Feb 21, 2018

Jit Chawla

Chief Consultant

MACRA: MIPS and APMs for Small Practices

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About EHR 2.0

© 2017 EHR 2.0. All rights reserved. To purchase reprints of this document, please email info@ehr20.com.

EHR 2.0 Mission: To assist healthcare organizations develop and implement practices to secure IT systems and comply with HIPAA/HITECH regulations.

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About the speaker: Jit Chawla

© 2017 EHR 2.0. All rights reserved. To purchase reprints of this document, please email info@ehr20.com.

▪ Master of Health Administration, Clinical Informatics Certificate

▪ Chief Consultant for technology and management consulting firm. Years of experience helping practices with achieving Meaningful Use, PQRS and Value-Based Modifier initiatives.

▪ Six Sigma Green Belt, Toastmaster Club Member, competitive tennis player, foodie and loves to travel

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Agenda Topics

About MACRA and MIPS/ APM Programs

How it works

Why should you care

Next steps for you

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Origin of MIPS

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MIPS: Components

Source: CMS Press Office press release 4/27/16 http://www.hhs.gov/about/news/2016/04/27/administration-takes-first-step-implement-legislation-modernizing-how-medicare-pays-physicians.html

Performance Category Details

Quality Clinicians choose to report six measures from a range of options that accommodate differences among specialties and practices

Advancing Care Information Clinicians choose to report customizable measures that reflect how they use technology in their day-to-day practice

Clinical Practice Improvement Activities

Rewards clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety

Cost Score based on Medicare claims using 40 episode-specific measures, meaning no reporting requirements for clinicians

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MIPS: Eligible Clinicians

PhysiciansPhysician Assistants

Nurse Practitioners

Clinical Nurse Specialists

Certified Registered Nurse

Anesthetists

Source: CMS Press Office press release 4/27/16 http://www.hhs.gov/about/news/2016/04/27/administration-takes-first-step-implement-legislation-modernizing-how-medicare-pays-physicians.html

These include:

Non-facing Clinicians

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MIPS: Eligibility Criteria

1. Revenue threshold –allowable charges Part B Medicare

AND

2. Volume threshold- number of Part B patients

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MIPS: Exclusions

The following are reasons for providers to not participate without incurring a penalty:

• Low Volume : Less than $30,000 per year from Medicare or fewer than 100 Medicare patients per year

• First year of participant in Medicare Part B Program

• Significant participation as an Advanced APM

• Operating as a Rural Health Clinics and Federally Qualified Health Centers paid differently under Medicare

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Example of a Quality Measure

Purpose: Reward for quality of care demonstration in certain populations

300 spanning various specialties (full list https://qpp.cms.gov/mips/quality-measures), some common ones are:

Diabetes Foot Exam:Numerator: Patients who received visual, pulse and sensory foot examinations during the measurement period.

Denominator : Patients 18-75 years of age with diabetes with an eligible visit (defined as a signed chart note with one of the following encounter types: Office Visit, Nurse Visit, Nursing Home Visit, or Home Visit) during the measurement period.

Denominator Exclusions: Patients who have had either a bilateral amputation above or below the knee, or both a left and right amputation above or below the knee before or during the measurement period.

• Performance Benchmark for MIPS: 76.17%

Source: practice fusion

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Quality Scoring

Source: CMSHHgov

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Calculating the Measure Quality Points

Source: acumend.com

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Quality Score

Source: CMSHHgov

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Example of ACI Base Measures

Purpose: Reward for use of the certified EMR to record and send certain data Total of 15 offered, (full list-https://qpp.cms.gov/mips/advancing-care-information) some common ones used are…

Source: www.cms.gov

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Example of ACI Performance Measures

Source: www.cms.gov

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ACI Criteria per Measure

Source: www.cms.gov

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ACI Scoring

Source: CMSHHgov

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Example of CPIA Measures

Purpose: Reward for care focused on care coordination, beneficiary engagement, and patient safety.

Total of 93 offered, (full list-https://qpp.cms.gov/mips/improvement-activities) some common ones used are…

Diabetes Screening- For people with schizophrenia or bipolar disease who are using antipsychotic medication.

Engagement of new Medicaid patients and follow-up-Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.

Implementation of antibiotic stewardship program- Measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics

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CPIA Measure Weights

Source: CMS.gov

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CPIA Scoring

Source: CMSHHgov

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CIPA Scoring

Source: CMSHHgov

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Cost Scoring

Source: CMSHHgov

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Cost Scoring

Source: CMSHHgov

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MIPS Overall Score

Source: CMSHHgov

50*60+ 100*15+80*25+0*0 = 65% * 100 = 65 points

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Points/Rewards Relationship

Source: CMSHHgov

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Incremental Payment Adjustments

Physician Fee Schedule

(updates)

APM(incentive payments)

MIPS(payment

adjustments)

0.5% 0.5%0.5% 0.5% 0.0% 0.0%0.0% 0.0% 0.0% 0.0%

2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

5.0% 5.0% 5.0%5.0% 5.0%

2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

+/-4%

+/-5%

+/-7.0%

2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

MIPS performance period +/- 9%

Key Takeaway: Physicians who have relied on payments going up year after year will be living in a world where, without change, they will be going down.

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MIPS Data Submission Methods

Source: Society of Thoracic Surgeons

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MIPS: Pick Your Pace - Performance Year 1

CMS announced new options for MIPS participants to increase flexibility in reporting in 2017.

Test

• Submit data for one quality measure, OR one improvement activity, OR the four required ACI measures and avoid a negative payment adjustment.

Partial

• Submit at least 90 days of data for more than one quality measure, OR more than one improvement activity, OR more than the four required ACI measures and avoid a negative payment adjustment. Partial participation also allows ECs to possibly receive a small positive payment adjustment.

Full

• Submit at least 90 days of data for all required quality measures, AND all required improvement activities, AND all four required ACI measures to avoid a negative payment adjustment. Full participation also allows ECs to possibly receive a moderate positive payment adjustment

Source: AAFP

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MIPS: Changes for 2018

Source: HITECHanswers

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MIPS: Changes for 2018

Source: HITECHanswers

REG OVERVIEW HOW WORKS WHY CARE NEXT STEPS

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MIPS: Changes for 2018

Source: HITECHanswers

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MIPS: Changes for 2018

Source: HITECHanswers

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MIPS: Changes for 2018

Source: HITECHanswers

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MIPS: 2018 Final Rule Stipulations

Source: HITECHanswers

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MIPS: 2018 Final Rule Stipulations

Source: HITECHanswers

REG OVERVIEW HOW WORKS WHY CARE NEXT STEPS

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MIPS Categories Weighting

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Definition:• Approach giving additional monies for high-quality, cost-efficient

care• Applicable to specific conditions, care episodes and populations• Advanced APMs (a subset), allow 5% higher incentive payment by

taking some risk related to patient outcomes• AAPM models include:

* Comprehensive End-Stage Renal Disease Care* Comprehensive Primary Care Plus* Medicare Shared Savings Program – Track 2* Medicare Shared Savings Program – Track 3* Next Generation ACO Model* Oncology Care Model (two-sided risk arrangement)* Comprehensive Care for Joint Replacement –Track 1

Alternate Payment Models

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APM Criteria

Source: CMSHHSgov

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Risk in APMs

Source: CMSHHSgov

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APM MIPS Criteria- SSP, Next Gen

Source: cms.gov

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APM MIPS Criteria- All other APMs

Source: cms.gov

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MACRA Programs Comparison

MACRA Strategy Advantages Disadvantages

MIPS • Familiarity with Legacy Programs • Incentives are highly dependent on measure selection and peer performance

• Downside risk up to 9% in 2022

MIPS APM • Eases report burden• If partially qualifying provider, may

be able to avoid MIPS reporting• Less likely to involve risk• May yield more than 5% bonus

• Do not get the 5% upside bonus, but still significant infrastructure costs associated with APMs

• Positive MIPS adjustments make it harder to achieve savings in APMs

Advanced APM • 5% lump sum bonus• Bonus is not counted against APM

medical budget• Physicians may be attracted to an

Advanced APM to avoid MIPS

• Downside risk amount can be substantial and varies by model

• Can participate without being a qualified provider; specialists may have a more difficult time qualifying

• Requires infrastructure investment• Some providers not ready to go at risk

REG OVERVIEW HOW WORKS WHY CARE NEXT STEPS

Source: Stroudwater

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Important MIPS related changes in 2018

January 1, 2018

•Deadline to begin including new codes and national provider number on Medicare claims

July 1, 2018

•HHS to begin providing info to each MIPS-eligible clinician about items and services provided to the professional’s patients by other suppliers and providers of services

December 2, 2018

•MIPS adjustments announced

December 31, 2018

•Statutory deadline for achieving national priority of widespread interoperability of EHRs

January 1, 2019

•First performance period for 2021 payment adjustments, including through Other Payer APMs

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Practical/ To Do Steps-Attestation for 2017

Step 1:Ensure that data is collected and organized for the various MIPS categories

Step 2:Login (or create an account with ) Quality Payment Program website. Can start early as 1/2/18 ( except Web Interface reporting starts at 1/22/18).

Step 3:Submit, deadline -March 31, 2018

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Practical/ To Do Steps-Attesting this year

Step 1:Ensure have certified EMR with MIPS reporting dashboard

Step 2:Look at revenue/ volume of patients in designated time period

Step 3:Pick Quality Metrics, EMR measures and list of Clinical Practice Improvement Areas that fit within your organization’s goals to achieve, ensuring can comfortably collect data on these measures

Step 4:Map out workflows, educate staff/providers on what data to record in EMR (if unable to do in-house seek outside expert consultation)

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Key Take Away Points

• Your reimbursement will be affected- like it or not !

• Get paid for taking good quality care of your patients

• MIPS not much different from past programs, APMs like ACOs

• Start now –proper workflow takes times, capture good data

• Don’t have to do everything on your own – not worth your time, cost-effective. Let the experts do their thing !

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MIPS/ MACRA Offerings

1. 2017 MIPS/ APM Attestation Assistance

2. 2018 MIPS/ APM Data Collection Assistance

3. MIPS/ APM Strategy Consulting

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EHR2.0/ AHS -Other Offerings

MACRA OVERVIEW MIPS ADVANCED APMs CPC+

OSHA Assessment and Consulting

Gold PackageSilver PackageBronze Package

Security Risk Analysis & HIPAA

Meaningful Use Medicaid Assistance

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Thank you!

Jit Chawlainfo@acehealthsolutions.com

(919) 228-8744www.acehealthsolutions.com

© 2017 EHR 2.0. All rights reserved. To purchase reprints of this document, please email info@ehr20.com.

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