Update on MACRA/MIPS Najeeb Mohideen MD, FASTRO,FACR ACR Commission on RO, Economic Committee Chair ASTRO Health Policy Committee ASTRO Payment Reform Committee Northwest Community Hospital, Arlington Heights, IL

Milestones in Healthcare Transformation 2010 Patient Protection and Affordable Care Act (PACA) Healthcare expansion & Payment Reform Transitioning payment for healthcare from volume based to value based will reduce the cost of care and bend the cost curve (ACOs, PCMH, SIMs, P4P, HC Innovation Awards, etc…) HHS Secretary Silva Burwell’s Spring 2015 Announcement 30% of all Medicare payments will be tied to quality or value through Alternative Payment Models by the end of 2016 and 50% by 2018. 2015 Medicare Access and CHIP Reauthorization Act (MACRA) Eliminated the Sustainable Growth Rate (SGR) formula Establishes a combination of automatic rate increases and incentives for docs to participate in pay-for-performance programs and alternative payment models.

MACRA:Overhaul in Medicare Payment Overview of Medicare Access & CHIP Reauthorization Act (MACRA) Physicians can choose between a Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APM) Merit-Based Incentive System (MIPS) Physicians are scored based on Quality, Resource use, Clinical practice improvement, Meaningful use of EHR. Physicians receive a score of 1-100, and will be paid on an adjusted scale. APMs– Alternative Payment Models Qualified APMs will pay lump sum incentive payments (5%) to health care providers starting in 2019.

Medicare payments under MACRA Baseline PFS Updates 0.5% 0% 0.25% ±4% ±5% ±7% ±9% MIPS* Under MACRA, qualifying APM participants in “eligible” APMs: Are exempt from MIPS Receive annual 5% lump sum bonus payments from 2019-2024 Receive a higher fee schedule update for 2026 and onward 5% lump sum bonus 0% +0.5% PFS APMs 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 * Additional bonus available for exceptional performance

Merit-Based Incentive Payment System 4 Categories: Quality Performance(50%) Builds of PQRS program and some parts of the VM. Resource Use (10%) Builds off the cost component of the VM. Advancing Care Information (25%) Builds off of and replaces the Meaningful Use program. Clinical Practice Improvement Activities (15%) Activities that improve the clinical practice or delivery of care. Expanded practice access, population management; care coordination; shared decision-making; telehealth; patient safety and practice assessment; maintenance of certification; etc. For quality, many of the PQRS measures will be carried over, but new measures will also be added. Clinical practice improvement activities is a brand new category that has never been incorporated in other programs. Will be interesting to see how this develops and is evaluated. Providers will receive a score in each category, which will then be summed up for a composite score used to determine whether they receive a bonus or penalty on a sliding scale.

Quality Performance Similar to existing PQRS program, and will adopt measures from existing program. Measures: 6 measures One cross-cutting measure One outcome measure OR a high priority measure (appropriate use, patient safety, efficiency, patient experience, or care coordination) Can also choose to report a specialty measure set. For each measure: • CMS publishes deciles based on national performance in a baseline period (2-years prior to the performance period). • Exception – Performance period is used if a baseline benchmark is not available • Eligible clinician’s performance is compared to the published decile breaks. • Points are assigned based on which decile range the performance data is located. All scored measures receive at least 1 point. • Partial points are assigned within deciles based on percentile distribution. • Rules for special cases: • Eligible clinicians with performance in the top decile will receive the maximum 10 points. • Eligible clinicians who do not report enough measures will receive 0 points for each measure not reported, unless they could not report these measures due to insufficient applicable measures.

Some Existing PQRS Measures Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer Pneumonia Vaccination Status for Older Adults: Documentation of Current Medications Oncology: Medical and Radiation – Pain Intensity Oncology: Medical and Radiation – Plan of Care for Pain Preventive Care and Screening: Tobacco Use

Quality Performance If the measures are reported using a QCDR, EHR, or a qualified registry, then the measures must be reported for 90 percent of all patients to which each the denominator of the measure applies, regardless of the payer. If the measures are reported via claims, then the measures must be reported for 80 percent of Medicare Part B patients to which each measure applies. CMS also proposes that Qualified Clinical Data Registry (QCDR) non-MIPS measures must go through a rigorous approval process during the QCDR self-nomination process, and then be assigned a unique identifier that can only be used by the QCDR that proposed the measure. Seeking clarification regarding whether or not non-MIPS measures approved for use in a QCDR qualify as MIPS comparable measures in the Advanced APM program

Quality Performance

Resource Use CMS will calculate these measures based on claims. Providers do not report any measures. Measures: Episode-based measures. Medicare Spending Per Beneficiary Measure Total Per Capita Cost Measure The basis for this category will be the existing condition and episode-based measures, the total per capita cost measure, and the Medicare Spending per Beneficiary measure that are part of the current Value-based Payment Modifier (VM) program. Performance for these measures will be attributed and assessed based on administrative claims data, rather than data submitted by ECs or groups. Additionally, CMS will continue to develop care episode groups, patient condition groups, and patient relationship categories to incorporate into this category

MACRA Requires Development of Three New Types of Codes Care Episode Groups (and associated codes) Patient Condition Groups (and associated codes) Patient Relationship Categories (and associated codes)

Patient Relationship Categories (i) considers themself to have the primary responsibility for the general and ongoing care for the patient over extended periods of time;  (ii) considers themself to be the lead physician or practitioner and who furnishes items and services and coordinates care furnished by other physicians or practitioners for the patient during an acute episode; (iii) furnishes items and services to the patient on a continuing basis during an acute episode of care, but in a supportive rather than a lead role; (iv) furnishes items and services to the patient on an occasional basis, usually at the request of another physician or practitioner; or (v) furnishes items and services only as ordered by another physician or practitioner

Episode Grouping

Advancing Care Information Eliminates Meaningful Use all-or-nothing scoring methodology for the entire category. Base Score and Performance Score Base Score Objectives: Protect Patient Health Information Electronic Prescribing Patient Electronic Access to Health Information Care of Coordination Through Patient Engagement Health Information Exchange Public Health and Clinical Data Registry Reporting Modified Stage 2 available for 2017. Half score still based on yes/no attestation. Providers have some flexibility because they can receive partial credit for some measures. Also opportunity for bonus points for reporting to multiple public health and clinical data registries.

Advancing Care Information The base score will be yes/no statement for the applicable measures, with only “yes” counting for credit toward 50 percent of the advancing care information category. The performance score will be based on performance in the objectives and measures for Patient Electronic Health Access, Coordination of Care through Patient Engagement, and Health Information Exchange

Advancing Care Information

Advancing Care Information

Clinical Practice Improvement Activity Providers can select from over 90 activities: Participating in a Qualified Clinical Data Registry (QCDR) Participation in AHRQ patient safety organization. Use of telehealth services and analysis of data for quality improvement. Provide episodic care management, including management across transitions and referrals. Activities fall into two categories: medium- and high-weighted activities. Reporting Period: 90 continuous days during the performance period

CPIA Subcategories

MIPS: CPIA Minimum Selection of one activity for a partial score Activities categorized as “medium” or “high” weight earning 10 or 20 points respectively Full Credit for 60 points Year One Weight: 15%

MIPS Performance Category Scoring

APMs APM is a generic term describing a payment model in which providers take responsibility for cost and quality performance and receive payments to support the services and activities designed to achieve high value APMs offer greater potential inherent risks and rewards than MIPS Under MACRA, qualifying APM participants in “eligible” APMs:

What makes an APM “eligible”? Under MACRA, “eligible” APMs must: Base payment on quality measures that are comparable to MIPS Require use of certified EHRs Bear more than “nominal financial risk” or be a medical home model

Pick Your Pace

First Option: Test the Quality Payment Program. With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar year. Submit Quality Payment Program information for a reduced number of days and qualify for a small positive payment adjustment submit information for part of the calendar year for quality measures, how your practice uses technology what improvement activities your practice is undertaking

Third Option: Participate for the full calendar year. For practices that are ready to go on January 1, 2017, you could qualify for a modest positive payment adjustment Quality measures, How your practice uses technology, and What improvement activities your practice is undertaking

Fourth Option: Participate in an Advanced APM in 2017. Join an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 or the OCM in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

Why Participate in MIPS? Many advantages over current quality programs: Sliding scale assessment (partial credit) vs. old “all or nothing” approach Credit for improvement, not just attainment Risk adjustment for health status and other socioeconomic factors Timely feedback reports and more attainable performance targets Flexibility beyond existing quality measures (beyond NQF-endorsed) Reporting via QCDRs for group practices Substantial bonuses for high performance Up to 3x more than the maximum penalty levels (up to 27%) Total MIPS bonuses and penalties must balance each other $500 million per year (up to 10%) for “exceptional performance” from 2019-2024

Care Episode Under MACRA The patient’s clinical problems at the time items and services are furnished during an episode of care Clinical conditions or diagnoses, Whether or not inpatient hospitalization occurs The principal procedures or services furnished and other factors determined appropriate

Patient Condition Groups Under MACRA The patient’s clinical history at the time of a medical visit combination of chronic conditions, current health status, and recent significant history (such as hospitalization and major surgery during a previous period, such as 3 months) other factors determined appropriate by the Secretary