MACRA, QPP, MIPS and APMs Rules of the Game

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MACRA, QPP, MIPS and APMs Rules of the Game
Make effective use of the 2017 and 2018
Transition Years
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About Your Speaker
Mike E.C. Schmidt Director of Certification and
Client Success at Eye Care Leaders
eyecareleaders.com
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Mike leads the teams at Eye Care Leaders which
focus on client success with MIPS and the related
ONC Health IT Certification program. He brings
more than 30 years of experience from the medical
device software and healthcare IT field,
including general management, marketing,
software management, and software development
positions in the ophthalmology, oncology and
radiology fields, including at Carl Zeiss
Meditec, Varian Associates, Siemens Medical
Systems and Pacsgear. Mike also owned and led
SES, a turnkey software development company
focusing on high-risk applications.
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With the increased regulation, Mike has focused
on MACRA, MIPS, Meaningful Use and other EHR
related regulatory concerns. He has spoken at
national conferences including at the User Group
Conferences for Medflow, Integrity, Management
Plus MD Office.
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Mike received his bachelors degree in
mathematics from the University of California at
Berkeley and his masters degree in mathematics
from the University of Washington at Seattle.
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Agenda
The MIPS Challenge Regulatory Update on the 2018
MIPS Proposed Rule The MIPS 2017 2018
Transition Years The MIPS Composite Performance
Score MIPS ACI Performance MIPS Improvement
Activities Performance MIPS Quality
Performance MIPS APMs and Advanced APMs Action
Items and Summary
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What is MIPS?
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Merit-Based Incentive Payment System 1 of 2
tracks of the Quality Payment Program
(QPP) Alternate Payment Models (APMs)
represent the other track Created by MACRA, a law
passed with bi- partisan support in 2015,
nothing to do with the Affordable Care Act, and
not going away
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MIPS is the most widely recognized acronym and
is often misused to refer to the program as a
whole MIPS and specifically APMs are intended to
rein in rising Medicare costs MIPS represents a
historic transition from the classic
Fee-For-Service model to a value- based
reimbursement model
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MIPS shifts power to the payer
Instead of the provider specifying the fee to be
paid the payer will pay what they determine
the
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services are worth!
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The payer measures several categories of provider
performance such as quality of care and cost of
care value-based reimbursement amounts are
calculated in terms of payment adjustments
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relative to the FFS schedule, which will continue
to
exist MACRA requires MIPS and its payment
adjustments to be budget neutral
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Congressional hopes for containing Medicare
costs lie primarily with the APMs, which put
increasing financial risk on the health care
delivery
organizations Over time, Congress hopes to move
increasing
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numbers of physicians from MIPS to APMs
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The Challenge of MIPS
Adjustments by Practice Size
Practice Size
Physicians with Negative Payment Adjustment
Physicians with Positive Payment Adjustment
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Solo
87
12.9
2-9
69.9
29.8
10-24
59.4
40.3
25-99
44.9
54.5
100
18.3
81.3
Proposed Rule Table 64, CMS estimatees based on
2014 data
? Small practices lack economy of scale
to manage MIPS performance effectively ? MIPS
has disproportional effects on ambulatory
specialties such as ophthalmology
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Regulatory Update CMS June,
2017 Proposed Rule for 2018 MIPS (1 of 3)
? 90-day reporting for 2018 MIPS EHR
and Improvement Activities ?But keeps 2018 MIPS
Quality reporting period at
the full calendar year
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? Allows old 2014 Edition CEHRT for one more
year ?But awards 10 MIPS ACI bonus points for
2015
Edition CEHRT in 2018 ?We recommend the upgrade
to 2015 Edition CEHRT in 2017 as soon as it is
available ? Broadens the MIPS exclusion, from
30,000 to 90,000 Medicare reimbursements per
provider per year ?Dramatically affects
optometrists AOA
estimates that all but 4000 optometrists
nationwide will be able to exclude from MIPS
2nd
? Declares 2018 as
and final transition year
? easier MIPS scoring than later years
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Regulatory Update CMS June,
2017 Proposed Rule for 2018 MIPS (2 of 3)
? Adds a 5-point small practice bonus,
starting in 2018 ? group TIN with no more than 15
individual NPI numbers ? intended to counteract
the Table 64 issue ? Larger practices should
re-assess their group TIN structure
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? Reinstates critically missing EHR workflow
exclusions, retroactive to 2017 ? Exclude from
eRx measure if writing fewer than 100
prescriptions ? Exclude from send summary of
care measure if referring / transitioning fewer
than 100 patients ? Exclude from new receive
summary of care measure in case of fewer than
100 new patients in the reporting period ? But
Direct messaging capability is still part of the
definition of Base EHR and required for CEHRT!
? With increased CMS auditing scrutiny, the
practice must
purchase a HISP license!
? Reinstates hardship exclusion for use of
CEHRT ? available only to small practices,
no more than 15 eligible clinicians (or to ones
in rural or HPSA locations) ? We do not recommend
to plan a priori to take advantage of this, but
it is a welcome safety valve in case of CEHRT
implementation issues
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Regulatory Update CMS June,
2017 Proposed Rule for 2018 MIPS (3 of 3)
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Delays MIPS Cost of Care scoring until
2019 Extends transition year MIPS quality scoring
rules ? 3-point floor for MIPS quality measure
scores ? Small practices earn the 3 points even
if the data
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threshold is not met Introduces Improvement
component to MIPS Quality scoring ? Nothing to do
with Improvement Activities Adds 11 new
Improvement Activities all eligible for EHR bonus
points ? Sadly, none appear attractive for eye
care Modified scoring with more points for
public health reporting measures ? Eye care
practices should sign up for syndromic
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surveillance reporting if their state PHA allows
it Virtual Group option for solo and small
practices to cooperate for a joint MIPS
submission and score ? Contact Eye Care Leaders
if you may be interested
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in having us facilitate this option for you
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The MIPS Transition Years 2017 2018
2017 2018 MIPS transition years will be
far easier than 2016 MMU2 / PQRS / VM
CMS estimated that for 2017 MIPS ? At
least 90 of MIPS eligible clinicians will
receive a positive or neutral MIPS payment
adjustment (for) the transition year, and that ?
at least 80 of clinicians in small and solo
practices with 1-9 clinicians will
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receive a positive payment adjustment.
If you do nothing, you will be penalized the
full amount ? 4 for 2017 5 for 2018
To avoid a penalty, only need to report a
single performance category Quality, or
Improvement Activities, or ACI (formerly
called Meaningful Use of Certified EHR
Technology)
Dont let the easy rules lull you into a
false sense of security ? If you only target
2017 and 2018, the gap with very large practices
will only grow ? You would fail in later
years ? It is time to plan and implement your
long-term MIPS strategy now ? Take proper
advantage of the Transition Years
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Limited Positive Payment Adjustments
MACRA requires payment adjustments to be
budget- neutral
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Positive adjustments are subject to a Scaling
Factor based on available funds from negative
payment adjustments With over 90 of physicians
expected to receive positive or neutral payment
adjustments for 2017, the funds from negative
payment adjustments are expected to be very
small Physicians who will not bother with MIPS
will be those planning to retire by 2019 or
those who receive relatively low total Medicare
reimbursements, further limiting the available
funds Expect positive adjustments earned for the
2017 performance year to be very small maximum
possible may be less than
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0.8 Expect positive adjustments tfor the 2018
performance year not to be much larger maximum
possible may be less than 1
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Main positive incentive will be for an
exceptional performance bonus ? Allocated
from a 500M / Year fund not required to be
budget-
neutral ? Shared by all eligible clinicians who
exceed a MIPS score above an exceptional
performance threshold ? A MIPS score of 70 in
the transition years will earn this bonus
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MIPS Payment Adjustments in the First 4 Years
MIPS Phase-In
2017
2018
2019
2020
Quality Reporting
90 days
Full year
Full year
Full year
ACI CPIA Reporting
90 days
90 days
TBD
Full year
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CEHRT Edition Required
2014
2015 for higher score
2015
2015
MIPS Performance Threshold
3
15
Mean
Mean
Exceptional Performance Threshold
70
70
Derived from PT
Derived from PT
Floor for MIPS Quality measures
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3
0
0
Quality Weighting
60
60
30
30
Cost Weighting
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0
30
30
Max. Negative Adjustment
-4
-5
-7
-9
Max. Positive Adjustment (Estimated)
0.8
1
7
9
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www.eyecareleaders.com
You have to learn the rules of the game. And then
you have to play better than anyone else. Albert
Einstein
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The
MIPS
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Composite Performance Score
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Diagram Legend PT Performance Threshold The
mean or median of all MIPS composite scores for
the performance year nationwide APT Additional
Performance Threshold The 1st quartile of MIPS
composite scores above the PT or the MIPS
composite score corresponding to the 1st
quartile of participants above the PT 25 of
PT 1st quartile of MIPS composite scores below
the PT SF Scaling Factor A factor calculated
to ensure that MIPS payment adjustments stay
budget neutral AAF Additional Adjustment
Factor Used to calculate the exceptional
performance bonus budgeted for 500M total
nationwide per year
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Participant Grades A meets or exceeds the
APT receives a positive adjustment proportional
to score plus an exceptional performance bonus B
exceeds the PT but is below the APT receives a
positive adjustment proportional to score, no
exceptional performance bonus C exactly at the
PT receives zero payment adjustment D below
the PT but above 25 of PT receives a negative
payment adjustment proportional to score F in
bottom 25 below PT receives maximum negative
payment adjustment
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Diagram Legend PT Performance Threshold The
mean or median of all MIPS composite scores for
the performance year nationwide APT Additional
Performance Threshold The 1st quartile of MIPS
composite scores above the PT or the MIPS
composite score corresponding to the 1st
quartile of participants above the PT 25 of
PT 1st quartile of MIPS composite scores below
the PT SF Scaling Factor A factor calculated
to ensure that MIPS payment adjustments stay
budget neutral AAF Additional Adjustment
Factor Used to calculate the exceptional
performance bonus budgeted for 500M total
nationwide per year
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Participant Grades A meets or exceeds the
APT receives a positive adjustment proportional
to score plus an exceptional performance bonus B
exceeds the PT but is below the APT receives a
positive adjustment proportional to score, no
exceptional performance bonus C exactly at the
PT receives zero payment adjustment D below
the PT but above 25 of PT receives a negative
payment adjustment proportional to score F in
bottom 25 below PT receives maximum negative
payment adjustment
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MIPS Reimbursement Every Performance Point Will
Count
Year
2016 (VM)
2017 2018 MIPS Transition Year
MIPS in 2019 Later Years
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Description
Top 5 of Quality and/or Cost get payment
adjustment Bottom 5 get - payment adjustment
Minimum reporting for one of 1. Quality
(PQRS) 2. Improvement Activities 3. ACI
Payment adjustments depend linearly on
performance 1. Quality 2. Cost 3.
Improvement Activities 4. ACI
Most Providers
Get no payment adjustment
Will avoid a negative payment adjustment
Will get a payment adjustment
Payment Adjustment
Very few
Very small
Depends on performance
Payment Adjustment -
Very few
Very few
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MIPS
ACI
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(Advancing
Care
Information) Performance
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MIPS in 2019 Later Years
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