What Ob-gyns Need to Know about the MACRA Quality Payment Program ACOG Grand Rounds Slide Deck

What Is MACRA? The Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act of 2015 (MACRA) replaced the faulty sustainable growth rate (SGR).​ MACRA passed with near-unanimous bipartisan support in both the House and the Senate.​ The intent of the law is to move physicians and other providers to deliver care that is reimbursed through an alternative payment model (APM) and ensure that payments are tied to quality Last updated 2/7/2017.

Quality Payment Program CMS has renamed MACRA the Quality Payment Program (QPP).  ​ The final rule was released on October 14 and is more than 2,000 pages.​ ACOG submitted comments in response to the proposed rule and provided suggestions of how CMS can improve its proposal. Some of ACOG’s recommendations have been incorporated into the final version of the QPP. Last updated 2/7/2017.

Two Different Tracks Merit-based Incentive Payment System (MIPS) Sunsets current Meaningful Use (MU), Value-based Payment Modifier (VM), and Physician Quality Reporting System (PQRS) programs at the end of 2018, rolling requirements into a single program.​ Adjusts Medicare payments beginning in 2019. Advanced Alternative Payment Models (APMs) Requires significant share of provider revenue or patients seen in APM with two- sided risk, quality measurement, and use of certified EHR technology (CEHRT) or a federal medical home model demonstration​. Provides financial incentives (5% annual bonus in 2019-2024) and exemption from MIPS requirements. Last updated 2/7/2017.

Key Changes in the Final Rule Transition period for MIPS Different low-volume threshold for individuals and groups: ≤$30,000 in Medicare Part B allowed charges or ≤100 Medicare patients No cost measurement in the first performance period Fewer required improvement activities Fewer required measures in the Advancing Care Information category Shortens reporting period for Advancing Care Information to 90 days for future reporting periods Allows obstetrics and gynecology practices to be considered medical homes in future models under the Advanced APM track Last updated 2/7/2017.

Pick Your Pace: What to Expect in MACRA’s 2017 Transitional Year Source: Centers for Medicare & Medicaid Services’ final rule for implementing Quality Payment Program under the Medicare Access and CHIP Reauthorization Act of 2015 By Janie Boschma, POLITICO Pro DataPoint 2 3 1 Submit at least 90 days of data Earn at least a neutral, if not a positive, adjustment for submitting three months of data and meeting requirements for any one of three categories (quality, improvement activities, and advancing care information). Submit nothing Receive the full 4 percent negative adjustment. Submit something Avoid a negative payment adjustment for submitting partial 2017 data, such as complete data for one quality measure or one improvement activity. MIPS submission options for 2017 transition year: 2017 Submit a full year of data Earn a positive adjustment of up to 4 percent — and potentially an additional positive adjustment depending on performance — for submitting a full year’s data in all three categories. Receive payment adjustment for 2017 performance on or after Jan. 1, 2019 (and begin collecting 2019 data) Dec. 31, 2017 First performance period ends March 31, 2018 Deadline to submit 2017 MIPS data Oct. 2, 2017 Last day to begin 2017 MIPS data collection Jan. 1, 2018 Begin collecting 2018 MIPS data 2017: CMS outlines parameters for 2018 period and payments for 2020 and after KEY DATES Jan. 1, 2017 First day to begin collecting MIPS data CMS provides feedback on 2017 performances TR A NSI TIO N YEA R Last updated 2/7/2017.

MIPS Merit-based Incentive Payment System Last updated 2/7/2017.

Merit-based Incentive Payment System (MIPS) Summary Sunsets current Meaningful Use (MU), Value-based Payment Modifier (VM), and Physician Quality Reporting System (PQRS) programs at the end of 2018, rolling requirements into a single program. Adjusts Medicare payments based on performance on a single budget- neutral payment beginning in 2019. Applies to physicians, NPs, clinical nurse specialists, physician assistants, and certified nurse anesthetists. Providers that meet a low-volume threshold or who are new to billing Medicare do not have to participate. Last updated 2/7/2017.

Low-volume Threshold Low-volume threshold: ≤100 Medicare patients or ≤$30,000 Medicare Part B allowed charges Examples If a practice sees 90 Medicare patients and submits $50,000 in allowed Medicare charges, it is exempt from MIPS. If a practice sees 120 Medicare patients and submits $28,000 in allowed Medicare charges, it is exempt from MIPS. Last updated 2/7/2017.

MIPS Performance Categories 20% 40% 60% 80% 2019 2020 2021+ MIPS Score Components 50% 30% 10% 25% 15% Quality Measures Cost Improvement Activities Advancing Care Information MIPS is made up of 4 performance categories Quality Cost Improvement Activities Advancing Care Information The categories’ weight will change during the first 3 years of the program to give less weight to quality scores and more weight to cost over time. Last updated 2/7/2017.

Quality Performance Category The quality category accounts for 60 percent of the MIPS score in the first year. Clinicians choose 6 measures to report. For groups with 16 clinicians or more, CMS will automatically calculate all-cause hospital readmission based on claims. When selecting the 6 quality measures, you must choose 1 outcome measure (if available) or another high-priority quality measure. If fewer than 6 measures apply to the individual MIPS eligible clinician or group, you will only be required to report on each measure that is applicable. Last updated 2/7/2017.

Cost Performance Category The cost category will not be scored in the first year. In future performance periods, CMS calculates scores based on Medicare claims, meaning there are no additional reporting requirements for clinicians under this category. Measures will be based on total per capita cost, total spending per Medicare beneficiary, and episode groups. For the 2017 performance period, physicians will receive feedback on their performance in this category, but no score. Last updated 2/7/2017.

Advancing Care Information Performance Category – Base Score The base score accounts for 50 points of the total Advancing Care Information category score. To receive the base score, clinicians must provide the numerator/denominator or yes/no for each objective and measure. Last updated 2/7/2017.

Advancing Care Information Performance Category – Base Score – cont’d For ob-gyns using an EHR certified to the 2015 standard, there are 5 objectives and associated measures: Security Risk Analysis Electronic Prescribing Provide Patient Access Send a Summary of Care Record Request/Accept a Summary of Care Last updated 2/7/2017.

Advancing Care Information Performance Category – Performance Score Accounts for up to 90 points of the total Advancing Care Information score. Select measures that best fit your practice from these objectives: Provide Patient Access Patient-specific Education View, Download, and Transmit (VDT) Secure Messaging Patient-generated Health Data Send a Summary of Care Request/Accept a Summary of Care Clinical Information Reconciliation Immunization Registry Reporting Last updated 2/7/2017.

Advancing Care Information Performance Category – Combining Base and Performance Scores The clinicians’ base score, performance score, and bonus points (if applicable) are added together for a total of up to 155 points. If clinicians earn 100 points or more then they receive the full 25 points in the Advancing Care Information performance category. If clinicians earn less than 100 points, their overall score in MIPS declines proportionately. Last updated 2/7/2017.

Improvement Activities Performance Category Accounts for 15 percent of the MIPS score in the first year. Clinicians will have more than 90 options to choose from in the following categories: Expanded practice access Beneficiary engagement Achieving health equity Population management Patient safety and practice assessment Emergency preparedness and response Care coordination Participation in an APM, including a medical home model Integrated behavioral and mental health Last updated 2/7/2017.

Improvement Activities Performance Category – cont’d The maximum total points in this category will be 40 points. There are different weights for the activities. Highly-weighted activities are worth 20 points Other activities are worth 10 points. Last updated 2/7/2017.

Improvement Activities Performance Category – cont’d MACRA statute requires that clinicians receive credit toward scores in this category for participating in Alternative Payment Models (APMs) and Patient-Centered Medical Homes (PCMH). APMs do not have to meet the same standard as an Advanced APM to get credit under this performance category. Clinicians participating in an accredited PCMH will get full credit under this category and do not have to attest to any other activities. Last updated 2/7/2017.

Reporting Mechanisms for MIPS Physicians who report as individuals can report quality measures through claims. Physicians can report data via third parties for the quality, advancing care information, and improvement activities performance categories: Qualified Registries Qualified Clinical Data Registries (QCDRs) Electronic health records (EHRs) Certified survey vendors Within each performance category, you must use the same reporting mechanism, but you can use different mechanisms for different categories. Last updated 2/7/2017.

MIPS Payment Adjustments In the first year, adjustments are calculated so that: Non-exempt ob-gyns and other providers who do not submit data will be subject to a negative penalty of 4 percent. Non-exempt ob-gyns who submit at least one measure in quality or improvement activity or the 4/5 required advancing care information measures will not be subject to any negative adjustments. Non-exempt providers who submit at least 90 consecutive days of data on more than one measure in the quality or improvement activities or more than the required advancing care information measures may be eligible for a small positive payment adjustment. Non-exempt providers who submit a full year of data on quality, advancing care information, and improvement activities may be eligible for a positive payment adjustment of up to 4 percent. Exceptional performers may be eligible for even higher payment adjustments. Last updated 2/7/2017.

MIPS Payment Adjustments – cont’d Currently, the first performance year will be calendar year (CY) 2017 and the first payment adjustment year will be CY2019. In the first five payment years of the program, $500 million is available for performance bonuses that are exempt from budget neutrality for exceptional performance. Last updated 2/7/2017.

Advanced APMs Advanced Alternative Payment Models Last updated 2/7/2017.

Advanced APM Bonus Rewards Participation in New Models Requires significant share of provider revenue in APM with two-sided risk and quality measurement or a federal medical home model demonstration Provides financial incentives (5% annual bonus in 2019-2024) and exemption from MIPS requirements Includes partial qualifying mechanism that allows providers that fall short of APM requirements to report MIPS measures and receive corresponding incentives or to decline to participate in MIPS Last updated 2/7/2017.

What Counts As an Advanced APM? Model approved by the Physician-Focused Payment Models Technical Advisory Committee (PTAC) Model developed by the Centers for Medicare and Medicaid Innovation (CMMI) Medicare Shared Savings Accountable Care Organization (ACO) Demonstration under the Medicare Health Care Quality Demonstration Program Any demonstration required by Federal law Last updated 2/7/2017.

What APMs Currently Exist That Qualify As Advanced? Comprehensive End-stage Renal Disease Care Model for Large Dialysis Organizations with 2-sided Risk Comprehensive Primary Care Plus Medicare Shared Savings Program – Track 2 and Track 3 Next Generation ACO Model Oncology Care Model with 2-sided Risk Last updated 2/7/2017.

Advanced APM Standards Bear a certain amount of financial risk. An Advanced APM will meet the financial risk requirement if CMS withholds payment, reduces rates, or requires the entity to make payments to CMS if its actual expenditures exceed expected expenditures. The amount of risk that an APM Entity potentially owes to CMS must be at least equal to: For performance periods 2017 and 2018, 8 percent of the estimated average total Medicare Part A and B revenues of participating APM Entities, or 3 percent of the expected expenditures for which an APM Entity is responsible under the APM. Base payments on quality measures comparable to those used in the MIPS quality performance category. Require participants to use certified EHR technology (CEHRT). Last updated 2/7/2017.

Medical Home Model Standards Medical home models that have been expanded under the Innovation Center authority qualify as Advanced APMs regardless of whether they meet the financial risk criteria. Medical home models must focus on primary care and accountability for empaneled patients across the continuum of care. Advanced APM that are medical homes have financial risk standards that are somewhat less stringent. Last updated 2/7/2017.

Additional Requirements To qualify for incentive payments, clinicians will have to receive enough of their payments or see enough of their patients through Advanced APMs. In 2019 and 2020, the participation requirements for Advanced APMs are only for Medicare payments or patients. Starting in 2021, the participation requirements for Advanced APMs may include non- Medicare payers and patients, including those with Medicare Advantage plans. Payment Year 2019 2020 2021 2022 2023 2024 and beyond Percentage of Payments 25% 50% 75% Percentage of Patients 20% 35% Last updated 2/7/2017.

Looking Forward What ACOG Is Doing to Help Fellows Last updated 2/7/2017.

What ACOG Is Doing to Help Fellows Get Ready On ACOG’s MACRA QPP webpages you can find a range of materials on requirements for ob-gyns and how Medicare payment has changed under MACRA. Go to www.acog.org/macra. Attend our in-person workshops in Tampa, Albuquerque, or Atlanta. Check out the Education and Events section for more details and registration. If you have questions, you can email practicemanagement@acog.org. You can also visit CMS’ webpage www.qpp.cms.gov. Last updated 2/7/2017.

What ACOG Is Doing to Help Fellows Get Ready We are continuing to partner with other medical associations to improve and simplify these regulations We have convened taskforces to work on creating alternative payment models for maternity care and gynecologic procedures We are working to define quality measures that matter - including meaningful patient-reported outcomes so that participation in the QPP will enhance and improve our practices. Last updated 2/7/2017.

Last updated 2/7/2017.