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MACRA COST MEASURES POST-FIELD TESTING WEBINARWednesday, March 27, 20191:00 – 2:30 p.m. ET
Disclaimer
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference.
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.
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Acronyms Included in this Presentation
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Acronym Definition
CMS Centers for Medicare & Medicaid Services
DRG Diagnosis Related Group
EBCM Episode-Based Cost Measure
E&M Evaluation and Management
MAP Measure Applications Partnership
MUC Measures Under Consideration
MIPS Merit-based Incentive Payment System
MSPB Medicare Spending Per Beneficiary
NQF National Quality Forum
QRUR Quality and Resource Use Report
TEP Technical Expert Panel
TIN Tax Identification Number
TIN-NPI Tax Identification Number/National Provider Identifier
TPCC Total Per Capita Cost
MACRA Cost Measures Post-Field Testing WebinarAgenda
• Introduction
• Revised Total Per Capita Cost Measure
• Revised Medicare Spending Per Beneficiary Clinician Measure
• Episode-Based Cost Measures
• Q&A Session
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INTRODUCTION
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MIPS Cost Performance Category for 2019 Performance Period Includes Ten Cost Measures
• MIPS composite performance score is calculated for eligible clinicians using four categories: (i) quality, (ii) cost, (iii) improvement activities, and (iv) promoting interoperability
• MIPS Cost Performance Category constitutes 15 percent of Final Score in MIPS 2019 performance period
• MIPS inventory of cost measures for CY 2019 performance period:
- 8 EBCMs
- MSPB measure
- TPCC measure
• CMS continues to develop and refine cost measures for potential future use in MIPS
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New EBCMs Were Developed and Current MSPB and TPCC Measures Were Re-evaluated for Potential Use in MIPS
• In 2018, CMS and Acumen, the measure development contractor, developed 11 new EBCMs for potential use in MIPS
• Two existing MIPS measures also underwent re-evaluation as part of the measure maintenance process described in the CMS Measures Management System Blueprint
• Throughout measure development and re-evaluation, a broad range of stakeholders provided input into the measures
- EBCMs were developed with input from stakeholders through a TEP, Clinical Subcommittees and measure-specific workgroups, Person & Family Committee, and public comment
- MSPB and TPCC were refined with stakeholder input through a TEP, an expert workgroup, and public comment
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Newly Developed EBCMs and Revised MSPB and TPCC Were Field Tested Before Consideration of Potential Use in MIPS
• Eleven newly developed episode-based cost measures- Acute Kidney Injury Requiring New Inpatient Dialysis
- Elective Primary Hip Arthroplasty
- Femoral or Inguinal Hernia Repair
- Hemodialysis Access Creation
- Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
- Lower Gastrointestinal Hemorrhage
- Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
- Lumpectomy, Partial Mastectomy, Simple Mastectomy
- Non-Emergent Coronary Artery Bypass Graft (CABG)
- Psychoses/Related Conditions
- Renal or Ureteral Stone Surgical Treatment
• Two revised cost measures*- Medicare Spending Per Beneficiary (MSPB) clinician
- Total Per Capita Cost (TPCC)
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* The MSPB clinician and TPCC measures that were field tested are separate from the measures used in the 2017 to 2019 MIPS performance periods. Field testing information about the revised MSPB clinician and TPCC measures did not affect eligible clinicians’ MIPS score or payment adjustments.
Field Testing Took Place in October and November 2018
• CMS conducted field testing for 11 newly developed episode-based cost measures and revised MSPB and TPCC measures from October 3 to November 5, 2018- Over 20,000 field test reports were downloaded during this
period, including 2,300+ EBCM reports, 5,000+ MSPB clinician reports, and 12,000+ TPCC reports
• Goal of field testing was to gather stakeholder feedback on:- Draft measure specifications - Field test report templates- Supplemental documentation
• Input was gathered through an online survey
• Feedback received during field testing was taken into consideration for potential measure refinement and for future measure development activities
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The Measures Were Refined After Field Testing to Incorporate Stakeholder Feedback Received
• After field testing, Acumen summarized stakeholder feedback received from field testing for:
- Measure-specific workgroups for the episode-based cost measures
- TEP and an expert workgroup for revised MSPB and TPCC
• The TEP and workgroups considered the feedback received in recommending refinements to the measures
• After going through this refinement process, the cost measures were presented to the MAP in December 2018 and January 2019
Measures Were Presented to the MAP in December 2018 and January 2019
• In December 2018, the MAP Clinician Workgroup discussed the 11 episode-based cost measures and two revised measures and established a preliminary recommendation of Conditional Support for Rulemaking
• In January 2019, the MAP Coordinating Committee reviewed the Clinician Workgroup recommendations and finalized the following recommendations:- Conditional Support for Rulemaking for 10 episode-based cost
measures and the revised MSPB clinician measure
- Do Not Support for Rulemaking for Psychoses/Related Conditions episode-based cost measure
- Do Not Support with Potential for Mitigation for the revised TPCC measure
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CMS Will Consider Stakeholder Feedback in Determining Next Steps for the Measures
• Stakeholder comments and MAP feedback will be reviewed to determine next steps for the 11 episode-based measures and 2 revised measures
• Plan to submit measures for NQF endorsement in an upcoming cycle
- The condition for the MAP recommendation of ‘Conditional Support for Rulemaking’ is NQF endorsement
• Further education and outreach is planned to increase awareness about the measures and provide more opportunities for clinicians and stakeholders to learn about them
• A report summarizing the field testing feedback received will be posted on the MACRA Feedback Page in April 2019
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Cost Measures Will Undergo Routine Maintenance
• Cost measures will follow the standard 3-year maintenance cycle, as outlined in the CMS Measures Management System Blueprint- Routine updates will occur annually and there will be
comprehensive review every 3 years
• Stakeholders can provide input on the measures at any time, by submitting comments to CMS through:- The Quality Payment Program Service Center ([email protected])
- Acumen, the measure development contractor ([email protected])
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Opportunities for Providing Stakeholder Input
• Cost Measure Development Process- Membership in the Clinical Subcommittees or measure-specific workgroups (refer to slide
51 for link to Call for Nominations)
• Field testing of new and revised measures
• MAP public comment periods
• Annual notice-and-comment rulemaking process
• Annual measure maintenance process- Recommend updates and potential refinements for developed measures in
conjunction with the measure workgroups
• NQF endorsement- The cost measures will be submitted for NQF endorsement in a future cycle
• Quality Payment Program Service Center- Email any comments and/or inquiries to [email protected]
• Acumen Project Inbox- Email any comments and/or inquiries to [email protected]
A document outlining in more detail the opportunities for providing stakeholder input is available here will be posted on the MACRA Feedback Page in April 2019.
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REVISED TPCC MEASURE
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Current TPCC Was Introduced for Use in MIPS CY 2017 Performance Year
• Background:
- The current TPCC measure has been part of the MIPS cost performance category since the 2017 MIPS performance year
- Prior to its use in MIPS, CMS used a version of the TPCC measure in the VM Program and reported it in annual QRURs
- After MACRA ended the VM Program, TPCC was added to the MIPS cost performance category
• Clinician familiarity with measures from VM and QRURs
• Cover large number of patients
• Provide important measurement of clinician contribution to overall costs
• Tested and reliable for Medicare populations
• The TPCC measure has been revised before consideration for potential use in MIPS
• Stakeholder feedback has suggested refining to:
- Better identify a primary care relationship
- Allow for multiple clinicians and clinician groups to be attributed responsibility for a patient’s primary care management
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Re-Evaluation to Address Stakeholder Concerns Has Been Informed by TEP and Public Comment
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TEP
August 2017
• TEP provided initial input on direction of refinements, considering prior public comments
• Suggested focusing on attribution and service assignment
TEP
May 2018
• TEP provided input on specific approaches to refining attribution methodology
• Refinements should be to: o identify start and
end of clinician’s primary care responsibility for a patient
o account for shared responsibility across clinicians
Field Testing
October-November 2018
• Acumen conducted extensive education and outreach activities: o Sent mass email
outreacho Held office hours for
relevant specialty societies
o Hosted national field testing webinar
o Posted draft specifications, sample field test report on CMS website
• Nearly 13,000 TPCC field test reports downloaded
TEP
November 2018
• TEP considered field testing feedback and recommended further refinements to specialty exclusions
Revised TPCC Refinements Address Stakeholder Feedback About Current TPCC
Current TPCC Revised TPCC
• Triggering based on plurality of E&M (can be just one)
• Triggering requires primary care E&M and an additional primary care E&M or primary care service
• Cost assigned prior to seeing beneficiary
• Cost assigned only on and after seeing the beneficiary
• Single attribution to TIN-NPI • Multiple attribution to TINs/TIN-NPIs
• Primary care clinician given precedence over non-primary care providers in attribution
• Exclusion of non-primary-care specialists and clinicians providing high frequency of non-primary-care services
• Risk factors determined 1 year prior to measurement period
• Risk factors determined 1 year prior to each beneficiary-month
• Two risk models: 1/ New Enrollee Model2/ Community Model
• Three risk models:1/ New Enrollee Model2/ Community Model3/ Institutional Model
• Annualization of cost for beneficiary death
• No grouping of cost after beneficiary’s death
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Overview of Revised TPCC Measure Construction Steps
1) Trigger candidate events by identifying a primary care E&M service with a confirming primary care service or E&M claim
2) Apply attribution exclusions to remove clinicians who may be unrelated to primary care management
3) Initiate a year-long risk window from candidate event, and attribute bene-months within the measurement period for TIN/TIN-NPI
4) Calculate beneficiaries’ payment-standardized monthly cost
5) Risk adjust cost to account for beneficiary-level risk factors
6) Apply specialty-adjustment to account for cost variation across clinician specialties
7) Calculate TPCC measure score as the mean payment standardized, risk-adjusted, and specialty-adjusted monthly cost for attributed beneficiary-months
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Revised TPCC Measure Addresses Feedback About Attribution While Maintaining Measure Intent of Capturing Overall Cost of Care
• The measure identifies the start of a primary care relationship through a primary care E&M service (“candidate event”) in combination with another service
• This opens a one-year risk window divided into 4-week blocks (“bene-months”)
• The measure evaluates the average cost across the bene-months for the attributed clinician during the risk window and measurement period
Risk Window (1 Year)
Measurement Period
Attributable Beneficiary-Months
Non-attributable Months
Beneficiary-months when all Part A and B costs are assigned
Clinician A: primary care E&M service
Clinician B: primary care E&M service
Candidate Event
Revised TPCC Only Holds Clinician Accountable After Identifying Start of Primary Care Relationship
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Current TPCC
Measurement Period
TPCC Episode Window (1 year)
Yearlong period when all Part
A and B costs are assigned
Clinician A: primary care E&M
service
Clinician B: primary care E&M
service
Revised TPCC
Measurement Period
Risk Window (1 Year)
Beneficiary-months when all
Part A and B costs are
assigned
Clinician A: primary care E&M
service
Clinician B: primary care E&M
service
Candidate Event
Feedback Received After Field Testing Informed Additional TPCC Measure Refinement
Revised TPCC Measure (During Field Testing)
Revised TPCC Measure (Refined After Field Testing)
Exclusions
Exclusion of clinicians based on service category exclusions. Clinicians performing high frequency of non-primary-care-related services are excluded.
Added HCFA specialty exclusions for clinicians who belong to any of the 56 HCFA specialties identified as not reasonably responsible for providing primary care. The inclusion of the specialty exclusion was considered and approved by the TEP.
Risk Adjustment
No specialty adjustment included to focus on other measure refinements. The measure does not account for the difference in cost that is due to a clinician’s specialty.
A specialty adjustment has been added, which is a cost adjustment that is applied to account for costs that vary across specialties and across TINs with varying specialty compositions.
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Stakeholder Feedback About Revised TPCC Measure Has Been Addressed
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Concern About Revised TPCC Measure Clarification
All-cost measure holds clinician accountable for costs outside of their control
TPCC measure’s intent is to capture the overall cost of care as a broad, population-based measure
Measure is too complex CMS will hold additional education and outreach activities (e.g., meeting with AMA, public webinar, produce updated specifications)
Need for further testing and stakeholder input
Measure is tested for validity and reliability;Updated National Summary Data Report will be released; Measure has a mean reliability of 0.95 for TINs with 20 beneficiaries and a mean adjusted reliability of 0.82;If the measure is proposed for use in MIPS, there will be further public comment opportunity
New attribution approach expands attributed clinicians too extensively (e.g., to specialized TINs with a PA or NP billing one E&M)
Confirming E&M or other primary care service must be present;Multiple attribution is used to focus on care coordination for patients; Attributed TINs and TIN-NPIs provide large share of E&Ms to attributed beneficiaries
Double-counting of costs and beneficiaries with episode-based measures
No double counting because each measure is compared to expected costs for its own beneficiaries/episodes
Attribution Methodology Prevents Attribution to Non-Primary Care Related Specialties
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Number of Attributed Clinicians Across Top HCFA Specialties
HCFA Specialty
# Attributed Clinicians
Current TPCC Revised TPCC
All 203,958 326,649
Family Practice 62,208 73,346
Internal Medicine 54,205 64,240
Nurse Practitioner 37,938 64,610
Physician Assistant 19,002 32,971
Cardiology 5,507 19,966
Dermatology 3,479 0
General Practice 3,069 4,044
Urology 1,822 0
Ophthalmology 1,354 0
Geriatric Medicine 1,305 1,666
The coverage figures provided in this table and in all other tables throughout this presentation are based on the clinicians/clinician groups billing Part B Physician/Supplier claims under a MIPS eligible clinician specialty, and do not reflect other MIPS eligibility criteria (e.g., Advanced APM participation).
Performance by Group Practice (TIN) Size
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TIN Size # of TINs Mean Reliability
Distribution of Measure Score
Mean 25th 50th 75th
All TINs 77,479 0.95 $1,053 $921 $1,040 $1,161
1 40,139 0.94 $1,024 $890 $1,016 $1,144
2-10 26,094 0.95 $1,082 $956 $1,058 $1,173
11-50 7,341 0.96 $1,109 $970 $1,076 $1,197
51+ 3,200 0.98 $1,134 $1,016 $1,097 $1,202
Concluding Thoughts For Revised TPCC
• The TPCC measure helps meet program goal of having a broad population measure rewarding care management that avoids acute events and their consequences
• Revised TPCC addresses many of the stakeholder comments with current TPCC, particularly regarding identification of primary care relationship
• Revised TPCC is both reliable and valid, and fulfills CMS’s intention of refining TPCC through stakeholder input since its initial implementation into MIPS
The measure specifications for the revised TPCC measure that is updated after field testing will be posted on the MACRA Feedback Page in April 2019
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REVISED MSPB CLINICIAN MEASURE
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Current MSPB Was Introduced for Use in MIPS CY 2017 Performance Year
• Background:
- The MSPB measure has been part of the MIPS cost performance category since the 2017 MIPS performance year
- Prior to its use in MIPS, CMS used a version of the MSPB measure in the VM Program and reported it in annual QRURs
- After MACRA ended the VM Program, MSPB was added to the MIPS cost performance category
• Clinician familiarity with measures from VM and QRURs
• Covers a large number of patients
• Provides important measurement on clinician contribution to overall costs
• Tested and reliable for Medicare populations
• The MSPB measure has been revised before consideration for potential use in MIPS
• Stakeholder feedback has suggested refining to:
- Ensure attributed clinicians are responsible for a patient’s care during an episode
- Remove certain services identified as unlikely to be influenced by the clinician’s care decisions
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Measure Development Process for Revised MSPB Clinician Measure
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TEP
August 2017
• TEP provided initial input on direction of refinements, considering prior public comments
• Suggested focusing on attribution and service assignment
TEP
May 2018
• TEP provided input on specific approaches to refining attribution methodology and excluding services
• Refinements should be to: o Attribute at TIN
level firsto Customize
attribution for Medical and Surgical MS-DRG
o Group episodes by MDC for service exclusions
MSPB Service Refinement Workgroup
June - July 2018
• Acumen convened a workgroup dedicated to defining service exclusions by MDCs, groups of MS-DRGs
• Workgroup composed of 25 clinicians from a wide range of medical backgrounds
Field Testing
October - November 2018
• Acumen conducted extensive education and outreach activities:
• Sent mass email outreach
• Held office hours for relevant specialty societies
• Hosted national field testing webinar
• Posted draft specifications, sample field test report on CMS website
• Over 5,000 MSPB clinician field test reports downloaded
TEP
November 2018
• TEP considered field testing feedback and had the opportunity to recommend any further refinements
Overview of Revised MSPB Clinician Measure Construction Steps
1) Identify episodes as admissions to IPPS hospitals, excluding episodes meeting defined criteria (e.g. beneficiary is enrolled in Part C)
2) Attribute the medical or surgical episode to TIN(s)/TIN-NPI(s)
3) Exclude unrelated services and calculate the observed episode cost
4) Risk adjust cost to account for beneficiary-level risk factors
5) Calculate the measure score as the payment standardized, risk-adjusted, average episode cost
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Revised MSPB Clinician Measure Addresses Concerns from Stakeholders
• The revised MSPB clinician measure is focused on inpatient care
• It assesses TIN(s) and TIN-NPI(s) that are involved in the course of care provided to a beneficiary
• An episode includes all Medicare Parts A and B claims in the period immediately prior to, during, and following the beneficiary’s hospital stay, excluding a defined list of services
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MSPB Clinician Episode Window
30 Days Post-DischargeIndex Admission
3 Days
Pre-Admission
Index Admission
(Admission to an
IPPS Hospital)
Index Admission
Duration (Admission
to Discharge)
Services Included in
Episode
Services Excluded
from Episode
Revised MSPB Refinements Address Feedback About Current MSPB
Current MSPB Revised MSPB
• Attributed each episode to the TIN-NPIbilling the plurality of costs for Medicare Part B services rendered during an index admission
• Separate attribution methods for medical and surgical episodes:- Medical episodes: Attribute to TIN(s) billing
substantial share of E&Ms during index admission and TIN-NPIs teaming up in that care
- Surgical episodes: Attribute surgical episodes to the surgeon(s) performing the main procedure of an episode
• Attributed Medical episodes first at the TIN-NPI level
• Attribute Medical episodes first at the TIN level
• Single attribution to TIN-NPI • Multiple attribution to TINs/TIN-NPIs
• All-cost measure that included all Medicare Part A and B claims paid during the period from three days prior to the index admission through 30 days after discharge
• Unrelated services excluded, specific to groups of DRGs aggregated by MDC-level
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Performance by Group Practice (TIN) Size
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TIN’s # of Clinicians
# of TINs Mean Reliability
Distribution of Measure Score
Mean 25th 50th 75th
All TINs 20,853 0.77 $18,838 $17,730 $18,701 $19,791
1 6,854 0.69 $19,096 $17,727 $18,942 $20,285
2-10 7,821 0.76 $18,904 $17,786 $18,785 $19,890
11-50 3,788 0.85 $18,569 $17,674 $18,522 $19,431
51+ 2,390 0.92 $18,305 $17,685 $18,386 $19,031
Attributing at the Group Practice Allows for Joint Responsibility Without Decrease in Reliability
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TIN-NPI Attribution Method
# of Attributed TIN-NPIs
Mean ReliabilityMean Share of E&M
Claims Billed By Attributed TIN-NPI
TIN Level 30% Rule* 127,529 0.69 30.5%
TIN-NPI 30% Rule** 73,729 0.67 49.3%
* Attribution method used in revised MSPB measure: a TIN-NPI is attributed if they bill at least one E&M within a TIN that bills at least 30% of E&Ms during the inpatient stay** Alternative attribution method for comparison: a TIN-NPI is attributed if they bill at least 30% of E&MS during the inpatient stay
Concluding Thoughts for Revised MSPB Clinician Measure
• Revised MSPB clinician measure addresses the majority of stakeholder feedback regarding the current MSPB measure used in MIPS
• Attribution better focused on clinicians managing an inpatient stay, and certain costs unlikely to be influenced by the attributed clinicians’ care decisions are removed from the measure
• Revised MSPB clinician is both reliable and valid, and fulfills CMS’s intention of refining MSPB through stakeholder input since its initial implementation into MIPS
The measure specifications for the revised MSPB clinician measure that is updated after field testing will be posted on the MACRA Feedback Page in April 2019
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EPISODE-BASED COST MEASURES
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CMS is Developing EBCMs for Potential Use in the MIPS Cost Performance Category
• EBCMs represent the cost to Medicare for the items and services delivered to a patient during an episode of care
• EBCMs differ from the TPCC and MSPB measures because they only include items and services that are related to the episode and within the reasonable influence of the attributed clinician for a clinical condition or procedure
• Measure development approach gathers detailed clinical input on each component of episode-based cost measures from Clinical Subcommittees and measure-specific workgroups
- 8 measures developed in Wave 1 (May 2017 – January 2018) are currently in use in the cost performance category for the 2019 MIPS performance period
- 11 measures developed in Wave 2 (April 2018 – December 2018) underwent field testing and were reviewed by the MAP in December 2018 and January 2019
• Upcoming Wave 3 of measure development will include chronic condition EBCMs in addition to procedural and acute inpatient EBCMs
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19 EBCMs Developed to Date Cover Range of Acute Inpatient Conditions, Procedures, and Specialties
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Measure Development Process Incorporates Stakeholder Input at Each Step
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Technical Expert Panel (TEP)
• Serves a high-level advisory role and provides guidance on overall direction of measure development and re-evaluation
• Includes representatives recruited through public call for nominations from specialty societies, academia, healthcare administration, and person and family organizations
• Meetings in 2016-2018
Clinical Committee
(Aug-Sept 2016)
• Provided expert input to develop draft list of episode groups and trigger codes for episode-based cost measures
• Draft list used as starting point for episode-based cost measure development
• 70+ clinical experts from 50+ professional societies recruited through public call for nominations
Clinical Subcommittees (CS)
• Provide detailed clinical input to build out all components of episode-based cost measures
Wave 1 (May 2017-Jan 2018)
• 7 Subcommittees, comprising approx. 150 clinicians affiliated with nearly 100 societies
• Developed 8 measures
Wave 2 (April 2018-Dec 2018)
• 10 Subcommittees comprising over 265 clinicians affiliated with more than 120 societies
• Developed 11 measures
Person and Family Committee (PFC)
• Includes Medicare beneficiaries and their caregivers and family members
• Contributed detailed input on episode development prioritization, episode windows, and service assignments to be shared with CS
• Identified services perceived as aiding recovery or helping to avoid unnecessary cost and complications
• Meetings June 2017 –September 2018
Steps for Construction of Episode-Based Cost Measures
1) Identify episodes as (i) IP stays for treatment of specific acute conditions as identified by certain MS-DRGs (for acute IP medical condition episode groups) or (ii) procedures as identified by specific CPT/HCPCS codes (for procedural episode groups)
2) Attribute episodes to the TIN that bills at least 30% of the E&M codes during the trigger IP stay and to any TIN-NPI who bills any IP E&M codes as part of an attributed TIN (for acute IP medical condition episode groups) or to TIN-NPIs that bill the trigger code(s) (for procedural episode groups)
3) Assign costs for clinically related services occurring during the episode window and calculate the observed episode cost
4) Apply exclusions to remove certain episodes and their costs from measure calculation
5) Risk adjust cost to account for risk factors
6) Calculate the measure score as the payment standardized, risk-adjusted, average episode cost
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EBCMs Only Account for Costs Clinically Related to the Condition or Procedure
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• EBCMs inform clinicians on the cost of their beneficiary’s care for which they are responsible during an episode’s timeframe
• Only items or services that are clinically related and within the reasonable influence of the attributed clinician that occur within the episode window are assigned to the episode
• The cost of the assigned services is summed to determine each episode’s standardized observed cost
Attribution for Acute IP Medical Condition Episode Groups Reflects the Team-Based Nature of Inpatient Care
• Attribute to TINs billing at least 30 percent of E&M codes during the trigger IP stay and TIN-NPIs billing at least one E&M code with a TIN meeting the attribution threshold during the IP stay
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Procedural Episode Groups are Attributed to Clinician(s) Performing the Procedure
• Identify the procedure that triggers an episode group using CPT/HCPCS codes on Part B Physician/Supplier claims
• Attribute the episode to the TIN(s) and TIN-NPI(s) found billing the trigger code for the procedure
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Feedback Received After Field Testing Informed Additional EBCM Refinement
• Measure-specific feedback received during field testing informed each workgroup’s refinement for the specifications of each measure
44
COPD Measure (During Field Testing) COPD Measure (Refined After Field Testing)
Sub-Groups
Included two sub-groups: • COPD Exacerbation with Mechanical Ventilation > 24
hours• COPD Exacerbation with no Mechanical Ventilation <
24 hours
Replaced field testing sub-groups with the following sub-groups:• COPD Exacerbation with No Non-Invasive Positive Pressure
Ventilation (NIPPV) or Mechanical Ventilation (MV)• COPD Exacerbation with NIPPV < 96 hours without MV• COPD Exacerbation with MV < 24 hours • COPD Exacerbation with MV 24-96 hours
Measure-SpecificExclusions
Included the following exclusions:• COPD Exacerbation after Lung Resection • Inpatient COPD Exacerbation in Lung Transplant
Patient• Patients that Leave Against Medical Advice
Added the following exclusions:• Mechanical Ventilation (MV) > 96 hours • Non-invasive Positive Pressure Ventilation (NIPPV) > 96 hours • Patients Receiving Active Treatment for Lung Cancer
Service Assignment
Included assigned services for the following categories:• Bronchoscopy• COPD Exacerbation • Cardiac Complications• Diabetic Complications• Physical Therapy / DME• Post-Acute Care • Pulmonary Complications, Other • Renal Failure and Metabolic Abnormalities • Sepsis• Thromboembolism (DVT/PE)
Edited the following service assignment:• Do not assign services related to hip fracture and other
sequelae of falls if they occur after discharge from hospitalization
• Assign services related to inhaled medications• Do not assign services related to initial ambulance transport
to the hospital• Do not assign services related to pneumothorax
Performance by Group Practice (TIN) Size –Procedural Episode
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Episode GroupTIN’s # of Clinicians
# of TINsMean
Reliability
Distribution of Measure Score
Mean 25th 50th 75th
Femoral or Inguinal Hernia Repair
All TINs 2,250 0.86 $4,075 $3,901 $4,237 $4,457
Femoral or Inguinal Hernia Repair
1 436 0.81 $3,975 $3,706 $4,197 $4,441
Femoral or Inguinal Hernia Repair
2-10 574 0.86 $3,967 $3,656 $4,192 $4,430
Femoral or Inguinal Hernia Repair
11-50 316 0.85 $4,021 $3,805 $4,214 $4,448
Femoral or Inguinal Hernia Repair
51+ 924 0.89 $4,148 $3,989 $4,262 $4,470
Performance by Group Practice (TIN) Size –Acute Condition Episode
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Episode GroupTIN’s # of Clinicians
# of TINsMean
Reliability
Distribution of Measure Score
Mean 25th 50th 75th
COPD All TINs 3,779 0.70 $12,783 $8,730 $10,205 $14,596
COPD 1 476 0.58 $13,298 $8,844 $10,404 $15,595
COPD 2-10 907 0.63 $13,146 $8,873 $10,444 $15,163
COPD 11-50 980 0.69 $12,814 $8,776 $10,230 $14,647
COPD 51+ 1,416 0.79 $12,668 $8,682 $10,143 $14,415
Attributing at the Group Practice Allows for Joint Responsibility Without Decrease in Reliability
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Episode Base Cost Measure – Acute
Conditions
TIN-NPI Attribution Method
# of Attributed TIN-NPIs
Mean Reliability
Mean Share of E&M Claims
Billed By Attributed TIN-
NPI
COPD TIN Level 30% Rule* 10,178 0.47 36.0%
COPD TIN-NPI 30% Rule** 2,915 0.45 57.5%
Psychoses/Related Conditions
TIN Level 30% Rule* 5,541 0.88 42.3%
Psychoses/Related Conditions
TIN-NPI 30% Rule** 3,051 0.86 62.4%
* Attribution method used in acute condition measures: a TIN-NPI is attributed if they bill at least one E&M within a TIN that bills at least 30% of E&Ms during the inpatient stay** Alternative attribution method for comparison: a TIN-NPI is attributed if they bill at least 30% of E&MS during the inpatient stay
Resources for EBCM Measure Development
The following resources will be available on the MACRA Feedback Page in April 2019:
• EBCM Measure Specifications
- Comprised of the methodology documents and measure codes list files that were updated after field testing for each EBCM
• PFC Guiding Principles Document
- Document shared with the CS that contains general principles for episode group prioritization that was shared with the CS members as they discussed and voted episode groups to develop for Wave 2
• PFC Findings Documents
- Document shared with the measure-specific workgroups prior to the post-field testing refinement of the measures, compiling findings from in-depth interviews with PFC members with relevant experience for each EBCM
• National Summary Data Report
- Document updated after field testing that presents national-level summary statistics on the cost measures and provides regression analysis results
• October-November 2018 Field Testing Feedback Summary Report
- Document summarizing the stakeholder feedback received from field testing 48
CMS Plans to Develop Chronic Condition EBCMs in Upcoming Wave 3 of Measure Development
• For Wave 3 of measure development, CMS and Acumen plan to develop chronic condition cost measures along with additional acute condition and procedural measures
• Acumen plans to convene a Chronic Condition CS- Currently recruiting primary care practitioners and specialists with
experience treating chronic conditions on an ongoing basis
• Acumen will share input received from the TEP regarding prioritization and the measure development framework for chronic condition EBCMs
• Similar to process used in Wave 2, the Chronic CS will select chronic episode group(s) for development and provide criteria for recruiting a smaller, measure-specific workgroup for each episode group- Workgroup will provide detailed input on measure specifications - Workgroup will have targeted and balanced composition reflecting types of
clinicians providing care for patients with selected chronic condition
49
Framework Used in Waves 1 and 2 Will Apply to Chronic Condition Measure Development in Wave 3
• Initial waves of measure development used robust framework specific to acute inpatient medical condition and procedural episode group development
• Key principles from this framework carry over to chronic condition measures- Attribution of episodes to eligible clinicians should be clear at time of
service - EBCMs should be actionable, focusing on costs under the influence of
attributed clinicians- Cost measures should account for patient complexity and comorbidities- Cost measures should be aligned with quality measures to ensure
consideration of aspects of quality that are not reflected in EBCMs themselves
• At the same time, core components of the previous episode group development framework require reassessment and revision to address the unique issues inherent to continuous care management for chronic diseases
• Chronic condition EBCMs function separately from TPCC, as EBCMs focus on a single condition
50
Nomination Period for Wave 3 of Measure Development is Now Open
• The Call for Subcommittee nominations is available here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/TEP-Currently-Accepting-Nominations.html#a0311
• If you would like to be contacted when we open the nomination period for future Clinical Subcommittees, please provide your contact information on our mailing list here: https://www.surveymonkey.com/r/macra_clinical_subcommittee_mailing_list
51
Q&A SESSION
52
Q&A Session Information
To ask a question, please dial:
1-866-452-7887
If prompted, use passcode: 1391935
Press *1 to be added to the question queue
You may also submit questions via the chat box
Speakers will answer as many questions as time allows
If there are additional questions, please direct the questions to: [email protected] you can call at 1-866-288-8292
53
Resources for Cost Measures Available in April 2019
• The Measure Specifications updated after field testing- Revised TPCC measure- Revised MSPB measure- Episode-Based Cost Measures
• PFC Documents- Guiding Principles- Measure-Specific Findings
• Stakeholder Input Opportunities Document
• National Summary Data Report updated after field testing
• October-November 2018 Field Testing Feedback Summary Report
• Resources will be available on the MACRA Feedback Page.
Please direct any additional comments or inquiries to:
• Quality Payment Program Service Center: [email protected]
• Acumen Project Inbox: [email protected]
54
APPENDIX A: REVISED TPCC MEASURE CONSTRUCTION
55
Overview of Revised TPCC Measure Construction Steps
1) Trigger candidate events by identifying a primary care E&M service with a confirming primary care service or E&M claim
2) Apply attribution exclusions to remove clinicians who may be unrelated to primary care management
3) Initiate a year-long risk window from candidate event, and attribute bene-months within the measurement period for TIN/TIN-NPI
4) Calculate beneficiaries’ payment-standardized monthly cost
5) Risk adjust cost to account for beneficiary-level risk factors
6) Apply specialty-adjustment to account for cost variation across clinician specialties
7) Calculate TPCC measure score as the mean payment standardized, risk-adjusted, and specialty-adjusted monthly cost for attributed beneficiary-months
56
Step 1: Trigger Candidate Events to Identify Start of Primary Care Relationship
• A primary care E&M service is considered a candidate event for attribution if the primary care relationship is confirmed by:
- Another E&M or primary care service by the same TIN within 90 days; or
- A primary care service by any TIN within +/- 3 days
57
Measurement Period
Candidate Event
Clinician A: Primary Care
E&M Service
Clinician B: Primary Care
E&M Service
+90 Days-3 Days
Step 2: Apply Attribution Exclusions to Remove Specialists Unlikely to Provide Primary Care
• Clinicians’ candidate events are excluded from attribution if:- The specialty of the billing clinician is unrelated to primary care
management; or- The clinician performs any of the following services for beneficiaries often
enough• Global surgery• Anesthesia• Therapeutic radiation• Chemotherapy
• Exclusions help remove TINs or TIN-NPIs unrelated to primary care management from attribution
• Both rules motivated by discussions with the TEP and public comments- First rule developed after field testing
58
Step 3: Initiate Year-long Risk Window and Attribute Beneficiary-Months
• Each candidate event initiates a one-year risk window, which is divided into beneficiary-months
• Only the portion of beneficiary months covered by the measurement period and risk window are considered for measure calculation
59
Risk Window (1 Year)
Measurement Period
Attributable Beneficiary-Months
Non-attributable
Months
Beneficiary-months when all
Part A and B costs are
assigned
Clinician A: primary care E&M
service
Clinician B: primary care E&M
service
Candidate Event
Step 4: Calculate Payment Standardized Monthly Cost
• All service costs incurred during the attributable beneficiary months are grouped and standardized
• No costs incurred prior to a candidate event are attributed
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Risk Window (1 Year)
Measurement Period
Non-attributable
Months
Beneficiary-Months When All
Part A and B Costs Are
Assigned
Clinician A: Primary Care
E&M Service
Clinician B: Primary Care
E&M Service
Candidate Event
Beneficiary’s Other Grouped
Services
Beneficiary’s Other Services
Not Grouped
Grouped Services Services Not Grouped
Step 5: Calculate Risk-Adjusted Monthly Costs
• Patient characteristics and comorbidities are captured during the year prior to each bene-month
• Beneficiary risk score is calculated using CMS-HCC model (New Enrollee Model, Community Model, Institutional Model)
• Risk-adjusted monthly cost for each beneficiary is calculated by dividing observed cost by the assigned risk factor
61
Step 6: Calculate Specialty-Adjusted Costs for Each TIN or TIN-NPI
• Expected cost for a specialty is calculated by taking a weighted average of risk-adjusted costs for that specialty nationally
• Specialty-adjusted cost for a TIN or TIN-NPI is equal to risk-adjusted cost divided by expected cost across the relevant specialties
• This method parallels the specialty adjustment in the Current TPCC measure
- Specialty adjustment was removed for field testing to make the measure simpler, but has been added back to the measure in response to field testing feedback
62
Step 7: Calculate The TPCC Measure Score
• The measure score is the average risk-adjusted and specialty-adjusted monthly cost calculated across all beneficiary months attributed to a TIN or TIN-NPI in the measurement period
63
Measurement Period
Beneficiary A
Beneficiary B
Beneficiary C
Beneficiary D
Attributable Beneficiary Months Non-Attributable Months
TIN/TIN-NPI Measure Score
Average Cost Across All Attributable
Beneficiary Months =
APPENDIX B: DETAILS ON TPCC REFINEMENT AND SUMMARY STATISTICS
64
Refinement 1: Attribution Methodology Identifies Primary Care Relationships and Includes Costs Only After Start of Relationship
Current TPCC Revised TPCC
• Attribution is to the single TIN-NPI billing the majority of primary care E&M cost
• Primary care E&M service must have confirming event for attribution
• Prevents attribution based on a single primary care E&M
• Only one clinician can be attributed • Multiple clinicians can be attributed to reflect joint responsibility and changes in primary care relationship (e.g., for beneficiaries who move during the year)
• Once attributed, clinician is responsible for whole year of costs, regardless of timing
• Costs can only be attributed to clinician after seeing a beneficiary to improve actionability of measure
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Share of Primary Care E&M Billed by Attributed TIN and TIN-NPI Shows Strong Relationship
66
Provider TypeDistribution of Share of Attributed Beneficiary's E&Ms*
Mean 25th Percentile 50th Percentile 75th Percentile
TIN 52.8% 34.8% 55.8% 70.0%
TIN-NPI 45.0% 28.9% 42.8% 61.6%
* This table calculates the proportion of the beneficiary’s E&Ms that the attributed TIN/TIN-NPI billed during their candidate events. Only E&M codes billed by the TIN-NPIs belonging to specialties considered to be reasonably responsible for primary care were considered (i.e., the E&Ms billed by TIN-NPIs who are not excluded under the HCFA specialty exclusions).
Refined Attribution Methodology Prevents Cost Assignment for Services Prior to Clinician Seeing the Beneficiary
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Measure% of Part A/B Cost Assigned to
Attributed Clinicians Prior to Seeing Beneficiary
Current TPCC 13.7%
Revised TPCC 0.0%
Refinement 2: Attribution Identifies Clinicians Who Provide Primary Care Services
Current TPCC Revised TPCC
• Primary care clinicians are given precedence over non-primary careclinicians through two-step attribution based on plurality of primary care cost
• Specialists of any type can be attributed in the second step
• HCFA specialty information used to exclude specialties unlikely to provide primary care management (e.g., optometry)
• Clinicians who perform a high frequency of non-primary care services (e.g., global surgery, chemotherapy, anesthesia, therapeutic radiation) are excluded
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Revised TPCC Ensures Non-Primary Care Clinicians Are Not Attributed
69
Number of Specialists Attributed under Current TPCC who areExcluded under the Revised TPCC
HCFA Specialty # Attributed Clinicians
All 14,127
Dermatology 3,479
Urology 1,822
Ophthalmology 1,354
Podiatry 1,162
Neurology 942
Psychiatry 881
Emergency Medicine 704
Interventional Cardiology 631
Orthopedic Surgery 525
Optometry 475
Revised TPCC Results in Limited Attribution of TINs Through NPs and PAs Alone
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Frequency of Most Common HCFA Specialty In TINs Attributed Measure Via NP/PA Alone
Specialty % of TINs
TINs Attributed By Other Clinicians 86.7%
TINs Attributed By NP and/or PA alone 13.3%
Nurse Practitioner 6.7%
Physician Assistant 1.1%
Orthopedic Surgery 1.1%
Psychiatry 1.0%
Otolaryngology 0.4%
Urology 0.4%
Neurology 0.3%
Physical Medicine and Rehabilitation 0.3%
General Surgery 0.2%
Interventional Pain Management 0.2%
Refinement 3: Risk Adjustment Accounts for Changes in Health Status
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Current TPCC Revised TPCC
• Beneficiary risk score is determined by risk factors from one year prior to the measurement period
• Beneficiary risk score is determined by risk factors from one year prior to each beneficiary month to allow updates to health status (e.g., for emergent disease)
• Risk model used to determine beneficiary risk score is either:o new enrollee model, or o community model
Note: Both risk models include dual status as a risk adjustor
• Risk model used to determine beneficiary risk score is either:o new enrollee modelo community model, oro institutional model, to improve risk
adjustment for clinicians treating institutionalized patient population
Note: All models include dual status as a risk adjustor
Refinement 4: Costs Are Not Artificially Inflated for Beneficiaries Who Die
72
Current TPCC Revised TPCC
Measure annualizes cost for beneficiaries who die mid-year (e.g., beneficiary who is alive for 4 months has annualized cost of 3 times the cost while alive)
Costs examined for each bene-month so beneficiary who dies mid-year will not incur costs for rest of the year
Attribution Logic Allows for Shared Accountability
• Using candidate events to open overlapping risk windows results in multiple clinicians and clinician groups being attributed responsibility for a patient’s primary care management
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Measure
TIN TIN-NPI
% of Beneficiary-Months Attributed % of Beneficiary-Months Attributed
1 TIN 2+ TINs 1 TIN-NPI 2+ TIN-NPIs
Current TPCC 100.0% 0.0% 100.0% 0.0%
Revised TPCC 57.4% 42.6% 58.2% 41.8%
APPENDIX C: DETAILS ON MSPB CLINICIAN REFINEMENT AND SUMMARY STATISTICS
74
Refinement 1: Attribution Distinguishes Between Medical and Surgical Episodes
Current MSPB Revised MSPB Clinician
• Attributed to the single TIN-NPI billing the majority of Part B services during the index admission
• For medical episodes (index admission has a medical MS-DRG), the episode is attributed to the TIN(s) billing more than 30% of E&M codes during the inpatient stay. Episodes are attributed to any TIN-NPI(s) billing an E&M claim within an attributed TIN
• For surgical episodes (index admission has a surgical MS-DRG), the episode is attributed to the TIN(s) and TIN-NPI(s) performing the related surgical procedure during the inpatient stay
• A pre-defined list of CPT/HCPCS codes determines which procedures are related to the surgical MS-DRG
• Only one TIN-NPI can be attributed each episode
• Multiple TINs/TIN-NPIs can be attributed one episode
75
Refinement 1: Attribution Distinguishes Between Medical and Surgical Episodes
76
MSPB Surgical Episodes:
MSPB Clinician Episode Window
30 Days Post-DischargeIndex Admission3 Days
Pre-Admission
Index Admission
(Admission to an
IPPS Hospital)
Index Admission
Duration (Admission
to Discharge)
Procedure Related
to Surgical MS-DRG
Services Unrelated to
Surgical MS-DRGAttribute TIN and TIN-NPI on claim(s) with Related Procedure
MSPB Medical Episodes:
MSPB Clinician Episode Window
30 Days Post-DischargeIndex Admission3 Days
Pre-Admission
Index Admission
(Admission to an
IPPS Hospital)
Index Admission
Duration (Admission
to Discharge)
TIN A E&M Claims
TIN B E&M Claim
Attribute TIN A with over 30% of E&M claims; Attribute TIN-NPI(s) billing E&M claims in TIN A
Refinement 2: Service Assignment Exclusions Remove Cost Unlikely to be Influenced by Attributed Clinician
77
Current MSPB Revised MSPB Clinician
• Included all Medicare Parts A and B claims paid during the period from three days prior to the index admission through 30 days after discharge
• Unrelated services excluded specific to groups of MS-DRGs aggregated by MDC- level
• Service exclusion list developed by the MSPB Service Refinement Workgroup
Examples of exclusions include:
• No orthopedic procedures for episodes triggered by MS-DRGs under
Disorders of Gastrointestinal System (MDC 06 and MDC 07)
• No valvular procedures for episodes triggered by MS-DRGs under Disorders of
the Pulmonary System (MDC 04)
• No hospice costs for all episodes
Refinement 2: Service Assignment Exclusions Remove Cost Unlikely to be Influenced by Attributed Clinician
78
Current MSPB
MSPB Clinician Episode Window
30 Days Post-DischargeIndex Admission3 Days
Pre-Admission
Index Admission
(Admission to an
IPPS Hospital)
Index Admission
Duration (Admission
to Discharge)
Included Services
Excluded Services
Revised MSPB clinician
MSPB Clinician Episode Window
30 Days Post-DischargeIndex Admission3 Days
Pre-Admission
Index Admission
(Admission to an
IPPS Hospital)
Index Admission
Duration (Admission
to Discharge)
Included Services
Excluded Services
Top 10 HCFA Clinician Specialties
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Distribution of Attributed Clinicians Across Top HCFA Specialties Using Revised MSPB Clinician in Comparison to Current MSPB
HCFA Specialty
# Attributed Clinicians
Current MSPB Revised MSPB
All 48,765 127,529
Internal Medicine 18,633 39,642
Cardiology 3,609 10,712
Orthopedic Surgery 7,192 7,853
Family Practice 3,253 7,548
Physician Assistant 127 6,471
General Surgery 1,787 5,986
Nurse Practitioner 305 5,795
Nephrology 1,259 5,691
Pulmonary Disease 1,456 5,534Gastroenterology 818 3,509
