MACRA’s Quality Payment Program Year 2: What’s in Store for 2018?

October 10, 2017

Jessica Barth

MACRA’s Quality Payment Program

►MACRA = Medicare Access and CHIP Reauthorization Act of 2015

►The Quality Payment Program overhauled the way Medicare pays for

clinicians’ services

► Big impact: clinicians who participate in Medicare serve more than 57

million seniors

► Repealed the Medicare Sustainable Growth Rate

►2017 was the first year

► CMS called it the Transition Year

► Performance measurement began January 1 for payment year 2019

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The Policy Behind the QPP

►CMS’s goals

► Improve health outcomes

► Spend wisely

► Minimize burden of participation

► Be fair and transparent

► Increase adoption of alternative

payment models

► Improve data and information

sharing

► Maximize participation

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►Movement toward value-based payments

►Emphasis on population health and care coordination rather than

fee-for-service approach

The QPP’s Two Paths

►Clinicians choose one of two tracks:

► Merit-based Incentive Payment System (MIPS)

► Fee-for-service environment

► Consolidated existing payment incentive programs like Meaningful Use and

Physician Quality Reporting System (PQRS)

► Ties payment to quality

► Advanced Alternative Payment Models (Advanced APMs)

► Gives clinicians who participate in innovative payment models an incentive

payment

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MIPS – Who Can Participate?

►MIPS-eligible clinicians include physicians, PAs, NPs, CNSs, and

CRNAs

►Exclusions

► Clinicians new to Medicare

► Clinicians below the low-volume threshold

► Clinicians significantly participating in A-APMs

►Voluntary participation

► 2017-18: excluded clinicians may participate (no payment adjustments)

► 2019 and beyond: excluded clinicians who exceed one of the low-

volume threshold measures may opt in and receive adjustments

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MIPS – How Does It Work?

►Providers can submit data and score points in four categories:

► Quality

► Improvement

► Advancing Care Information

► Cost (currently weighted at 0%, but set to ramp up)

►Payment adjustments are based on the clinician’s total score

►A bonus is available to the highest performers

►MedPAC has criticized the fact that MIPS relies on self-reported data

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MIPS Category Weights

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Am I Eligible to Participate?

►Clinicians should have received a letter from CMS informing them if

they have to report quality measures

► Sent in April and May 2017

►Online look-up tool available at https://qpp.cms.gov/participation-

lookup

► Uses NPI

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MIPS Pros and Cons

►Pros

► Rich bonus pool

► Can receive a small positive payment adjustment for partial year (90

day) participation in 2017

►Cons

► Relatively complicated

► Uncertainty created by active rulemaking could stymie informed

decision-making

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A-APMs

►CMS goal of encouraging the availability and adoption of A-APMs

►APMs are programs that incentivize quality and value

►To be Advanced, an APM must:

► Require participants to use certified EHR technology

► Provide payment based on quality measures

► Either be a Medical Home model or require participants to bear more

than a nominal amount of financial risk

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A-APMs – How Does the Incentive Work?

►Clinicians become qualifying A-APM participants by reaching a certain

set percentage of their payments or patients comping from A-APMs

►Then they get a 5% annual bonus

►Creates a “payment cliff”

► Uncertainty about reaching threshold may diminish participation

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Examples of A-APMs

► Comprehensive ESRD Care – Two-Sided Risk

► Comprehensive Primary Care Plus

► Next Generation ACO Model

► Shared Savings Program, Track 2 and Track 3

► Oncology Care Model – Two-Sided Risk

► Comprehensive Care for Joint Replacement Model

► Other models, like Cardiac Rehab

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Pros and Cons of A-APMs

►Pros

► Excluded from MIPS reporting

► 5% bonus calculated on all of Part B business (not just payments from

A-APMs)

► Possibility of higher updates

►Cons

► Payment cliff creates uncertainty

► Clinicians bear some downside risk

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The Proposed Rule

►CMS published June 30, 2017 – 1058 pages

► CMS took comments through August 21

►Covers second and future years of the QPP

►The Trump Administration’s first significant step in shaping the QPP

► Incremental changes

►Focus on simplification and reducing clinical burden, particularly for

smaller and rural entities

►Final Rule expected before the end of the year

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CMS Official Statement about the Proposed Rule

“We’ve heard the concerns that too many quality programs, technology

requirements, and measures get between the doctor and the patient.

That’s why we’re taking a hard look at reducing burdens. By proposing

this rule, we aim to improve Medicare by helping doctors and clinicians

concentrate on caring for their patients rather than filling out paperwork.

CMS will continue to listen and take actionable steps towards alleviating

burdens and improving health outcomes for all Americans that we

serve.”

- Seema Verma, CMS Administrator

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Proposed Changes to MIPS – Low-Volume Threshold

►More providers exempted

►Excludes providers or groups who bill less than $90,000 in Part B

allowed charges OR provide care for fewer than 200 Part B enrolled

beneficiaries

► Transition Year exclusion criteria were less than $30,000 in charges or

fewer than100 beneficiaries

► CMS specifically sought comments on opt-in provision

►An additional 134,000 providers excluded on top of the 800,000

already excluded

► Diminishes eligible clinicians to 36% (but that 36% represent 58% of

Part B charges)

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Proposed Changes to MIPS – Virtual Groups

►Virtual Groups are a new way for solo practitioners and small groups

(10 or fewer clinicians) to participate in the QPP

► No restriction on Virtual Group size

►Participants must elect at the beginning of a performance period;

election cannot be changed once the performance period starts

► Use same data submission mechanisms

►CMS will create a Model Agreement for groups to use

►CMS sought comments on definition, composition, election process,

and reporting requirements

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Proposed Changes to MIPS - Scoring

Payment Adjustment Transition Year Year 2 Proposed

Positive + Bonus 70 or more 70 or more

Positive 4-69 16-69

Neutral 3 15

Negative 0 (-4%) 0 (-5%)

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Proposed Changes to MIPS – Facility-Based Scoring

► Offers option to use facility-based scoring for facility-based clinicians;

clinicians are assessed in the context of the facility where they work

► Aligns with the Hospital Value Based Purchasing Program to reduce clinician

reporting burden

► Converts hospital Total Performance Score into a MIPS quality performance

category

► To be eligible as an individual, 75% of services in the ED or inpatient setting;

to be eligible as a group, 75% of clinicians must meet eligibility as individuals

► CMS sought comments on whether participation should be opt-in or opt-out

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MIPS – Proposed Changes by Category

►Quality

► Minimum performance period would change from 90 days to 12 months

►Advancing Care Information

► Continuing to allow 2014 CEHRT

► 10 bonus points for caring for complex patients or using 2015 CEHRT

exclusively

► Some accommodations for small practices

► Improvement

► More categories to choose from

►Cost

► CMS will start to track cost and provide feedback in 2018

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MIPS – Other Proposed Changes

►Allowing providers to use multiple mechanisms for submitting

performance data within a performance category

► Transition Year allowed only one per category

► Calls for study of other data collection methods

►5-point bonus for clinician/group in a small practice as long as they

submit data on at least one performance category

► CMS sought comments about whether this should be extended to rural

practices

►Up to 3-point bonus for caring for complex patients

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MIPS – What Stays the Same

►Proposed rule leaves exceptional performance bonus pool of $500

million in place from 2019 through 2024

►For 2019 the category weights stay the same:

► Quality - 60% (50% in 2020, 30% in 2021)

► Advancing Care Information - 25%

► Improvement Activities - 15%

► Cost – no weight (10% in 2020, 30% in 2021)

► CMS sought comments on retaining cost at 0% for 2018

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Changes to A-APMs

►Extending the revenue-based nominal amount standard through 2020

► Allows an APM to qualify as an Advanced if participants must bear total

risk of at least 8% of their Medicare Parts A and B revenue

►Changing the nominal amount standard for Medical Home Models so

that the minimum required amount of total risk increases more slowly

►Providing more detail on the implementation of the All-Payer

Combination Option

►Giving more detail on how eligible clinicians participating in selected

A-APMs will be assessed under the A-APM scoring standard

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What Do the Providers Think?

►BNA survey of 1,000 physicians (July 2017)

► 57% of physicians surveyed planned to participate in MIPS

► 18% in A-APMs

► 25% weren’t planning to participate or weren’t sure

►One-third of participating physicians plan to do the minimum – avoid a

penalty by reporting on one measure

►83% wanted more educational opportunities to help them prepare

►Providers other than physicians need to be aware of the QPP

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Technical Assistance

►Free assistance available to clinicians

►Technical Assistance Resource Guide available at

http://qpp.cms.gov/resources/education

► Documents

► Help line

► E-mail address for questions

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A Time of Uncertainty

►What will HHS Secretary Tom Price’s departure mean for the direction

of the QPP?

►CMS issued a proposed rule August 15 scaling back programs to

bundle payments to hospitals such as the Comprehensive Care for

Joint Replacement Program

►Seema Verma has announced CMS is seeking proposals as it

prepares to take its Center for Innovation in a new direction

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Q&A

THANK YOU

Contact information available at www.faegrebd.com

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