Quality Payment Program American Health Quality Association Kevin Larsen, MD, FACP Director, Continuous Improvement and Strategy Centers for Medicare & Medicaid Services

Disclaimers This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

The Quality Payment Program The Quality Payment Program policy will: Reform Medicare Part B payments for more than 600,000 clinicians Improve care across the entire health care delivery system Clinicians have two tracks to choose from: The Merit-based Incentive Payment System (MIPS) If you decide to participate in traditional Medicare, you may earn a performance-based payment adjustment through MIPS. Advanced Alternate Payment Models (APMs) If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model. OR Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population.

Quality Payment Program Strategic Goals Improve beneficiary outcomes Enhance clinician experience Increase adoption of Advanced APMs Maximize participation Improve data and information sharing Ensure operational excellence in program implementation Quick Tip: For additional information on the Quality Payment Program, please visit QPP.CMS.GOV

What is the Merit-based Incentive Payment System? Performance Categories Quality Cost Improvement Activities Advancing Care Information Moves Medicare Part B clinicians to a performance-based payment system Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice Reporting standards align with Advanced APMs wherever possible

Car with no dashboard

Only those who provide care can improve care

What do you know about your patients when they are not in your clinic? Population Health What do you know about your patients when they are not in your clinic?

When do you need to know it? Now that you are responsible for people who are not currently in your clinic (medical home, ACO etc) What do you need to know? Who needs to know? When do you need to know it? How will you get it?

Outpatient Testing/Pharmacy/DME The Spectrum of Care is Vast… High Acute Care Hospital Psych Hospital Emergency Department PACE Home Health LTACH Outpt. Rehab Adult Day Care Intensity of Care Outpt. Behav. Health CBS IRF SNF Hospice Facility Urgent Care Physician Office Nursing Home Outpatient Testing/Pharmacy/DME Home Hospice Assist Living Living at Home Low Acuity of Illness High Adapted from Derr and Wolf, 2012

Outpatient Testing/Pharmacy/DME …as are the Barriers to Care Coordination High Acute Care Hospital Psych Hospital Emergency Department PACE Home Health LTACH Outpt. Rehab Adult Day Care Intensity of Care Outpt. Behav. Health CBS IRF SNF Hospice Facility Urgent Care Physician Office Nursing Home Outpatient Testing/Pharmacy/DME Home Hospice Assist Living Living at Home Low Acuity of Illness High Adapted from Derr and Wolf, 2012

“Small Data is our short term focus” Dr. Joe Kimura Dr. Joe Kimura Provider/Care Team Level Analytics – The action is happening at the microsystem level so business intelligence and analytic systems need to support work at the care team/individual physician level. BI systems need to easily and seamlessly telescope metrics up and down all levels of the organization and align metrics across cost to quality to patient experience domains. Robust physician level analytics will require new analytic methods since methods developed for large populations can be glaringly problematic. For example, episode groupers offer significant conceptual appeal when aiming to understand clinician practice pattern variation driving expense differences for similar quality outcomes. However, at the individual PCP or specialist level, the methodological problems are magnified and limits validity and provider acceptance.

Data and Quality Reporting Aggregators CMS- Quality Payment Program (QPP) PQRS, CPC+ CMS surrogates Qualified Clinical Data Registries (QCDR) State Medicaid Offices HRSA Specialty Registries Health Information Exchanges Regional Measurement Collaboratives

HRSA Resources- practical resources

Technical resources Ecqi.healthit.gov

INTEROPERABILITY

Barriers to interoperability Custom Solutions don’t scale

Data in Motion

Data at Rest

HHS Currently CMS ACO HRSA HAB FDA Sentinel CMS PQRS HRSA UDS CMS LTPAC CDC NHSN Hospital A Hospital B

HHS Opportunity HRSA HAB CMS ACO FDA Sentinel CMS PQRS HRSA UDS CMS LTPAC CDC NHSN Hospital A Hospital B

Standard Interoperability “Building Blocks” Vocabulary & Code Sets How should well-defined values be coded so that they are universally understood? Semantic Interoperability Content Structure How should the message be formatted so that it is computable? Syntactic Interoperability Transport How does the message move from A to B? Security How do we ensure that messages are secure and private? Building blocks for Health IT can be broken into 4 areas: Security and transport: Syntactic Interop Content Structure and Vocab: Semantic Interoper Services How do health information exchange participants find each other?

Measure alignment Macro- measure alignment (e.g. Million Hearts measures) Micro- measure alignment (e.g. data definitions within measures- “report once”) Standards alignment (e.g. use Health IT certification standards- QRDA) Program alignment- (e.g. CMS aligning all provider quality reporting into QPP)

Common Data Elements- the future A terminology based metadata solution frees data consumers from data interpretation

Health IT eCQM Certification Policy Modular- choose which measures you want Validate to QRDA standard (schematron) Capture Data > QRDA1 Calculate QRDA3 Report QRDA1, QRDA3 MU2 eCQM certification is basic competency certification- not extensive robust certification of all pathways through a measure. It also only tests the vendor product not the implementation. Quality is specific to clinical context, provider specialty. Therefore modular certification requires ability to certify only the data capture appropriate to a dental EHR, or a pediatric EHR.

Quality Payment Program

These clinicians include: Eligible Clinicians: Quick Tip: Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function. Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients a year. These clinicians include: For the first two years, those that are eligible to participate in MIPS are physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who bill under Medicare Part B. For the third and future years under MIPS we can expand those that are eligible to include occupational therapists, physical therapists, clinical social workers, dietitians, etc. Those clinicians that are not currently eligible to participate in MIPS for the first two years do have the ability to volunteer to report and one of the reasons why you may choose to volunteer to report under the MIPS program is that you are currently participating in PQRS and you want to gain experience under MIPS before you are required to do so. Physicians Physician Assistants Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetists

Who is excluded from MIPS? Clinicians who are: Significantly participating in Advanced APMs Newly-enrolled in Medicare Below the low-volume threshold Enrolled in Medicare for the first time during the performance period (exempt until following performance year) Medicare Part B allowed charges less than or equal to $30,000 a year OR See 100 or fewer Medicare Part B patients a year Receive 25% of your Medicare payments OR See 20% of your Medicare patients through an Advanced APM Who is excluded from MIPS? Clinicians newly enrolled in Medicare: Clinicians who enroll in Medicare for the first time during a performance period are exempt from reporting on measures and activities for MIPS until the following performance year. Clinicians below low-volume threshold: Medicare Part B allowed charges less than or equal to $30,000 a year; OR see 100 or fewer Medicare Part B patients in a year Clinicians significantly participating in Advanced APMs.

What are the Performance Category Weights? Weights assigned to each category based on a 1 to 100 point scale Transition Year Weights— 25% 60% 0% 15% 25% Quality Cost Improvement Activities Advancing Care Information There are specific category weights assigned to each of those four categories as defined by the MACRA law. You’ll note that those weights roll up to 100, as each MIPS eligible clinician’s Final Score will be based off of a 0 to 100 point scale. For the first year, the “transition” year, quality will account for 60% of the composite performance score, or 60 points. Cost will count 0% to allow clinicians to gain some familiarity with the MIPS program. Improvement Activities will count for 15%, or 15 points, and Advancing Care Information will count for 25%, or 25 points. Let’s take a deeper dive into the performance categories. Note: These are defaults weights; the weights can be adjusted in certain circumstances

How do Eligible Clinicians Participate in the Merit-based Incentive Payment System?

Pick Your Pace for Participation for the Transitional Year MIPS Participate in an Advanced Alternative Payment Model Test Pace Partial Year Full Year Some practices may choose to participate in an Advanced Alternative Payment Model in 2017 Submit some data after January 1, 2017 Neutral or small payment adjustment Report for 90-day period after January 1, 2017 Small positive payment adjustment Fully participate starting January 1, 2017 Modest positive payment adjustment Clinicians: Should assess readiness and decide how and when they’ll participate. Can choose to participate in 2017 as a test year by submitting a minimum amount of 2017 data to Medicare. Can choose to partially participate by submitting 90 days of 2017 data to Medicare. With this option, you may earn a small bonus. Can choose full participation by submitting a full year of data to Medicare. With this option, you may earn a moderate bonus. **Note: Not participating in the Quality Payment Program: If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment. MIPS Pick Your Pace for Participation Options: Test Pace An effort to help clinicians “experiment” with the program Preparing clinicians for broader reporting in 2018 and 2019 Clinicians must submit some data after January 1, 2017 What does “some” data mean? Eligible for a neutral or small payment adjustment Partial Year Clinicians report for a period of 90-days anytime after January 1, 2017 October 2, 2017 is the last day to begin reporting for the 90-day option Eligible for a small positive payment adjustment Full Year Option is for clinicians/practices that are prepared to fully participate starting on January 1, 2017 Eligible for a modest positive payment adjustment Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment.

MIPS: Choosing to Test for 2017 Submit minimum amount of 2017 data to Medicare Avoid a downward adjustment You Have Asked: “What is a minimum amount of data?” For Test Participation: Submit 1 quality measure or 1 Improvement activity or 5 advancing care information measures OR OR 4 or 5 Required Advancing Care Information Measures 1 Quality Measure 1 Improvement Activity

MIPS: Partial Participation for 2017 Submit 90 days of 2017 data to Medicare May earn a positive payment adjustment “So what?” - If you’re not ready on January 1, you can start anytime between January 1 and October 2 For Partial Participation: Clinicians can choose to report to MIPS for a period of time less than the full year performance period 2017 but for a full 90-day period at a minimum. They must report more than one quality measure, more than one improvement activity, or more than the 5 required measures in the advancing care information performance category in order to avoid a negative MIPS payment adjustment and to possibly receive a positive MIPS payment adjustment. Need to send performance data by March 31, 2018

MIPS: Full Participation for 2017 Submit a full year of 2017 data to Medicare May earn a positive payment adjustment Best way to earn largest payment adjustment is to submit data on all MIPS performance categories Key Takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted. For Full participation: Clinicians should report to MIPS for a full 90-day period or, ideally, the full year, and maximize the MIPS eligible clinician’s chances to qualify for a positive adjustment. In addition, MIPS eligible clinicians who are exceptional performers in MIPS, as shown by the practice information that they submit, are eligible for an additional positive adjustment for each year of the first 6 years of the program. Full participation in the MIPS would mean that clinicians should, at least, meet the following criteria: Report 6 Quality Measures Report 4 medium weighted or 2 high-weighted improvement activities Report 5 advancing care information measures

Bonus Payments and Reporting Periods MIPS payment adjustment is based on data submitted. Clinicians should pick what's best for their practice. Full year participation Is the best way to get the max adjustment Gives you the most measures to choose from Prepares you the most for the future of the program Partial participation (report for 90 days) You can still earn the max adjustment There isn't any set difference in bonus amounts between 90 days and full year. However, for quality measures in particular it can be difficult to meet the outcome measure requirement with only 90 days (and same is true for other "high priority" measures) we anticipate that folks who report for a year will have higher scores due to more reliable data and the ability to get bonus points for these types of measures. But if you report on 90 days and are a high performer, you could get higher positive incentives. So there is nothing built in to the scoring method that automatically gets you lower scores/fewer points for 90 days—it's just likely to pan out that way for some folks.

Submission Methods for MIPS Individual Group Qualified Clinical Data Registry (QCDR) Qualified Registry EHR Claims QCDR Administrative Claims CMS Web Interface CAHPS for MIPS Survey Attestation Quality Improvement Activities Advancing Care Information *Must be reported via a CMS approved survey vendor together with another submission method for all other Quality measures.

Small, Rural, and Health Professional Shortage Areas (HPSAs) You Have Asked: “Based on the requirements, can small or rural practices succeed in the Quality Payment Program?” We have heard these concerns and are taking additional steps to aid small, rural, and HPSAs, including: Reducing the time and cost to participate in the program Excluding more small practices through the low- volume threshold Allowing practices to pick their pace of participation Increasing the availability of Advanced APMs to small practices Increasing ability for clinicians practicing at Critical Access Hospitals (CAHs), Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs) to qualify as a Qualifying APM Participant Providing funding for direct technical assistance

Alternative Payment Models An Alternative Payment Model (APM) is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. APMs may offer significant opportunities to eligible clinicians who are not immediately able or prepared to take on the additional risk and requirements of Advanced APMs. Advanced APMs are a Subset of APMs APMs Advanced APMs

Advanced Alternative Payment Models Advanced Alternative Payment Models (Advanced APMs) enable clinicians and practices to earn greater rewards for taking on some risk related to their patients’ outcomes. It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs. Advanced APM- specific rewards + 5% lump sum incentive Advanced APMs

Advanced APMs in 2017 For the 2017 performance year, the following models are Advanced APMs: The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements on an ad hoc basis. Comprehensive End Stage Renal Disease Care Model (Two-Sided Risk Arrangements) Comprehensive Primary Care Plus (CPC+) Shared Savings Program Track 2 Shared Savings Program Track 3 Next Generation ACO Model Oncology Care Model (Two-Sided Risk Arrangement) For the 2017 performance year, the following models are considered Advanced APMs: Comprehensive End Stage Renal Disease Care Model (Large Dialysis Organization arrangement) Comprehensive Primary Care Plus (CPC+) Model Shared Savings Program Track 2 Shared Savings Program Track 3 Next Generation Accountable Care Organization (ACO) Model Quick Tip: Encourage clinicians to check back with CMS periodically, as a final list of Advanced APMs for the first performance year will be posted by January 1, 2017.

Future Advanced APM Opportunities MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and assess Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee. For the 2018 performance year, we anticipate that the following models will be Advanced APMs: This list may change. Be sure clinicians review the final list that is scheduled to be published on or before January 1, 2018. ACO Track 1+ New Voluntary Bundled Payment Model Comprehensive Care for Joint Replacement Payment Model (CEHRT) Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT) The initial list is expected to grow over the coming years, as CMS anticipates that the following models would qualify as Advanced APMs for the 2018 performance year: ACO Track 1+ New Voluntary Bundled Payments for Care Improvement Advancing Care Coordination through Episode Payment Models (Cardiac and Joint Care) Vermont All-Payer Model Quick Tip: Be sure clinicians review the final list that is scheduled to be published on or before January 1, 2018.

The Quality Payment Program provides additional rewards for participating in APMs. Potential financial rewards In Advanced APM Not in APM In APM MIPS adjustments MIPS adjustments + APM-specific rewards APM-specific rewards What about those who are in “Advanced” APMs –i.e. the ones that meet the criteria we described earlier? Like those in “regular” APMs, these individuals will receive APM-specific rewards, and some individuals (called “qualifying APM participants”) will be eligible for a 5% lump sum bonus. + If you are a Qualifying APM Participant (QP) = 5% lump sum bonus

When Does the Quality Payment Program Officially Begin? submit adjustment Performance year Feedback available 2017 Performance Year March 31, 2018 Data Submission Feedback January 1, 2019 Payment Adjustment Performance: The first performance period opens January 1, 2017 and closes December 31, 2017. During 2017, you will record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can provide care during the year through that model. Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, 2018. In order to earn the 5% incentive payment for participating in an Advanced APM, just send quality data through your Advanced APM.  Feedback: Medicare gives you feedback about your performance after you send your data.  Payment: You may earn a positive MIPS payment adjustment beginning January 1, 2019 if you submit 2017 data by March 31, 2018. If you participate in an Advanced APM in 2017, then you could earn 5% incentive payment in 2019. The first performance period for MIPS will be from January 1, 2017 through December 31, 2017. Remember, that during the first performance period, eligible clinicians have the “pick your pace” option in determining their level of participation. The first payment year for MIPS, where eligible clinicians will have their payments adjusted, will be in 2019, and will be based on the first performance period of 2017.

Technical Assistance and Support

Technical Assistance for Clinicians CMS has free resources and organizations on the ground to provide help to clinicians who are eligible for the Quality Payment Program:

Small, Underserved, and Rural Support Five-year technical assistance program authorized under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Designed for practices with 15 or fewer eligible clinicians. Includes small practices in: rural locations, health professional shortage areas (HPSAs), and medically underserved areas (MUAs). Goal is to provide on-the-ground support to eligible clinicians by: Assisting in the selection and reporting of appropriate Merit-based Incentive Payment System (MIPS) Quality measures and Improvement Activities; Optimizing their Health Information Technology (HIT); Supporting change management and strategic planning; and Evaluate their options for joining an Advanced Alternative Payment Model (APM). Support is available immediately and is FREE to clinicians in small practices.

Small, Underserved, and Rural Support Adds an additional layer to the multi-level outreach effort to help eligible clinicians understand, prepare for, and participate in the Quality Payment Program. Integrated Technical Assistance now includes: Quality Innovation Networks – Quality Improvement Organizations (QIN-QIOs) Small, Underserved, and Rural Support (SURS) Transforming Clinical Practice Initiative (TCPI) APM Learning Networks Quality Payment Program: qpp.cms.gov; email: qpp@cms.hhs.gov; or dial 1-866-288- 8292 (Monday-Friday 8AM-8PM ET). TTY users can call 1-877-715-6222. Shared goal of ensuring 100% of eligible clinicians have access to technical assistance.

National Coverage 11 uniquely experienced organizations to provide national coverage to eligible clinicians in small practices.

What’s Next? Developing the Year 2 Proposed Rule Virtual Groups Scoring Improvement Increasing engagement with patients and consumers Ongoing engagement with clinicians and professional societies Development of new APMs, working with PTAC on physician-focused APMs Development of a feedback loop from front line TA to CMS to understand what is happening on the front lines to inform policy and operations Development of interactive tools and website content based on user needs

Contact Information Kevin Larsen, MD, FACP Director Continuous Improvement and Strategy, CMS kevin.larsen1@cms.hhs.gov