JAMES R. CHRISTINA, DPM 301-581-9265 jrchristina@apma.org MIPS in 2017 a deep dive JAMES R. CHRISTINA, DPM 301-581-9265 jrchristina@apma.org October 1, 2015 forgiveness

Quality Payment Program SGR MACRA (The Medicare Access and CHIP Reauthorization Act of 2015) Quality Payment Program MIPS APM

MIPS Score Highest total of 100 EPs will receive either a positive or negative payment adjustment to Medicare part B fee schedule based on MIPS score Almost all podiatrists will report through MIPS first year Exceptional Performance Threshold 70 500M

Thresholds CMS set the Performance Threshold at 3 and the Exceptional Performance Threshold at 70, meaning that any clinician with a score of at least 3—which can be accomplished by submitting, for example, just one Quality measure—will avoid a negative adjustment, and those earning a score of at least 70 will be eligible for an Exceptional Performance Adjustment from the annual $500 million pool.

MIPS Adjustments 2019: -4% to +4% (based on 2017 score) 2020: -5% to +5% (based on 2018 score) 2021: -7% to +7% (based on 2019 score) 2022 : -9% to +9% (based on 2020 score)

MIPS Year 1 Mostly budget neutral Penalty no more than 4% Most positive adjustments no more than 4% …positive moved based on budget neutrality “Exceptional Performance” (MIPS Score of 70 or higher—access to additional $500 million bonus pool)

MIPS Two determination period options to meet 2017 low volume threshold: 9/1/2015 - 8/31/2016 or 9/1/2016 – 8/31/2017

MIPS MIPS reporting not limited to Medicare patients* (but some quality measures do have age ranges in their denominators so pay attention to them) *Reporting Quality Component by Claims method is exception

CHOSE YOUR COURSE OF PARTICIPATION Three options with regards to MIPS

MAXIMUM MIPS Clinicians can choose to 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.

MODERATE MIPS 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 and report more than one quality measure, more than one improvement activity, or more than the 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.

MINIMUM MIPS Clinicians can choose to report one measure in the quality performance category; one activity in the improvement activities performance category; or report the required measures of the advancing care information performance category and avoid a negative payment adjustment.

MINIMUM SCORE OF 3 For the 2017 transition year, if the measure is submitted but is unable to be scored because it does not meet the required case minimum (20), does not have a benchmark, or does not meet the data completeness requirement (at least 50% reporting rate), the measure will receive a score of 3 points

WHAT ABOUT NO MIPS? Four percent payment reduction on Medicare Part B Fee For Service Payments in 2019

MIPS Quality (60%) Choose 6 PQRS measures One must be an outcome measure (or if no outcome available then a high priority measure) All 6 must be reported by the same method

Quality Measures Submission Methods Claims 50% or more of Medicare Part B patients Registry 50% or more of all patients EHR 50% of all patients CMS Web Interface (groups of 25+) ALL SIX MUST BE SUBMITTED BY SAME MECHANISM

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QUALITY MEASURES Claims Reporting Documentation of Current Meds in the Medical Record Diabetes: Hemoglobin A1c (HbA1c) Poor Control - Intermediate Outcome Pain Assessment and Follow-Up Pneumococcal Vaccination Status for Older Adults BMI Screening and Follow Up Plan Influenza Immunization Screening for High Blood Pressure and Follow Up Tobacco Screening and Cessation Intervention

The Six Measures I Recommend Documentation of Current Meds in the Medical Record Pneumococcal Vaccination Status for Older Adults BMI Screening and Follow Up Plan Influenza Immunization Screening for High Blood Pressure and Follow Up Tobacco Screening and Cessation Intervention

Documentation of Current Medications in Medical Record*

Pneumococcal Vaccination Status for Older Adults

BMI Screening and Follow Up Plan

Influenza Immunization

Screening for High Blood Pressure and Follow Up

Tobacco Screening and Cessation Intervention

QUALITY MEASURES Registry Reporting Diabetes: Hemoglobin A1c (HbA1c) Poor Control - Intermediate Outcome Diabetes: Medical Attention for Nephropathy Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurologic Exam Diabetic Foot and Ankle Care, Ulcer Prevention – Examination of Footwear Documentation of Current Meds in the Medical Record Immunizations for Adolescents

QUALITY MEASURES Registry Reporting Functional Status Change for Patients with Foot or Ankle Impairments – Outcome Pain Assessment and Follow-Up Pneumococcal Vaccination Status for Older Adults Preventive Care & Screening: Body Mass Index (BMI) Screening & Follow-Up Plan Preventive Care and Screening: Influenza Immunization Screening for High Blood Pressure and Follow Up Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

Six RecommendedRegistry Measures (All patients) Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurologic Exam Diabetic Foot and Ankle Care, Ulcer Prevention – Examination of Footwear Documentation of Current Meds in the Medical Record Screening for High Blood Pressure and Follow Up Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Preventive Care & Screening: Body Mass Index (BMI) Screening & Follow-Up Plan

QUALITY MEASURES EHR Reporting Diabetes: Foot Exam Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) – Intermediate Outcome Diabetes: Medical Attention for Nephropathy Documentation of Current Medications in the Medical Record* Falls: Screening for Future Fall Risk* Pneumococcal Vaccination Status for Older Adults Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

QUALITY MEASURES EHR Reporting Preventive Care and Screening: Influenza Immunization Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

When choosing quality measures check minimum case requirements! Most minimum case requirements listed as 20

Advancing Care Information In 2017, there are two measure set options for reporting. The option you use to submit your data is based on your electronic health record edition. Option 1: Advancing Care Information Objectives and Measures Option 2: 2017 Advancing Care Information Transition Objectives and Measures You can report the Advancing Care Information Objectives and Measures (Option 1): If you have technology certified to the 2015 Edition; or If you have a combination of technologies from 2014 and 2015 Editions that support these measures. You can report the 2017 Advancing Care Information Transition Objectives and Measures (Option 2): If you have technology certified to the 2014 Edition; or If you have a combination of technologies from 2014 and 2015 Editions.

Advancing Care Information (25%) 4 Measures if using 2014 ONC Certified EHR (Transition—Option 2)

Advancing Care Information (25%) 40% credit just for reporting Other 60% depends on performance No more clinical decision support rule No more CPOE

Base Score + Performance Score + Bonus Points Total ACI Score Base Score + Performance Score + Bonus Points

ACI Base Score Base score: 10 points for reporting a measure Base Score: Max 40 Base Score: Can get 40 points just for reporting numerators/denominators or yes/no for 4 objectives Need numerator to be ≥ 1 for each

ACI Performance score Performance Score: Receive 1-20 points for each measure reported based on performance of that measure Performance Score: Max 80 points

ACI Bonus Points 5 Bonus Points for reporting to any additional public health or clinical data registry 10 Bonus Points for achieving one Improvement Activity via CEHRT

ACI Score 100 or above on ACI = full 25 MIPS points

MIPS ACI Base 4 Measures (Transition) Protect Patient Health Information (yes/no) MUST BE A “YES” OR ZERO FOR ACI Electronic Prescribing Provide Patient Electronic Access (numerator/denominator—performance weight up to 20%) Health Information Exchange (numerator / denominator—performance weight up to 20%)

ACI Can submit more than 4 measures (up to 11) for additional credit

ACI All 11 Measures Security Risk Analysis E-prescribing Provide Patient Electronic Access Health Information Exchange View, Download, or Transmit (VDT) (up to 10%) Provide Patient-Specific Education (up to 10%) Secure Messaging (up to 10%) Medication Reconciliation (up to 10%) Immunization Registry Reporting (0 or 10%) Syndromic Surveillance Reporting (5% bonus) Specialized Registry Reporting (5% bonus)

ACI Total Score Reporting Score (40) + Performance Score (80) + Bonuses (20) = 140 If earn 100 (or more), get the full 25 ACI score If earn less than 100, declines proportionately. It is not all or nothing!

Clinical Practice Improvement Activities (15%) List of more than 90 options Choose 4 activities if in a group of more than 15 clinicians Choose 2 activities if in a group of 15 or fewer clinicians

Clinical Practice Improvement Activities (15%) Medium weight = 10 points High weight = 20 points Activities double weighted if group of less than 15 Score = points / 40

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Clinical Practice Improvement Activities (15%) Registration in your state’s prescription drug monitoring program - Medium Implement Fall Screening & Assessment Program - Medium Provide 24/7 access to clinician who has real-time access to patient’s medical record - High Assess patient experience of care through surveys, advisory councils and/or other mechanisms - Medium Use decision support and standardized treatment protocols - Medium Program to send reports back to referring clinician - Medium

Clinical Practice Improvement Activities (15%) Collection and follow-up on patient experience and satisfaction data on beneficiary engagement - High Collection and use of patient experience and satisfaction data on access - Medium Consultation of the Prescription Drug Monitoring program - High Engagement of community for health status improvement - Medium Engagement of patients, family and caregivers in developing a plan of care - Medium

Clinical Practice Improvement Activities (15%) Engagement of patients through implementation of improvements in patient portal – Medium Implementation of condition-specific chronic disease self-management support programs - Medium Implementation of use of specialist reports back to referring clinician or group to close referral loop - Medium Improved practices that disseminate appropriate self-management materials - Medium Use of decision support and standardized treatment protocols - Medium

Cost (0% in 2017) Calculated by claims review so no additional reporting Higher points for more efficient resource use Each cost measure worth up to 10 points

APMs Exempt from MIPS payment adjustments Successful participation = 5% bonus and no MIPS adjustment Have to receive certain amount of payments or see certain number of patients through APM

Advanced APM Advanced APMs are those in which clinicians accept risk for providing coordinated, high- quality care.

APMA MACRA RESOURCES www.apma.org/macra

Resources For more information on Quality measures: https://qpp.cms.gov/measures/quality For more information on CPIA: https://qpp.cms.gov/measures/ia For more information on Advancing Care: https://qpp.cms.gov/measures/aci Quality Payment Program (CMS Web Page): https://qpp.cms.gov/

QUESTIONS