MACRA: Fundamentally Changing Physician Practices? MAC… · Oklahoma State Medical Association August 20, 2016 MACRA: Fundamentally Changing Physician Practices? Rev. 7/15/16

Oklahoma State Medical Association

August 20, 2016

MACRA: Fundamentally Changing Physician

Practices?

Rev. 7/15/16

© 2016 American Medical Association. All rights reserved.

Some general observations

• MACRA is complex

– More than a “replacement for the SGR”

– Law reflects the diversity of the profession

– Regulations can add complications

• Many of the new requirements are simply revisions of current requirements

• One goal of MACRA was to simplify administrative processes for physicians

– Compared to recent past/ current framework, the proposed regulations include significant improvements

– More improvements are needed—looking for net reduction in burden

• The proposed rule issued in April is a draft attempt to implement a complex law.

– Lengthy and detailed recommendations have been submitted for improvements

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MACRA establishes two Medicare paths for physicians

• MACRA was designed to offer

physicians two payment model

pathways:

• A modified fee-for-service model

(MIPS)

• New payment models that reduce

costs of care and/or support high-value

services not typically covered under

the Medicare fee schedule (APMs)

• In the beginning, most are expected to

participate in MIPS

MIPS

APMs

Merit-based

Incentive Payment

System (MIPS)

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MIPS components

Quality Reporting (was

PQRS)

Resource Use or Cost (was Value-based Modifier)

Advancing Care Information (was

MU)

Clinical Practice Improvement

Activities

MIPS

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MIPS aims: • Align 3 current independent programs

• Add 4th component to promote improvement and

innovation

• Provide more flexibility and choice of measures

• Retain a fee-for-service payment option

Clinicians exempt from MIPS: • First year of Part B participation

• Medicare claims < $10K AND patients < 100

• Advanced APM participants

AMA recommendation: • Increase low-volume threshold to $30K OR 100

patients

• Would exempt 29% of physicians (vs.

10%) while covering 93% of Medicare

spending

• Mean Medicare revenue per physician is

about $109K


Quality reporting vs. PQRS

PQRS

9 measures

Pass/fail approach

Measures must fall across specific quality domains

Quality in NPRM

6 measures

Partial credit allowed

Flexibility in choice of measures

AMA recommendations

Maintain scoring thresholds at 50% (vs.

proposed 80-90%)

Further reduce the number of required quality

measures to 4

Simplify the scoring methodology

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Resource use vs. VBM

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VBM

Included both quality reporting and resource-use measures; PQRS failure counted twice

Poor risk adjustment produced penalties for

treating sickest patients

No statutory limits on penalty risk

Resource Use in NPRM

Focuses solely on cost/ resource-use; no duplicative quality

reporting

41 episode-based measures proposed

Plans to improve attribution methods in

2018 (for 2020 payments)

AMA recommendations

Cost measures flawed, episode groups need testing/ improvement

Improve attribution methods for episodes

Develop pilot rather than using flawed measures

Do not incorporate Part D or B drug costs


Advancing care information vs. meaningful use

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MU

100% score required on all measures to avoid 5%

penalty

Included redundant measures and

problematic CPOE, CDS and clinical quality

measures

ACI in NPRM

Pass-fail program replaced with base and

performance scoring

Measures reduced

Performance score thresholds eliminated

Public health registry reporting reduced

AMA recommendations

50 point base score threshold still 100%; grant

credit for measures reported

Maintain existing measure exclusions

Permit proposals for more relevant measures

Establish a 90-day reporting period


CPIA basics

• 15% of total MIPS score

• 90-day reporting period MIPS weight

• 8 activity categories

• 90+ activities

• Do not need activities in each category CPIA categories

• 60 points = 100% CPIA score

• 7 of 8 categories have both high (20 points) and medium (10 points) weighted activities

Scoring

• Certified PCMH (60 points); other APM (30 points)

• Non-patient facing specialties & small rural practices need fewer points (one activity for partial credit, 2 activities for full credit)

Exceptions

• High weight activities should be expanded, required activities reduced

• Credit for APM participation should be increased

• Practices should be able to maintain CPIA activities over time Concerns

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CPIA categories

Expanded Practice Access

Population Management

Care Coordination

Beneficiary Engagement

Patient Safety & Practice

Assessment

Achieving Health Equity

Emergency Response and Preparedness

Integrated Behavioral &

Mental Healtah

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MIPS component weights and scoring in 2019

50%

25%

15%

10%

Component Weights

Quality

ACI

CPIA

Resource Use

Component Scoring • Quality:

– 80 points groups <10

– 90 points for larger groups

– Weight phases down to 30% in 2021

• Advancing Care Information:

– 50 points base score

– 80 points performance score

• Clinical Practice Improvement Activities:

– 60 points (3-6 activities; 2 activities for small and rural practices)

• Resource Use:

– 10 points per measure

– Score is average of attributable measures

– Weight phases up to 30% in 2021

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Calculating MIPS payment adjustments (2019)

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Quality score

weighted 50%

Cost score

weighted 10%

ACI score

weighted 25%

CPIA score

weighted 15%

Composite

Performance

Score (CPS)

CPS at threshold (tied to

average performance) = 0%

CPS above threshold = 0% to 4%

CPS below threshold = 0% to -4%

Depending on CPS distribution, upward

adjustments only could increase up to 3x to

maintain budget neutrality

Physicians with CPS scores

< 25% of threshold receive

maximum reduction

Up to $500 million available

2019-2024 to provide 10%

extra bonus for exceptional

performance (> top 25% of

those above the threshold)

Maximum adjustment ranges increase to +/- 5% in 2020, +/- 7%

in 2021, +/- 9% in 2022 onward


2019 (first year) penalty risks compared

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Prior Law 2019

adjustments

PQRS -2%

MU -5%

VBM -4% or more*

Total penalty risk -11% or more*

Bonus potential (VBM

only)

Unknown (budget

neutral)*

MIPS factors 2019 scoring

Quality measurement 50% of score

Advancing Care Info. 25% of score

Resource use 10% of score

Clinical improvement

activities

15% of score

Total penalty risk Max of -4%

Bonus potential Max of 4%, plus

potential 10% for high

performers *VBM was in effect for 3 years before MACRA passed, and

penalty risk was increased in each of these years; there

were no ceilings or floors on penalties and bonuses, only a

budget neutrality requirement.


Some observations about MIPS

Positives:

• Overlapping quality measurement across separate programs eliminated

• Overall reduction in measures, many thresholds eliminated

• More flexibility in measure choice

• Pass/ fail approach (largely) eliminated

• Financial risk from penalties significantly reduced

Issues to address:

• Aggregate administrative burden for practices is still too high

• A more holistic approach is needed to integrate the 4 components into a single program

• MU measures largely retained in ACI; need greater flexibility and focus on goal vs. process

• Methodological issues of VBM cost and quality measures remain

• Full-year reporting for most components

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Estimated impacts

• Estimated MIPS actuarial impact table (table 64) predicting payment cuts for small practices should be interpreted with caution

– Data used are based on successful participation of “eligible clinicians” in PQRS and VBM in 2014

• Moving away from pass/fail approach and other accommodations proposed for small practices not reflected in the analysis

• Does not reflect reduced risk of penalties under MACRA vs. previous law

• AMA recommended changes that could ease impact (e.g., raising low volume threshold)

• Many policymakers recognize small practices as an effective means of delivering high-value care

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Small practice accommodations

NPRM Provisions

• Low-volume MIPS exemption

• Fewer quality measures, CPIA reporting requirements

• Reporting category exemptions if insufficient measures applicable

• Cost score not calculated if volume insufficient for measures

AMA Recommendations

• Low-volume threshold should be increased

• Peer-to-peer comparisons on performance

• Further reduce reporting requirements

• Consistent definition of small practice

• Implement virtual group provision

• Maintain EHR exemption for lack of high speed Internet, physicians who do not refer patients

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Alternative

Payment Models

(APMs)

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APMs participation options as outlined by CMS

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Advanced APMs

Qualified Medical Homes

MIPS APMs

• “Advanced” APMs--term

established by CMS; these

have greatest risks and offer

potential for greatest

rewards

• Qualified Medical Homes

have different risk structure

but otherwise treated as

Advanced APMs

• MIPS APMs receive

favorable MIPS scoring

• Physician-focused APMs

are under development

Physician-

focused

APMs TBD


MACRA incentives for Advanced APM participation

Model design

• APMs have shared savings, flexible payment bundles and other desirable features

Bonuses

• In 2019-2024, 5% bonus payments made to physicians participating in Advanced APMs

Higher updates

• Annual baseline payment updates will be higher (0.75%) for Advanced APM participants than for MIPS participants (0.25%) starting 2026

MIPS exemption

• Advanced APM participants do not have to participate in MIPS (models include their own EHR use and quality reporting requirements)

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CMS criteria for Advanced APMs

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Advanced APMs

EHR use

Quality Reporting

Financial

Risk

• Participants must use certified EHR technology

• At least 50% of clinicians in first year, 75%

thereafter

• Payment based on quality measures

comparable to MIPS

• Bear “more than nominal risk” for monetary

losses (current proposal is 4% of total Medicare

expenditures)

• Expanded Medical Home models exempt from

risk

• Other Medical Home models have different

standards (2.5%-5% total Medicare revenues)

• Physicians may be Qualified Participants (QPs)

or Partially Qualified Participants (PQPs) based

on revenue and patient thresholds, with

differential rewards


Currently proposed Advanced APMs

Comprehensive ESRD Care Model

(currently 13 ESCOs)

Comprehensive Primary Care Plus

(coming in Fall 2016)

Medicare Shared Savings Track 2

(currently 6 ACOs, 1% of total)

Medicare Shared Savings Track 3

(currently 16 ACOs, 4% of total)

Next Generation ACO Model

(currently 18)

Oncology Care Model, 2-Sided

Risk Arrangement

(coming in 2018)

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MIPS APMs

Criteria

• Do not meet qualifications for Advanced APM—most likely financial risk

• Examples includes Track 1 ACOs, certified medical homes, bundled payment programs, any upside risk-only models

Advanced APM benefits do not apply

• Must participate in MIPS to receive any favorable payment adjustments

• Do not qualify for 5% APM bonus payments 2019-2024

• Not eligible for higher baseline annual updates beginning 2026

Other benefits

• Certified medical home participants get full CPIA score (60 points); others get half (30 points)

• APM-specific rewards (e.g., shared savings)

• Eligible for annual MIPS bonuses, which continue indefinitely (vs. 6 years for 5% APM bonuses)

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Requirements and payments for APM participants

Qualified

Participant in

Advanced APM

Partially Qualified

Participant in

Advanced APM

MIPS APM

participant

Patient and revenue

thresholds required

>25% revenues or >20%

patients in 2019, rising to

75% or 50%, respectively

by 2023

>20% revenues or >10%

patients in 2019, rising to

50% and 35%,

respectively, by 2023

None

Eligible for APM bonus,

higher updates

Yes No No

Must participate in MIPS No Optional (but no

performance adjustments

without MIPS)

Yes

MIPS scoring and

adjustments

N/A Favorable weighting and

scoring

Favorable weighting and

scoring

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APMs and MIPS reporting at a glance

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In an APM?

Yes No

In first year in Medicare or below the volume threshold?

Yes No

In an Advanced APM?

Yes No

Enough payments or patients to meet the threshold?

Yes No

Qualifying APM Participant. Eligible for:

• 5% lump sum bonus payment 2019-2024

• Higher fee schedule updates 2026 and beyond

• APM-specific rewards

• Exclusion from MIPS reporting

Not subject

to MIPS Subject to

MIPS

Partially qualified or MIPS

APM participant:

• Favorable CPIA scoring

• APM-specific rewards


Some observations about APM pathway

Positives

• Approach to quality measure requirements seems reasonable

• Initial EHR use proposal (50%) seems flexible (although threshold increases quickly)

• Performance judged on group basis

• Reasonable criteria for judging physician-focused payment models

Issues to address

• Too few qualified APMs will be available in 2017

• Timeline for developing new models is long; bonus payments intended to ease transition expire

• Risk requirements are unrealistic (e.g., risk for costs vs. revenues, no credit for investment)

• Risk requirements too complicated

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Moving Forward

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Timeline on payment adjustments

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2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

on

Fee

Schedule

Updates

MIPS

QPs in

Adv.

APMs

0.5% annual baseline updates No annual baseline updates

4% 5% 7% 9% Max Adjustment (additional bonuses

possible)

0.25%

or

0.75%

9% 9% 9%

5% bonus


Regulatory timeline

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NPRM comments deadline

• June 27, 2016

Final MACRA rule issued

• Fall 2016 (Nov. 1?)

MIPS measurement and APM participation begins

• Jan 1, 2017

Second year of measurement

• 2018

MIPS and APM pay adjustments for 2017 performance occur

• Jan 1, 2019

• Implementation timeline

concerns: • Short lead-time for

physicians to learn the

rules

• Inadequate time to

make practice

adjustments

• Too few APMs are

available

• AMA recommends

transitional reporting

year in 2017, to begin

July 1


AMA advocacy

• Our overarching aims in shaping regulations:

– Choice, flexibility, simplicity, feasibility, clinical relevance

• Four key issues:

– Start date and reporting period

– Accommodations for small and rural practices

– Complexity of the programs

– Expanding APMs

• Extensive Federation outreach

– MACRA Task Force, MIPS workgroup, APM workgroup, CMS listening sessions

• Extensive outreach to the Administration

• Keeping Congress informed, leveraging oversight function

• Developing tool chest of practical resources to help physicians make choices and succeed under new payment systems

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What Physicians

Can Do to Prepare

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Understand APM opportunities

• Confirm whether you are a participant in any of the Advanced APMs

– If so, evaluate whether you are likely to meet the threshold for significant

participation in an Advanced APM, which would qualify for your incentive

payments

• If not, contact your specialty society or state medical societies to find out

if there are APM opportunities for your practice

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Understand potential clinical practice

improvement activities

• Review CMS’s proposed list of clinical practice improvement activities

(CPIAs)

– Review AMA’s Steps Forward modules and determine whether your practice

would benefit from completing them in 2017 for CPIA credit

• If you participate in a medical home, ensure your certifications and

accreditations (as applicable) are current

– Certain types of medical homes receive full CPIA credit

• Consider which 90 days in 2017 would work best for your practice’s

CPIAs

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Understand your EHR

• If you have an EHR, make sure it is certified EHR technology (CEHRT)

– Using a certified EHR is essential for both APM participation and MIPS

reporting

• Speak with your EHR vendor about how their product supports the

requirements of MACRA

– Determine whether you will have 2014 or 2015 edition certified technology in

2017, as this will affect which measures on which you report in 2017

– If you are using 2014 edition certified technology, ask about your vendor’s

timeline of the transition from 2014 edition to 2015 edition

– Ask how their product will support Medicare quality reporting in 2017 and

subsequent years

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Understand your current quality & resource use

data

• Understand your current quality metrics reporting requirements and how

you are scoring across both Medicare PQRS and private payers

– Check your PQRS feedback reports

• Authorized representatives can access the 2014 Annual PQRS Feedback Reports

on the CMS Enterprise Portal

• QRUR contains data on individual patients & individual physicians

• If you are not already participating in a patient clinical data registry,

contact your specialty society about participating in theirs

– Data registries can streamline quality reporting and be used for the CPIA

component

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https://portal.cms.gov/


Take advantage of educational opportunities

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www.stepsforward.org

Completion of select STEPSForward™ modules meets eligibility

criteria for CPIA credit

http://www.stepsforward.org/


Stay informed

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www.ama-assn.org/go/medicarepayment

Leverage resources from the AMA and other Federation groups

• Contact your specialty or state

medical societies to find out if

there are APM opportunities for

your practice

• Seek out local support for your

quality improvement activities • Many local organizations such

as Practice Transformation

Networks provide resources

and technical support, often free

of charge, to help small

practices

New tools coming soon

http://www.ama-assn.org/go/medicarepayment



http://www.healthcarecommunities.org/CommunityNews/TCPI.aspx

http://www.healthcarecommunities.org/CommunityNews/TCPI.aspx


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Documents

MACRA: Fundamentally Changing Physician Practices? MAC… · Oklahoma State Medical Association August 20, 2016 MACRA: Fundamentally Changing Physician Practices? Rev. 7/15/16