as defined by the MACRA law. You’ll note that those weights roll up to 100, as each MIPS eligible clinician’s Final Score will be based off of a 0 to 100 point scale. For the first year, the “transition” year, quality will account for 60% of the composite performance score, or 60 points. Cost will count 0% to allow clinicians to gain some familiarity with the MIPS program. Improvement Activities will count for 15%, or 15 points, and Advancing Care Information will count for 25%, or 25 points. Let’s take a deeper dive into the performance categories.


MIPS Performance Category: QualityCategory Requirements• Replaces PQRS and Quality Portion of the Value Modifier

• 60% of final score

• Select 6 of about 300 quality measures (minimum of 90 days); 1 must be:– Outcome measure OR

– High-priority measure – defined as outcome measure, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination

• May also select specialty-specific set of measures

• Readmission measure for group submissions that have > 15 clinicians and a sufficient number of cases (no requirement to submit)

• Different requirements for groups reporting CMS Web Interface or those in MIPS-APMs

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Presenter

The Quality performance category, worth 60%, was created to add clinician flexibility to focus on the measures that are truly important to beneficiaries. Each eligible clinician will select six measures, which is a current decrease from what is required under PQRS. Additionally, under PQRS, clinicians are required to report on nine measures that cover three national quality strategy domains. Within MIPS, there is no requirement that clinicians would have to choose measures that cover a certain number of domains; rather, they are encouraged to choose measures that span as many domains as possible. Of those six measures, one must an outcome measure. If an outcome measure is not available, clinicians would need to select from another high priority measure. A high priority measure is defined as an outcome measure, appropriate use measure, patient experience, patient safety, efficiency measure, or care coordination measure. Clinicians can either select from the approximately 300 measures that will be available, or select a specialty specific set of measures that the CMS created together with multiple specialty societies. There are three additional population health measures that are automatically calculated for all clinicians.


MIPS Performance Category: Quality –Reporting

Individual clinicians may report through:

- Qualified Registry- Electronic Health Record

(EHR)- Qualified Clinical Data

Registry (QCDR)- Claims

Groups may report measures through:

- Qualified Registry - EHR- QCDR- CMS Web Interface (groups

of 25 or more)- CAHPS for MIPS Survey

• Counts as 1patient experience measure

• Must submit 5 other measures through a different mechanism above

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Presenter

Data on all of the measures within the Quality performance category can be submitted through multiple platforms. Individual clinicians may report measures through the following: Qualified Registry Electronic Health Record (EHR) Qualified Clinical Data Registry (QCDR) Claims �Clinicians reporting as groups may report measures through the following: Qualified Registry EHR QCDR CMS Web Interface (groups of 25 or more) CAHPS for MIPS Survey This option would count as one patient experience measure The group would be required to submit five other measures through a different submission mechanism (options 1-4)


Training Tips —Quality Category

1. Weighted at 60% for the first performance year- “So what?”— This category is a significant part of final score

2. Clinicians must select 6 measures unless 6 measures are not applicable- 1 must be an outcome measure

• If an outcome measure is not applicable, they must choose a high-priority measure

3. Clinicians may report individually or as a group

4. Special rules for web interface

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Presenter

Trainers! Let’s review the high-level points that will be key to conveying to other trainers. The Quality performance category is weighted at 60% for the first performance year “So what?” — This category is a significant chunk of the Final Score Clinicians must select six measures One must be an outcome measure If an outcome measure is not applicable, they must choose a high-priority measure Clinicians may report individually or as a group through various submission mechanisms



• The Quality performance category decreases the measure selection from 9 under PQRS to 6 under Quality Payment Program

- “So what?” • Reduces clinician burden

• Allows clinicians to focus on relevant measures

• Provides more time for clinicians to spend with patients

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Presenter

Other important considerations. The Quality performance category decreases the measure selection from nine under PQRS to six under QPP “So what?” — Reduces clinician burden, allows them to focus on relevant measures, and spend more time with patients The measures in the Quality category are endorsed by a consensus-based entity or are evidence-based



• PQRS participants may be familiar with many Quality measures, which account for 60% of final score- “So what?” — Provides for an easier transition as heavy

weighting of familiar measures can help clinicians succeed

• “Call for Quality Measures” for clinician input on measures- Approved measures will take effect 2 years after submission

- “So what?” — Clinicians will have a voice each year!

54

Presenter

Clinicians who participated in PQRS may be familiar with many of the Quality measures Quality category is most heavily weighted to help clinicians succeed—they are able to work with measures familiar from PQRS Clinicians will have a voice each year, as there will be a notice and comment period, known as the “Call for Quality Measures,” to help establish the list of measure under the Quality category Approved measures will take effect in the performance period two years after the measure is submitted


Knowledge Check

To earn full credit, how many measures must a clinician reporting individually select under the Quality performance

category?

� 3

� 6

� 9

� 15

55

Presenter

Interactive poll: To earn full credit, how many measures must a clinician reporting individually select under the Quality performance category? 3 6 9 15


MIPS Performance Category: Cost

• No reporting requirement; 0% of final score in 2017

• Clinicians assessed on Medicare claims data

• Uses measures previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR), but scoring is different

56

Presenter

The Cost performance category is worth 0% of a clinician’s Final Score for the first performance year. Clinicians will be assessed based on administrative Medicare claims data, including specific episode measures, for Medicare patients only and only for patients that are attributed to them. Therefore, there is no reporting requirement necessary for clinicians.


MIPS Performance Category: Cost – Reporting

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Cost Measures from VM

1. Medicare Spending Per Beneficiary (MSPB)

2. Total Per-Capita Cost for All Attributed Beneficiaries

Presenter

Even though there is not a reporting component to the Cost category, there are certain measures to which clinicians should become familiar, as these will be used to evaluate their Cost performance. The cost measures are divided into two groups, and all are risk-adjusted to accommodate for differences in patients. The first group focuses on cost measures from VM and includes: Medicare Spending Per Beneficiary (MSPB) Evaluates the costs of care related to inpatient hospital visits Total Per-Capita Cost for All Attributed Beneficiaries Evaluates the annual overall patient costs


MIPS Performance Category: Cost – Reporting Episode GroupThe episode group includes 10 measures:

1. Aortic/Mitral Valve Surgery 2. Cholecystectomy and Common Duct Exploration 3. Colonoscopy 4. Coronary Artery Bypass Graft (CABG)5. Hip Replacement or Repair 6. Inpatient Hip/Femur Fracture or Dislocation Treatment7. Knee Arthroplasty (Replacement)8. Lens and Cataract Procedures9. Mastectomy for Breast Cancer10. Transurethral Resection of the Prostate

58

Presenter

The second group of measures focuses on costs for episodes of care, which for this purpose include the procedure, anesthesia, wound care, and other related services. It does not include an office visit to another clinician for an unrelated condition. The specific measures are: Aortic/Mitral Valve Surgery Cholecystectomy and Common Duct Exploration Colonoscopy Coronary Artery Bypass Graft (CABG) Hip Replacement or Repair Inpatient Hip/Femur Fracture or Dislocation Treatment Knee Arthroplasty (Replacement) Lens and Cataract Procedures Mastectomy for Breast Cancer Transurethral Resection of the Prostate


Quick Tip

None of the measures are new!

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Presenter

Trainers! It is beneficial to explain to clinicians that none of the above measures are brand new. Certain measures, such as the MSPB and per-capita cost, were a component of the Value-based Modifier program. Similarly, the episode measures were derived from the feedback received on the Supplemental Quality and Resource use Reports, which began in 2015.


MIPS Performance Category: Cost –Reporting

• Clinicians do not select Cost measures

• Measure based on services delivered

• For a measure to be applied, a clinician must either:1. Bill for certain attributable services - Example: Aortic

valve replacement2. Provide services a minimum number of times

> 35 times for MSPB> 20 times for all other measures

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Presenter

Clinicians must understand that they do not select any of Cost measures. Instead, measures will be applied to them based upon the services that they deliver. For a measure to be applied to a clinician, one of two things must happen: The clinician bills for certain procedures, such as an aortic valve replacement, covered under the care episodes list The clinician provides services a minimum number of times Clinicians must have a minimum number of patients for these measures to be applicable. Every measure expect the MSPB requires at least 20 patients. The MSPB minimum requirement is 35 patients.


Pulse Check

Now that we have reviewed the first two MIPS performance categories, Quality and Cost, what is your level of confidence in training other trainers on this information?

� Very confident

� Somewhat confident

� Neutral

� None of this makes sense

61

Presenter

Real-time polling sample. Now that we have reviewed the first two MIPS performance categories, Quality and Cost, what is your level of confidence in training other trainers on this information? Very Confident Somewhat Confident Neutral None of this Makes Sense



Questions?

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Presenter

What questions do you have for us on the Quality or Cost performance categories?


MIPS Performance Category: Improvement Activities • Assesses participation in activities that improve clinical practice

- Examples: Shared decision making, patient safety, coordinating care, increasing access

• Clinicians choose from about 90+ activities under 9 subcategories:1. Expanded Practice Access

2. Population Management

3. Care Coordination

4. Beneficiary Engagement

5. Patient Safety and Practice Assessment

6. Participation in an APM

7. Achieving Health Equity

8. Integrating Behavioral and Mental Health

9. Emergency Preparedness and Response

63

Presenter

The Improvement Activities performance category will be new to most clinicians. This category, worth 15% of the clinician’s Final Score, assesses how much a clinician participates in activities that improve clinical practice. Examples of these activities include how well a clinician shares in decision making with the patient, improves patient safety, coordinates care, and increases access for patients. The Improvement Activities category also includes incentives that help drive participation in certified Patient-Centered Medical Homes and Alternative Payment Models. Clinicians will have the flexibility to choose from approximately 90 activities under nine subcategories. These include Expanded Practice Access, Population Management, Care Coordination, Beneficiary Engagement, Patient Safety and Practice Assessment, Participation in an APM, Achieving Health Equity, Integrating Behavioral and Mental Health, and Emergency Preparedness and Response.


MIPS Performance Category: Improvement Activities

• Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.

• Groups with 15 or fewer participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.

• Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.

• Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or the Oncology Care Model: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.

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MIPS Performance Category: Improvement Activities No clinician or group has to report more than 4 activities

Special consideration for :

• Practices with 15 or fewer clinicians

• Rural or geographic HPSA

• Non-patient facing

• APM

• Certified Medical Home

65

Presenter

Since this category will be new to most clinicians, there will be many questions around the requirements. The Improvement Activities category requires that no clinician or group has to report more than four activities. Additionally, there are special considerations for: Practices with 15 or fewer clinicians Rural or geographic Health Professional Shortage Areas (HPSAs) Non-patient facing APM Certified Medical Home


MIPS Performance Category: Improvement Activities General Rule (no special considerations)

• Choose 1 of the following combinations:– 2 high-weighted activities– 1 high-weighted activity and 2 medium-weighted activities – At least 4 medium-weighted activities

• A sample combination could include:– 1 medium-weighted activity from Beneficiary Engagement– 1 medium-weighted activity from Patient Safety and Practice

Assessment– 1 high-weighted activity from Integrated Behavioral Health

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Presenter

In order to receive the maximum score, a clinician must report on one of any of the following combinations: 2 high-weighted activities 1 high-weighted activity and 2 medium-weighted activities At least 4 medium-weighted activities An sample combination includes: 1 medium-weighted activity from the Beneficiary Engagement subcategory, 1 medium-weighted activity from the Patient Safety and Practice Assessment Subcategory, and 1 high-weighted activity from the Integrated Behavioral Health subcategory


MIPS Performance Category: Improvement Activities

Practices with 15 or Fewer Clinicians, Rural or Geographic HPSA, and Non-patient Facing

Choose 1 of the following combinations:

• 1 high-weighted activity OR

• 2 medium-weighted activities

67

Presenter

For practices with 15 or fewer clinicians, each activity is weighted either medium or high. In order to receive the maximum score, a clinician must report on one of the following combinations: 1 high-weighted activity 2 medium-weighted activities


MIPS Performance Category: Improvement Activities – Alternative Point Scoring

• Automatic 100% category score for clinicians in:

– Certified Patient-Centered Medical Homes

– Medical Home Models

– Comparable specialty practices

• For clinicians in an APM Entity, points assessed based on model criteria

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Presenter

Activity selection is the primary method for satisfying the Improvement Activities requirements, however there are alternative methods for clinicians to earn points to achieve the maximum points in the category. For example, if a clinician practices within a certified Patient-Centered Medical Home, Medical Home Models, or comparable specialty practice, it will automatically earn a 100% score for the Improvement Activities category. Additionally, if a clinician is a part of a multi-practice group, if only one group is certified as a PCMH, the entire group under the same TIN will earn a 100% score. Participating as a MIPS-APM entity is another method for earning points toward the Improvement Activities category. Clinicians who are involved in a MIPS-APM entity will earn full credit. Clinicians will then be responsible for selecting additional activities to fulfill the remaining requirements of the category.


MIPS Performance Category: Improvement Activities – Reporting• Must perform selected activities for 90 consecutive days

• Must attest each activity performed for 90-day period by selecting “Yes” during reporting

• May report activities through:

- Qualified Registry

- Electronic Health Record (EHR)

- Qualified Clinical Data Registry (QCDR)

- CMS Web Interface (for groups of 25 clinicians or more)

- Attestation data submission methods

69

Presenter

In addition to measure selection, there are several reporting requirements within the Improvement Activities category. Clinicians must perform selected activities for a period of 90-consecutive days Clinicians must attest that each activity was performed for the 90-day period by selecting “Yes” during reporting Clinicians may report activities through the following: Qualified Registry Electronic Health Record (EHR) Qualified Clinical Data Registry (QCDR)* CMS Web Interface (for groups of 25 clinicians or more) Please note that if clinicians choose to report through a QCDR, they must select and achieve each activity separately even though the inventory includes activities that incorporate QCDR participation.



• Improvement Activities category helps clinicians:

- Improve health outcomes

- Prepare for transition toward Advanced APM

• Clinicians have a voice

- “So what?” – Clinicians have opportunity to assist in determining future subcategories and activities

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Presenter

Trainers! As you process the key information on the Improvement Activities category, take a minute to consider a few additional important facts to convey to other trainers. Since the Improvement Activities category will be new to many clinicians, emphasize the notion that the activities in this category have a proven association with improved health outcomes AND prepare clinicians to transition toward an Advanced Alternative Payment Model Similar to the Quality performance category, clinicians will have a voice in determining future subcategories and activities


Training Tips — MIPS Improvement Activities

Clinicians will receive a 0 as their improvement activity score if they do not participate in an APM, a certified patient-centered medical home, or a Medical Home Model, and they do not report any activities

“Certified” means that a patient-centered medical home is nationally accredited by the Accreditation Association for Ambulatory Health Care, the National Committee for Quality Assurance, The Joint Commission Designation, or the Utilization Review Accreditation Commission or they meet the two criteria (certified a large number of medical organizations and meet national guidelines).

71

Presenter

Clinicians must know that if they are not participating in an APM, a certified PCMH, or a Medical Home Model and they do not report any activities, they will receive a 0 as a score “Certified” in this sense means that the PCMH is nationally accredited by either the Accreditation Association for Ambulatory Health Care, the National Committee for Quality Assurance, The Joint Commission Designation, or the Utilization Review Accreditation Commission


Training Tips — MIPS Improvement Activities

• A “certified” Medical Home Model generally includes:- Participants are primary care practices or multispecialty practices- Patients are empaneled to a primary clinician - The model must meet 4 of following 7 requirements:

1. Planned coordination of chronic and preventative care2. Patient access and continuity of care3. Risk-stratified care management4. Coordination of care across the medical neighborhood5. Patient and caregiver engagement6. Shared decision-making7. Payment arrangements in addition to, or substitute for, fee-for-service

payments

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Presenter

A “certified” Medical Home Model generally includes the following elements: Participants are primary care practices or multispecialty practices Patients are empaneled to a primary clinician The model must meet four of following seven requirements: Planned coordination of chronic and preventative care Patient access and continuity of care Risk-stratified care management Coordination of care across the medical neighborhood Patient and caregiver engagement Shared decision-making Payment arrangements in addition to, or substitute for, fee-for-service payments



Questions?

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Presenter

What questions do you have for us on the Improvement Activities performance category?


MIPS Performance Category: Advancing Care Information• Promotes patient engagement and interoperability using

certified EHR technology

• Replaces the Medicare EHR Incentive Program

• Greater flexibility in choosing measures

• In 2017, there are 2 measure sets for reporting based on EHR edition:

1. Advancing Care Information Objectives and Measures

2. 2017 Advancing Care Information Transition Objectives and Measures

74

Presenter

Unlike the Improvement Activities performance category, clinicians may be more familiar with the components of the Advancing Care Information category, as it is similar to the EHR Incentive Program. As an example, the measures found within the Advancing Care Information category are based on the measures adopted by the EHR Incentive Programs for Stage 3 in 2015. There are, however, some important changes that you as a trainer need to discuss. For instance, the category is not exclusive to physicians. In fact, it applies to all eligible clinicians participating in the MIPS program either as an individual or group. Additionally, Advancing Care Information eliminates the all-or-nothing reporting criteria that was found under the EHR Incentive Program and replaces it with a greater degree of flexibility for clinicians to choose the measures that fit their practice and patients.


MIPS Performance Category: Advancing Care Information — Reporting

Clinicians must use certified EHR technology to report

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For those using EHR Certified to the 2015

Edition:

Option 1: Advancing Care Information Objectives and

Measures

Option 2: Combination of the two measure sets

For those using 2014 Certified EHR

Technology:

Option 1: 2017 Advancing Care Information Transition Objectives

and Measures

Option 2: Combination of the two measure sets

Presenter

Clinicians need to understand that in order for them to report any of the measures under the Advancing Care Information category, they must use certified EHR technology. Depending on the EHR edition, there will be different objectives from which the clinician may choose to report.


MIPS Performance Category: Advancing Care Information

• Earn up to 155% maximum score, which will be capped at 100%

• Advancing Care Information category score includes:

- Base score (worth 50%)

- Performance score (up to 90%)

- Bonus score (up to 15%)

76

Presenter

For scoring purposes, clinicians may earn up to a maximum score of 155%, although this will be capped at 100%. You may be asking, “Why 155%?” This structure was deliberately created to ensure that clinicians had absolute flexibility to focus on measures that are the most relevant to them and their practices. The goal was to shift their concentration away from measures that were not applicable.



77

Advancing Care Information Objectives and Measures:

Base Score Required Measures

2017 Advancing Care Information Transition Objectives and Measures:

Base Score Required Measures

Objective Measure

Protect Patient Health Information Security Risk Analysis

Electronic Prescribing e-Prescribing

Patient Electronic Access Provide Patient Access

Health Information Exchange

Send a Summary of Care


Request/Accept a Summary of Care

Objective Measure

Protect Patient Health Information Security Risk Analysis

Electronic Prescribing e-Prescribing

Patient Electronic Access Provide Patient Access



Presenter



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Advancing Care Information Objectives and Measures

Objective Measure

Patient Electronic Access Provide Patient Access*

Patient Electronic Access Patient-Specific EducationCoordination of Care through Patient Engagement

View, Download and Transmit (VDT)

Coordination of Care through Patient Engagement

Secure Messaging

Coordination of Care through Patient Engagement

Patient-Generated Health Data

Health Information Exchange Send a Summary of Care*

Health Information Exchange Request/Accept a Summary of Care*

Health Information Exchange Clinical Information Reconciliation

Public Health and Clinical Data Registry Reporting

Immunization Registry Reporting

2017 Advancing Care Information Transition Objectives and Measures

Objective Measure

Patient Electronic Access Provide Patient Access*

Patient Electronic Access View, Download and Transmit (VDT)

Patient-Specific Education Patient-Specific Education

Secure Messaging Secure Messaging


Health Information Exchange*

Medication Reconciliation Medication Reconciliation

Public Health Reporting Immunization Registry Reporting

Presenter


MIPS Performance Category: Advancing Care Information – Completion AlternativesClinicians have the opportunity to earn a bonus score 2 ways:

1. Earn a 5% bonus for reporting to additional Public Health and Clinical Data Registry Reporting measures (aside from the Immunization Registry Reporting measure)

2. Earn a 10% bonus for using CEHRT to complete certain activities within the Improvement Activities performance category

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MIPS Performance Category: Advancing Care Information 1.Clinicians recognized as participating in a MIPS-APM entity will

automatically receive a 50% score in the category - Clinicians need to earn the remaining 50% to receive full credit in the category

2.If objectives and measures are not applicable to a clinician, CMS will reweight the category to zero and assign the 25% to the other performance categories to offset difference in the MIPS final score

3.If clinicians face a significant hardship and are unable to report advancing care information measures, they can apply to have their performance category score weighted to zero

4.Hospital-based MIPS eligible clinicians may choose to report under the Advancing Care Information Performance Category

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Training Tips — Policy Specific • Clinicians may have some experience with requirements if they participated

in the EHR Incentive Program- “So what?” — Connecting with prior experiences helps to ease clinician

anxiety

• ACI category gives clinicians flexibility in measure selection - “So what?” — Fewer measures required, more choice for clinicians

• Clinicians must use certified EHR technology to report

• To maximize their score, clinicians must submit base and report on measures applicable to their practice

Quick Tip: Discuss benefit of using CEHRT to succeed in other categories

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Presenter

Trainers! The following are the key points of the Advancing Care Information category that we should all focus on when delivering training to other trainers. Clinicians may have some experience with the requirements of this category if they participated in the EHR Incentive Program “So what?” — Connecting with prior experiences helps to ease clinician anxiety The Advancing Care Information category gives clinicians flexibility in choosing measures that are relevant to them “So what?” — Eliminates the “all-or-none” approach Clinicians must use certified EHR technology to report — this is a significantly important component Clinicians will have different objectives depending upon the edition of their CEHRT To maximize their score in the category, clinicians must submit the base and report on measures applicable to their practice This is known as the base and performance score Don’t forget to mention the bonus! Talking about the bonus may also be a good time for us to reassure and energize clinicians noting that, while they may not notice, their participation and efforts can result in cross-category success Example: “You earn a bonus for using CEHRT to accomplish activities under the Improvement Activities category


Pulse Check

If a trainer, or even a clinician, were to ask you a policy-specific question on either the Improvement Activities or Advancing Care Information performance categories, how confident do you feel you would be in answering the question accurately?

� Very confident

� Somewhat confident

� Neutral

� None of this makes sense

82

Presenter

Real-time polling sample. If a trainer, or even a clinician, were to ask you a policy-specific question on either the Improvement Activities or Advancing Care Information performance categories, how confident do you feel you would be in answering the question accurately? Very Confident Somewhat Confident Neutral None of this Makes Sense


Pulse Check Improvement Activities and ACI performance categories contain a lot of information, but are very important to a clinician’s overall MIPS Final Score and payment adjustment. What supplementary materials or resources would be beneficial for you to have as you go out and train other prospective trainers and/or clinicians?

� Topic-specific fact sheets� Question and answer sheets� Infographics � Blogs � eLearning modules� Other resources

83

Presenter

Real-time polling sample. The Improvement Activities and Advancing Care Information performance categories contain a lot of information, but are very important to a clinician’s overall MIPS Final Score and payment adjustment. What supplementary materials or resources would be beneficial for you to have as you go out and train other prospective trainers and/or clinicians? Topic-specific Fact Sheets Question and Answer Sheets Infographics Blogs eLearning Modules Other Resources (Note: If “other resources” is selected, we can take a few minutes to allow participants to comment on their ideas)


MIPS Vendor Reporting

• Health information technology (HIT) vendors submit data on behalf of clinicians for:

Quality



• If data for activities is derived from CEHRT, vendors must indicate data source and transmit data in a CMS-specified form and manner

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Advancing Care

Presenter

Before moving into the scoring and payment adjustment section, we should take a few minutes to reflect on the reporting mechanisms under the Quality Payment Program. As we have discussed, clinicians may directly report their performance category measures to CMS through a variety of mechanisms. However, it is important for us to all recognize that clinicians do not have to report on their own, either individually or as a group. The QPP has expanded the capabilities of Health Information Technology (HIT) vendors by allowing them to submit data on behalf of the clinicians for the Quality, Improvement Activities, and Advancing Care Information performance categories. Of course, as trainers, we have to be sure that we are communicating the nuances within this opportunity. For example, we need to ensure that the HIT vendors know that if the data for the Quality, Improvement Activities, and Advancing Care Information activities is derived from CEHRT, they must indicate the data source and transmit the data in a CMS-specified form and manner.


Lesson Summary


• The four MIPS performance categories are comprised of:

- Varying weights

- Measures

- Scoring components

- Reporting requirements

• HIT vendors may submit data for clinicians in several MIPS performance categories

85


Introduction to the Merit-based Incentive Payment System (MIPS)

Part III — Scoring

86


Lesson Objectives


• Provide an overview of MIPS scoring:- Points available within each MIPS performance category

- Methods to earn maximum credit in each category

- Ways to earn bonus points (if applicable)

- Computing the score for each category

- Calculating the MIPS final score

• Explain how payments are adjusted under MIPS

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How Are Clinicians Scored under MIPS?

Pick Your Pace: Review of 2017 Quality Payment ProgramOptions

1. Test Pace

2. Partial Year

3. Full Year

4. Advanced APM Participation

88

Presenter

Scoring, and ultimately the associated payment adjustment, will likely be one of the top questions that you will hear as you educate other trainers. Let’s begin this section of the training with a brief review of the important information to convey for the first performance year. During 2017, clinicians will have the opportunity to “pick their pace” in how they want to participate in the Quality Payment Program. Remember, there are four options: Option 1: Test Pace Option 2: Partial Year Option 3: Full Year Option 4: Participate in an Advanced Alternative Payment Model Quick Interactive Knowledge Check (comment only): How many days worth of data must a clinician report under the “Partial Year” option? In addition to the participation options, each performance category will be assigned a certain weight during the first year. Quality — 60% Cost — 0% (Remember trainers, we want clinicians to get a feel for the program, hence the reweight) Improvement Activities — 15% Advancing Care Information — 25% The question now becomes, “How is each performance category scored?”


MIPS Scoring for Quality (60% of Final Score)

Select 6 of the approximately 300 available quality measures (minimum of 90 days)

• Or a specialty set

• Or CMS Web Interface measures

• Readmission measure is included for group reporting with groups with at least 16 clinicians and sufficient cases

89

Presenter

Let’s begin with individual clinicians. Within the Quality performance category, clinicians will need to select six measures to report. It is a good idea for us to encourage clinicians to select the measures that are most appropriate for their practice and patient population. Of the six measures, clinicians need to select one outcome measure OR a high priority measure if an outcome measure is not available. It is important to note that high priority measures are classified as those related to patient safety, patient experience, care coordination, efficiency, patient outcomes, and appropriate use.



• Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks

– Benchmarks based on historical data (if available); or performance period if historical benchmark is not available

– Failure to submit performance data for a measure = 0 points

90

Presenter

Clinicians will receive between 1 and 10 points on each quality measure based on their performance against various benchmarks. These benchmarks are based on historical data, so it is good practice for all of us to encourage clinicians to monitor their performance throughout their chosen performance period. Zero points will be awarded to any clinician who fails to submit performance data for a chosen quality measure.


MIPS Scoring for Quality (60% of Final Score) Transition year participants automatically receive 3 points for completing and submitting a measure• If a measure can be reliably scored against a benchmark, then clinician can

receive 3 – 10 points– Reliable score means the following: – Benchmarks exists (see next slide for rules)– Sufficient case volume (>=20 cases for most measures; >=200 cases for

readmissions)– Data completeness met (at least 50 percent of possible data is submitted)

• If a measure cannot be reliably scored against a benchmark, then clinician receives 3 points

– Easier for a clinician that participates longer to meet case volume criteria needed to receive more than 3 points

91

Presenter

Alternatively, during the first year of the program, all clinicians are eligible to automatically receive 3 points just for completing and submitting a measure.



92

• More About Benchmarks- Separate benchmarks for different reporting mechanisms

• EHR, QCDR/registries, claims, CMS Web Interface, administrative claim measures, and CAHPS for MIPS

- All reporters (individuals and groups regardless of specialty or practice size) are combined into one benchmark

- Need at least 20 reporters that meet the following criteria:

• Meet or exceeds the minimum case volume (has enough data to reliably measured)

• Meets or exceeds data completeness criteria

• Has performance greater than 0 percent

• Why this matters? Not all measures will have a benchmark. If there is no benchmark, then a clinician only receives 3 points.

Presenter



Bonus Points

Clinicians receive bonus points for either of the following:

1. Submitting an additional high-priority measure

- 2 bonus point for each additional outcome and patient experience measure

- 1 bonus point for each additional high-priority measure

2. Using CEHRT to submit measures to registries or CMS

- 1 bonus point for submitting end-to-end

93

Presenter

There are also bonus points available (which will be capped at 10% of the denominator in the Quality performance category score), and we should encourage clinicians to take advantage of this opportunity. Clinicians will receive bonus points for accomplishing either of the following two requirements: Submit an additional high-priority measure Two bonus point for each outcome and patient experience measure One bonus point for each additional high-priority measure Use CEHRT to submit measures to registries or CMS One bonus point for submitting end-to-end The absolute maximum number of points an individual clinician (or for groups with fewer than 15 clinicians) may earn in the Quality performance category is 60.



Total Quality Performance Category Score =

Points earned on required 6 quality measures + Any bonus points

Divided by maximum number of points*

(Maximum score cannot exceed 100%)

*Maximum number of points = # of required measures x 10

94

Presenter

The equation for the Quality performance category score is very straightforward for individual clinicians: Total Quality Performance Category Score = points earned on the required six quality measures + any bonus points earned / the maximum number of points



• Maximum Number of Points- CMS Web Interface Reporter total score

– 120 points for groups with complete reporting and the readmission measure

– 110 points for groups with complete reporting and no readmission measure

• Other submission mechanisms total score– 70 points for 6 measures + 1 readmission measure

– 60 points if readmission measure does not apply

95

Presenter

It is important to note that the calculation for clinicians in groups of 15 or more is the same. However, the maximum number of points available to groups of clinicians is 70. This change is due to the fact that groups of clinicians will also be measured on readmissions, which CMS will calculate from claims data. Please be aware that groups of clinicians will only be measured if they have more than 200 cases. So for groups, the maximum points in the Quality category is 70 (6 submitted measures + 1 readmission measure). Also, as it relates to group reporting, there is special scoring for those clinicians submitting through the CMS Web Interface. Groups submitting Quality data via CMS Web Interface must have at least 25 clinicians and must submit data on 15 measures, however CMS will use the Medicare Shared Savings Program benchmarks and only score performance on the subset of 12 measures upon which the MSSP measures performance. Bonus points will be available for reporting high-priority measures and using EHR for end-to-end electronic reporting. All together, the total possible points for the category is 130 points (12 measures for performance x 10 points + 1 all-cause hospital readmission measure x 10).


MIPS Scoring for Cost (0% of Final Score in Transition Year)• Clinicians can earn maximum 10 points per episode Cost

measure based on performance compared to benchmark within performance period

• No submission requirements

- Clinicians assessed through claims data

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Presenter

Knowledge Check: Do clinicians need to report any cost data? As a quick review, the Cost performance category is comprised of two overall measures: Total Per-Capita Spending and Medicare Spending Per Beneficiary. The category also has 10 episode specific measures that looks at costs for a specific type of care. Clinicians can earn a maximum of 10 points per episode cost measure based on their performance compared to the benchmark within the performance period. Please remember that clinicians do not have to submit these cost measures; rather, these measures will be assessed through claims data. And since clinicians do not have to report, they will not receive a zero on any measure for failing to submit data.


Readjustment Options� If a clinician only has 1 Cost measure with a required

case minimum, then that measure is scored accordingly and the overall Cost performance category score will be adjusted to reflect that 1 measure

� If a clinician does not have any measures meeting the required case minimum, then a Cost score will not be calculated

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MIPS Scoring for Cost (0% of Final Score in Transition Year)

Presenter

An additional benefit for clinicians in the Cost category for the first year is readjustment. For example, if a clinician only has one cost measure with a required case minimum, then that measure is scored accordingly and the overall Cost performance category score will be adjusted to reflect that one measure. If a clinician does not have any measures meeting the required case minimum, then a Cost score will not be calculated.


MIPS Scoring for Cost (0% of Final Score in Transition Year)

Cost Performance Category Score =

Points assigned for scored measures

Divided by number of scored measures

Multiply by 10 possible points for each measure

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Quick Tip: No bonus points in cost performance category.

Presenter

Here is the equation for the Cost performance category: Cost Performance Category Score = points assigned for scored measures \ (number of scored measures x 10 possible points for each measure)


MIPS Scoring for Improvement Activities(15% of Final Score) • Total points = 40

• Activity weights- Medium = 10 points- High = 20 points

• Activity weights (for clinicians in small, rural, and underserved practices or with non-patient facing clinicians or groups)- Medium = 20 points- High = 40 points

• Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice

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Presenter

Earlier we discussed that the Improvement Activities performance category score was comprised of a selection of activities that were deemed either medium-weighted or high-weighted. Let’s discuss the points assigned to each weight. Activities with a medium-weight are worth 10 points each. Activities with a high-weight are worth 20 points each. The maximum allowable number of points that clinicians may earn in the Improvement Activities category is 40 points. There is one very important distinction to note within the category for clinicians who are in small practices, rural practices, practices in Health Professional Shortage Areas (HPSAs), and non-patient facing roles. The number of points assigned to each “weighting” are different for these specific clinicians. Medium-weight activities are worth 20 points each, while high-weight activities are worth 40 points each. And remember, clinicians who practice in a Patient-Centered Medical Home, Medical Home Model, or similar specialty practice automatically receive full credit for the category.


MIPS Scoring for Improvement Activities(15% of Final Score)

Improvement Activities Performance Category Score =

Total number of points for completed activities

Divide by total maximum number of points (40)

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Quick Tip: Maximum score cannot exceed 100%

Presenter

Now that we all have an idea of how the points will be distributed, let’s take a look at the category calculation. Improvement Activities Performance Category Score = (total number of points earned for completed activities \ total maximum number of points (40)) x 100


MIPS Scoring for Advancing Care Information(25% of Final Score) • Base score

- Clinicians must submit a numerator/denominator OR Yes/No combination for each of the following measures:

• Protect Patient Health Information

• Electronic Prescribing

• Patient Electronic Access

• Health Information Exchange: Send Summary of Care

• Health Information Exchange: Request/Accept Summary of Care

Failure to meet reporting requirements will result in base score of 0

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Presenter

The Advancing Care Information performance category score is the sum of a base score, performance score, and earned bonus points. The base score accounts for 50% of the overall category score and includes the following measures: Protect Patient Health Information Electronic Prescribing Patient Electronic Access Health Information Exchange: Send Summary of Care Health Information Exchange: Request/Accept Summary of Care As we learned earlier, clinicians must submit a numerator/denominator OR yes/no combination for each respective measure. Failure to meet the reporting requirements will result in the base score being zero.


MIPS Scoring for Advancing Care Information(25% of Final Score)

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Each measure is worth 10 percentage points. Clinicians are given a “performance rate” for each measure, and rates correspond to category percentages as follows:

1-10 = 1%11-20 = 2%21-30 = 3%31-40 = 4%41-50 = 5%51-60 = 6%61-70 = 7%71-80 = 8%81-90 = 9%90-100 = 10%

Performance Score

6 optional measures:

1. Patient Specific Education2. View, Download or Transmit3. Secure Messaging4. Patient Generated Health Data5. Clinical Information Reconciliation6. Public Health and Clinical Data Registry Reporting (5 options)

Presenter

In addition, eligible clinicians can score additional points, known as the performance score, based on the required measures that we discussed in the base score or the following 6 optional measures: 1. Patient Specific Education 2. View, Download or Transmit 3. Secure Messaging 4. Patient Generated Health Data 5. Clinical Information Reconciliation 6. Public Health and Clinical Data Registry Reporting (5 options) MIPS eligible clinicians can also receive bonus points for some improvement activities that use CEHRT.


MIPS Scoring for Advancing Care Information(25% of Final Score) Bonus Points

1. 5% bonus for reporting on any of these registry measures:

• Syndromic Surveillance Reporting

• Electronic Case Reporting

• Public Health Registry Reporting

• Clinical Data Registry Reporting

2. 10% bonus for using CEHRT to report Improvement Activities

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Presenter

Clinicians have the opportunity to receive bonus points in two ways: A 5% bonus will be earned for reporting on any of the following registry measures: Syndromic Surveillance Reporting Electronic Case Reporting Public Health Registry Reporting Clinical Data Registry Reporting Using CEHRT to report on activities in the Improvement Activities category will receive a 10% bonus


MIPS Scoring for Advancing Care Information(25% of Final Score)

Advancing Care Information Performance Category Score =

Base score

+

Cumulative performance score

+

Bonus points

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Quick Tip: Maximum score cannot exceed 100%

Presenter

To determine the performance category score for Advancing Care Information, use the following calculation logic: Advancing Care Information Performance Category Score = base score + cumulative performance score + bonus points


Knowledge Check

Which MIPS performance category does not require clinicians to submit data, but scores them on various episode Cost measures derived from claims data?

� Quality

� Cost

� Improvement Activities

� Advancing Care Information

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Presenter

Knowledge check. Interactive poll. “Which MIPS performance category does not require clinicians to submit data, but scores them on various episode cost measures derived from claims data?” Quality Cost Improvement Activities Advancing Care Information


Knowledge Check

Which of the following is NOT a component to the Advancing Care Information performance category base score?

� Protecting Patient Health Information

� Electronic Prescribing

� Reporting Medicare Per-Beneficiary Spending (MPBS)

� Health Information Exchange: Send Summary of Care

� Health Information Exchange: Request/Accept Summary of Care

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Presenter

Knowledge Check Interactive poll. “Which of the following is NOT a component to the Advancing Care Information performance category base score?” Protecting Patient Health Information Electronic Prescribing Reporting Medicare Per-Beneficiary Spending (MPBS) Health Information Exchange: Send Summary of Care Health Information Exchange: Request/Accept Summary of Care


Calculating the Final Score Under MIPSFinal Score = [(clinician Quality performance category score x actual

Quality performance category weight) +

(clinician Cost performance category score x actual Cost performance category weight)

+(clinician Improvement Activities performance category score x actual

Improvement Activities performance category weight) +

(clinician Advancing Care Information performance category score xactual Advancing Care Information performance category weight)]

x100

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Presenter

When calculating the Final Score, CMS will multiply the score for each performance category by the assigned weight of the category, then adds the weighted scores to derive a value between 0 and 100. The equation logic is as follows: Final Score = [(clinician Quality performance category score x actual Quality performance category weight) + (clinician Cost performance category score x actual Cost performance category weight) + (clinician Improvement Activities performance category score x actual Improvement Activities performance category weight) + (clinician Advancing Care Information performance category score x actual Advancing Care Information performance category weight)] x 100


Calculating the Final Score Under MIPS

Reweighting Option - For clinicians that cannot be scored within a MIPS

performance category

- “So what?” • Reduces the reporting burden on clinicians

• Gives clinicians flexibility to focus on categories specific to their practice

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Presenter

Of course, as we have discussed throughout this lesson, CMS will reweigh certain categories if a clinician cannot be scored. For the first year, if a clinician cannot be scored on Advancing Care Information then the percentage for this category will be added to the Quality performance category. This would make Quality worth 85%, Cost worth 0%, Improvement Activities worth 15%, and Advancing Care Information worth 0%. This is just one example of reweighing. If a clinician can only be measured on the Improvement Activities performance category, then the clinician will not receive a Final Score; rather, the clinician will be assigned the performance threshold score and awarded a neutral payment adjustment.


Transition Year 2017Final Score Payment Adjustment

>70 points x Positive adjustmentx Eligible for exceptional performance bonus –

minimum of additional 0.5%4 – 69 points x Positive adjustment

x Not eligible for exceptional performance bonus

3 points x Neutral payment adjustment1 – 2 points x Negative payment adjustment0 points x Negative payment adjustment of -4%

x 0 points = does not participate

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Ways to achieve final score of at least 3 points:• Advancing care information – Report on 5 required measures• Improvement activities – Attest to at least 1 improvement activity• Quality – Submit at least 1 out of at least 6 quality measures; more measures are

required for groups who submit using the CMS Web Interface measures


How Are Payments Adjusted Under MIPS?• Positive, negative, neutral adjustments

Based on CMS-established threshold വ First year threshold = 3 out of 100 points

വ “So what?” — Clinicians reporting some data will easily achieve this threshold

• Clinicians at or above the performance threshold will receive a neutral or positive adjustment factor based on a linear sliding scale

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Presenter

Now that we know how the Final Score is calculated, let’s discuss the method in which payments are adjusted as a result of the score. The law requires MIPS to be budget neutral. Therefore, clinicians’ MIPS scores within the four performance categories would be used to compute a positive, negative, or neutral adjustment to their Medicare Part B payments. The performance threshold is what will be used to determine which clinicians in the MIPS program will receive a positive, negative, or neutral adjustment. For the first year, CMS has established a very low threshold of 3 out of a possible 100 points. All clinicians need to do the first year is earn 3 points to avoid a negative payment adjustment. It is important to remember that this could be achieved as long as clinicians are participating through one of the “pick your pace” options. Clinicians with a Final Score at or above the performance threshold will receive a neutral or positive adjustment factor on a linear sliding scale. This means an adjustment of 0% is assigned for a Final Score at the performance threshold, while an adjustment factor for a final score of 100 would receive the highest available positive adjustment. While the payment adjustment percentage begins at +/- 4% in 2019, it will gradually increase to 5% in 2020, 7% in 2021, and 9% in 2022. The 9% payment adjustment will then continue on beyond 2022 as the standard of the MIPS program.


Additional Adjustment Factors for MIPS • Scaling factor to be applied to positive adjustments only

• “Exceptional Performer” category

- Incentive funding of $500,000,000 annually

- Clinicians who meet or exceed the threshold may receive up to a 10% bonus adjustment

- Final scores of 70 or more qualify for additional payment • Additional payments start at 0.5 percent and increase

with the final score

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Presenter

Trainers! Please be aware that in addition to the standard payment adjustment percentages, there is a scaling factor that may be applied to positive adjustments only. Since the MACRA statue requires MIPS to be budget neutral, a maximum scaling factor of 3.0 was introduced to ensure compliance. This means that clinicians in the program who have performed well and received a positive payment adjustment will be eligible to have their maximum payment adjustment percentage increased. For example, in 2019, if a clinician receives a positive 4% payment adjustment, he or she could also receive up to a 12% adjustment based off of the up-scaling factor of 3.0. Aside from the budget neutrality scaling factor, there is an “exceptional performer” category with incentive funding of $500,000,000 annually. Clinicians who meet or exceed the established performance threshold for the year will be eligible to receive an additional adjustment factor of up to 10%. Final scores of 70 or more qualify for additional payment. Additional payments start at 0.5 percent and increase with the Final Score. All together in 2019, a high-performing eligible clinician could receive a positive 4% payment adjustment with a 3.0 point up-scaling factor for a total positive payment adjustment of 12%. The same clinician could also receive an “exceptional performer” bonus of an additional 10%.


How Are Payment Adjustments Applied?CMS:

• Applies payment adjustments to each combination of TIN and NPI a clinician uses to bill Medicare (each enrollment)

• Uses logic models for certain rare cases. For example:

1. If a clinician participates in an MIPS-APM entity…

Then the APM entity final score is used

2. If a clinician submits as a group and as an individual (but is not a MIPS-APM entity)…

Then highest final score for TIN/NPI combination is used

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Presenter

For the purposes of payment adjustments, and we will discuss payments in greater depth shortly, CMS assigns the adjustments to the combination of the TIN and NPI, regardless of whether performance was measured at the individual or group level. If a clinician billed under more than one TIN during the performance period, and the eligible clinician starts working in a new practice (creating a new TIN/NPI combination) during the performance period, then CMS will take the clinician’s highest final score from the performance period and assign the score to the clinician in the new practice (TIN/NPI combination) during the payment year. CMS has also created logic for certain rare cases. For example: If a clinician is a participant in a MIPS-APM entity, then the APM entity final score would be used instead of any other final score If a clinician submits as a group and as an individual (but is not a MIPS-APM entity), then CMS would use the highest final score for the TIN/NPI combination


When Are MIPS Payment Adjustments Announced?

Transition year payment adjustments:

• Announced December 1, 2018

• Applied to Medicare payments in 2019

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Presenter

Payment adjustments for the first year of the MIPS program will be announced no later than December 1, 2018. These adjustments will be applied to items and services provided by clinicians during 2019 that are reimbursed under Medicare Part B.


Can a Clinician Dispute a Final Score or Payment Adjustment?

Mechanism: Targeted (Informal) Review

MIP-eligible clinicians may request a review of the calculation of the:

1. MIPS adjustment factor

2. Additional MIPS adjustment factor, as applicable

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Presenter

Yes. Clinicians who want to dispute their Final Score or payment adjustment have the opportunity to request targeted (informal) review.


Lesson SummaryIn this lesson, you have learned that:

• Each MIPS performance category has:- Different measure selection requirements

- Various scoring standards

- Unique equations to compute each performance category score

• The MIPS final score for clinicians is the sum of the clinician’s performance category scores

• Payments to clinicians are adjusted based on the MIPS final score

• Clinicians have the opportunity to earn an “Exceptional Performer” bonus

• Targeted review is available to clinicians as a dispute resolution mechanism

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Questions?

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Presenter

What questions do you have for us on scoring and payment adjustments related to the MIPS program?


How Do We Get Ready for Transition Year of the Quality Payment Program?

Group Discussion

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Presenter

Interactive chat. Allow the trainers to send in their thoughts on what they think are the best steps to get started. We need to capture these comments. “As a group, what do we think are the best steps for getting ready for the initial year of Quality Payment Program?”


Getting Ready for the Transition Year

Let’s —• Build an identity of collaboration• Remind clinicians to update their information

• Identify important deadlines

• Keep listening and providing feedback

• Remember the program is new—let’s support each other

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Next Steps

CMS will hold “Office Hours” sessions for program-specific questions related to Quality Payment Program, MIPS, APMs, and more.

• Service Center — October 24

• QIN-QIOs — October 27

• TCPI (PTNs, SANS) — October 27

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Documents

Introduction to the Quality Payment Program · MACRA shifts the payment equation from the services that are only one part of the clinician’s job to the overall work of the clinician