Quality Payment Program 2019: Year 3 Proposed Rule The information contained in this presentation is for general information purposes only. The information is provided by UK HealthCare’s Kentucky Regional Extension Center and while we endeavor to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to content.

Kentucky Regional Extension Center Overview UK’s Kentucky REC is a trusted advisor and partner to healthcare organizations, supplying expert guidance to maximize quality, outcomes and financial performance. To date, the Kentucky REC’s activities include: Helping bring over $100 million incentive dollars to providers throughout the Commonwealth Assisting more than 3,400 individual providers across Kentucky, including primary care providers and specialists Helping more than 95% of the Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) within Kentucky Working with more than 1/3 of all Kentucky hospitals Supporting dozens of practices and multiple health systems with practice transformation and preparation for value based payment Physician Services Kentucky Medicaid EHR Incentive Program & Mock Audit (Promoting Interoperability) Security Risk Analysis & Project Management Patient Centered Medical Home (PCMH) Consulting Patient Centered Specialty Practice (PCSP) Consulting Value Based Payment & MACRA Support Hospital Services HIPAA Security Assessment Electronic Quality Reporting Support REC Service Lines Kentucky REC Description RJC

Objectives Year 3 Quality Payment Program Overview 2019 Physician Fee Schedule Overview Support & Assistance Questions

2019 Quality Payment Program (QPP) Overview

QPP NPRM Y3: MACRA Timeline Jan – Dec 2018: 2nd Performance Period = +/- 5% November 2018: Final Rule expected for Year 3 Jan – Dec 2019: 3rd Performance Period = +/- up to 7% NPRM Released July 12, 2018 Comment Period Ends September 10, 2018 Impacts 2019 Performance Periods for QPP Final rule is set to be released prior to the end of 2018, that will finalize any changes to the QPP for program year 3. For Y3 what is at stake is 7%

MACRA Eligible Clinicians (ECs) 5 Types of Eligible Clinicians (ECs): Physicians, PAs, NPs, CNS, CRNA Proposing to expand to: PT, OT, CSW, & Clinical Psychologist Not Covered by MACRA: Hospitals/ Medicare Part A payments FQHCs/RHCs & Medicaid Providers (non dual-eligible) Exclusions: 1st year ECs Less than $90K and/or 200 Medicare patients and proposed 200 PFS Advanced APM Qualifying Provider Different Scoring & Reporting Requirements: “Non-patient facing” clinicians MIPS APMs PAs, NPs, CNS, CRNA, PT, OT, CSW, & Clinical Psychologist MIPS eligible clinicians: MIPS applies to Medicare Part B clinicians including: Physicians Physician assistants Nurse practitioners Clinical nurse specialist Certified registered nurse anesthetists Proposed to expand to: Physical therapists Occupational therapists Clinical social workers Clinical psychologists Scoring flexibility: CMS is proposing that in Y3, the reweight would be extended to include OT, PT, CSW & Clinical Psychologist

QPP NPRM Y3: Low Volume Threshold $90,000 in Part B 200 Medicare Patients 2018 PY Eligibility: $90,000 in Part B 200 Medicare Patients 200 Covered PFS 2019 PY Eligibility: Low Volume Threshold: For Year 3, CMS is proposing to revise the criteria for low-volume threshold to include a third criterion for determining MIPS eligibility. To be excluded from MIPS, clinicians or groups would need to meet one of the following three criterion: have ≤ $90K in Part B allowed charges for covered professional services provide care to ≤ 200 beneficiaries OR provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS)

QPP NPRM Y3: Opt-In Option Opt-In Eligible > $90K Medicare Part B OR > 200 Medicare Patients Covered services -Once opted--Once opted-in, the decision is IRREVOCABLE and CANNOT be changed Opt In: Starting in Year 3, clinicians or groups would be able to opt-in to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criterion in, the decision is IRREVOCABLE and CANNOT be changed

QPP NPRM Y3: Proposed Reporting Options Individual Virtual Group Group Individual or Group Reporting: Under MIPS, clinicians will have the option to be assessed as a group either under a single TIN or utilizing Virtual Groups or as individual ECs across all four MIPS performance categories. *Proposing to remain the same as Year 2

QPP NPRM Y3: Virtual Groups Same requirements as PY 2, with these changes: TINs would be able to inquire about TIN size prior to making an election from Aug. 1 – Dec. 31 of the CY, prior to the performance period TIN size inquiries would be made via the QPP Service Center QPP NPRM Y3: Virtual Groups Virtual group policies remain the same as Year 2, with the following change: • Beginning with 2019 the virtual group eligibility determination period aligns with the first segment of data analysis under the MIPS eligibility determination period. o For example: Oct. 1, 2017 to Sept. 30, 2018 (including a 30-day claims run out) Virtual Group election is the same as Year 2, with the following change: • As part of the virtual group eligibility determination period, TINs would be able to inquire about their TIN size prior to making an election during a 5-month timeframe, which would begin on August 1 and end on December 31 of a calendar year prior to the applicable performance period. TIN size inquiries would be made through the Quality Payment Program Service Center. Technical assistance resources already available to stakeholders would continue to be available The requirement for virtual groups to have a formal written agreement between each member of a virtual group remains the same for Year 3 • For 2019, a designated virtual group representative must e-mail a virtual group election to MIPS_VirtualGroups@cms.hhs.gov by December 31 of the calendar year prior to the start of the applicable performance period

QPP NPRM Y3: Proposed Glossary of Terms Collection type Set of quality measures with comparable specifications and data completeness criteria MIPS CQMs (Clinical Quality Measures) Proposed to replace what was formerly referred to as registry measures Submitter type The MIPS EC, group, or third party intermediary acting on behalf of a MIPS EC or group Submission type The mechanism by which a submitter type submits data to CMS Collection type: a set of quality measures with comparable specifications and data completeness criteria including, as applicable: electronic clinical quality measures (eCQMs); MIPS clinical quality measures (CQMs); Qualified Clinical Data Registry (QCDR) measures; Medicare Part B claims measures; CMS Web Interface measures; the CAHPS for MIPS survey measure; and administrative claims measures. Submitter type: as the MIPS eligible clinician, group, or third party intermediary acting on behalf of a MIPS eligible clinician or group, as applicable, that submits data on measures and activities. Submission type: as the mechanism by which the submitter type submits data to CMS, including, as applicable: direct, log in and upload, log in and attest, Medicare Part B claims, and the CMS Web Interface. There is no submission type for cost data because the data is only submitted for payment purposes.

QPP NPRM Y3: Individual Data Submission Types Performance Category Submission Type Submitter Type Collection Type Quality Direct Log-in & Upload Medicare Part B Claims Individual 3rd Party Intermediary eCQMs *MIPS CQMs QCDR Measures *formerly known as registry measures Cost No data submission required Improvement Activities Log-in & Attest PI In Year 3, individual eligible clinicians would be able to submit a single measure via multiple collection types (e.g. MIPS CQM, eCQM, QCDR measures and Medicare Part B claims measures) and be scored on the data submission with the greatest number of measure achievement points

QPP NPRM Y3: Group Data Submission Types Performance Category Submission Type Submitter Type Collection Type Quality Direct Log-in & Upload CMS Web Interface Group 3rd Party Intermediary eCQMs *MIPS CQMs QCDR Measures CMS Web Interface Measures CMS Approved Survey Vendor Measure Administrative Claims Cost No data submission required Improvement Activities Log-in & Attest PI Individual Groups and Virtual Groups would be able to use multiple collection types. • The Quality performance category would be scored if groups submit data using multiple collection types (e.g. MIPS CQM, eCQM, QCDR measures, and Medicare Part B claims measures) • CMS Web Interface cannot be scored with other collection types other than the CMS approved survey vendor measure and/or administrative claims measures *formerly known as registry measures

MIPS: 2019 Reporting Timeframes Quality: IA: PI: Cost: Reporting Requirement: 365 days Reporting Requirement: At least 90 days in program year Reporting Requirement: At least 90 days in program year *Reporting Requirement: 365 days *no reporting required Must Submit by March 31st 2020

QPP NPRM Y3: Threshold 0 – 7.5 Points = Full 7% Penalty 7.51 – 29.99 Points = -7% and < 0% 30 Points = Neutral Payment Adjustment 30.01 - 79.99 Points = > 0% and Not Eligible for $500M Pool > 80 = > 0% and Eligible for Split of $500M Pool Performance Threshold: 30 Points Providers who score below 30 points in their final score will receive penalties. If providers choose to not participate (subject to the full 7% penalty in Medicare payments in 2021) If provider scores 30 points to 80 the provider will qualify for a modest positive adjustment factor If provider scores 80+ they fall in the exceptional performance category which qualifies for a higher positive adjustment factor If a MIPS eligible clinician is scored on fewer than two performance categories, a final score equal to the performance threshold will be assigned and the MIPS eligible clinician will receive a payment adjustment of 0%

QPP NPRM Y3: Proposed Changes to Quality Final Score: Measures: Requirements: Submission: % Final Score: Measures: Contribution to final score proposed to move from 50% to 45% Bonus Points for additional High Priority Measures; except Web Interface Small Practice Bonus of 3 points Requirements: 60% data completion for PY 2019 Current version of eCQMs must be used Direct Log-in & Upload Log in & Attest Part B Claims CMS Web Interface Quality Performance Category Proposed Changes: Weight to final score: 45% in Year 3 Maintain the same reweighting criteria Multiple Submissions Allowed: In Year 3, individual eligible clinicians would be able to submit a single measure via multiple collection types and be scored on the data submission with the greatest number of measure achievement points Groups and Virtual Groups would be able to use multiple collection types. The Quality performance category would be scored if groups submit data using multiple collection types CMS Web Interface cannot be scored with other collection types other than the CMS approved survey vendor measure and/or administrative claims measures Bonus Points: High-Priority Measures (after first required measure) Discontinue high-priority measure bonus points for CMS Web Interface Reporters Small Practice Bonus: •The small practice bonus will now be added to the Quality performance category, rathe rthan in the MIPS final score calculation •Add 3 points in the numerator of the Quality performance category for MIPS eligible clinicians in small practices who submit data on at least 1 quality measure

QPP NPRM Y2: Proposed Changes to Cost Final Score: Measures: Requirements: Submission: Contribution to final score proposed to move from 10% to 15% Measure 1: Spending per Beneficiary Measure 2: Total per capita costs Adding 8 episode- based measures Measure 1: MSPB 35 cases Measure 2: TPCC 20 cases Episode based measures: Procedures 10 cases Inpatient 20 cases No reporting requirement Data pulled from Administrative Claims Cost Performance Category Proposed Changes: Weight to final score: 15% in Year 3 Measures: The Total Per Capita Cost and MSPB measures will be the same as in Year 2, with the following changes: 8 episode-based measures will be added to the list of Cost measures Case minimum of 10 for procedural episodes and 20 for acute inpatient medical condition episodes Measure Attribution: Same as Year 2 with the following changes: For procedural episodes, episodes will be attributed to each MIPS eligible clinician who renders a trigger service as identified by HCPCS/CPT procedure codes. The outpatient measure topics to be included: Elective Outpatient Percutaneous Coronary Intervention Knee Arthroplasty Revascularization for Lower Extremity Chronic Critical Limb Ischemia Routine Cataract Removal with Intraocular Lens (IOL) Implantation Screening/Surveillance Colonoscopy For acute inpatient medical condition episodes, episodes will be attributed to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30 percent of the inpatient E&M claim lines in that hospitalization. The inpatient measure topics to be included: Intracranial Hemorrhage or Cerebral Infarction Simple Pneumonia with Hospitalization ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) Scoring Improvement: Cost performance category percent score will not take into account improvement until the 2024 MIPS payment year

QPP NPRM Y2: Proposed Changes to Cost Procedural Episodes Acute Inpatient Medical Condition Episodes Attribution will be to each MIPS EC who renders a trigger service as identified by HCPCS/CPT procedure codes. Elective Outpatient Percutaneous Coronary Intervention Knee Arthroplasty Revascularization for Lower Extremity Chronic Critical Limb Ischemia Routine Cataract Removal with Intraocular Lens (IOL) Implantation Screening/Surveillance Colonoscopy Attribution will be to each MIPS EC who bills inpatient E&M claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30%. Intracranial Hemorrhage or Cerebral Infarction Simple Pneumonia with Hospitalization ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)

QPP NPRM Y3: Proposed Facility-Based Scoring Criteria for Individual Eligibility for Facility-based Measurement An EC who provides 75% or more of covered professional services in POS codes 21, 22, or 23 during the eligibility period Definition EC must have at least one claim with POS 21, 22 or 23 Additional Proposed Criteria EC score will be based on score facility is receiving payment on beginning October of EC performance year 1st Performance Year 2019/Payment Year 2021 Scoring Improvement: Given that improvement is already captured in the distribution of the MIPS performance scores that is used to translate a Hospital VBP Program Total Performance Score into a MIPS Quality performance category score, there is no additional improvement scoring for facility-based measurement for either the Quality or Cost performance categories Scoring - Special Rules: Some hospitals do not receive a Total Performance Score in a given year in the Hospital VBP Program, whether due to insufficient quality measure data, failure to meet requirements under the Hospital IQR Program, or other reasons. In these cases, CMS would not calculate a facility-based score based on the hospital’s performance, and facility-based clinicians would be required to participate in MIPS via another method.

QPP NPRM Y3: Proposed Facility-Based Scoring To be designated as a group, 75% of clinicians within the TIN must have facility based status Group Eligibility Groups or Individual ECs must submit PI & IA categories CMS will automatically score quality for facility based providers MIPS Submission Requirements Facility-based group is attributed to the hospital at which a plurality of its facility-based clinicians are attributed If CMS is unable to identify a facility with a VBP score to attribute clinician’s performance, that clinician is not eligible for facility-based measurement Attribution Automatically applied to MIPS eligible clinicians and groups who are eligible and who would benefit by having a higher combined Quality and Cost Score Election Facility-Based Quality and Cost Performance Categories Proposed Changes: Measurement: For facility-based scoring, the measure set for the fiscal year Hospital Value-Based Purchasing (VBP) program that begins during the applicable MIPS performance period will be used for facility-based clinicians Applicability – Individual: MIPS eligible clinician furnishes 75 percent or more of their covered professional services in inpatient hospital, on-campus outpatient hospital, as identified by POS code 22, or an emergency room, based on claims for a period prior to the performance period Clinician must have at least a single service billed with the POS code used for the inpatient hospital or emergency room Applicability – Group: Facility-based group is one in which 75 percent or more of the MIPS eligible clinician NPIs billing under the group’s TIN are eligible for facility-based measurement as individuals Attribution: A facility-based clinician is attributed to the hospital at which they provide services to the most Medicare patients A facility-based group is attributed to the hospital at which a plurality of its facility-based clinicians are attributed If unable to identify a facility with a VBP score to attribute a clinician’s performance, that clinician is not eligible for facility-based measurement and will have to participate in MIPS via other methods Election: Automatically apply facility-based measurement to MIPS eligible clinicians and groups who are eligible for facility-based measurement and who would benefit by having a higher combined Quality and Cost score No submission requirements for individual clinicians in facility-based measurement but a group must submit data in the Improvement Activities or Promoting Interoperability performance categories in order to be measured as a group under facility-based measurement

QPP NPRM Y3: Proposed Facility-Based Quality & Cost Measures Hospital Consumer Assessment of Healthcare Providers and Systems (including Care Transitions Measure) HCAHPS Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (AMI) Hospitalization MORT-30-AMI Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Heart Failure (HF) Hospitalization MORT-30-HF Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Pneumonia (PN) Hospitalization MORT-30-PN Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Replacement Arthroplasty (TKA) THA/TKA National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure CAUTI National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure CLABSI American College of Surgeons – Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure Colon & Abdominal Hysterectomy SSI National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure MRSA Bacteremia National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure CDI Elective Delivery PC-01 Payment-Standardized Medicare Spending Per Beneficiary (MSPB) MSPB Benchmarks: Benchmarks for facility-based measurement are those that are adopted under the Hospital VBP Assigning MIPS Category Scores: Both the Quality score and Cost score for facility-based measurement are reached by determining the percentile performance of the facility determined in the VBP program for the specified year and awarding a score associated with that same percentile performance in the MIPS Quality and Cost scores for those clinicians who are not scored using facility-based measurement EC performance year 2019 based on hospital measure data collection from 2018, paid in October 2019 to hospitals

QPP NPRM Y3: Proposed Changes to IA Final Score: Measures: Requirements: Submission: Contributes up to 15% of final score Small, NPF, Rural/HPSAs receive increased weighting Removing: IA CEHRT Bonus 1 existing IA Adding: 6 New Activities Modified: 5 Existing Activities 40 pts needed across 2-4 activities Re-weighting for: Non-patient facing Small practices HPSA locations ASC-based Direct Log-in & Upload Log in & Attest Improvement Activities Inventory: In Year 3, the timeframe for the Annual Call for Activities and the improvement activities inventory would be modified Modifications include the addition of one new criteria in this category, “Include a public health emergency as determined by the Secretary” and the removal of “Activities that may be considered for a Promoting Interoperability bonus” Adding 6 new Improvement Activities Modification of 5 existing Improvement Activities Removal of 1 existing Improvement Activity Scoring: PI Bonus: In Year 3, the Promoting Interoperability bonus will be removed

QPP NPRM Y3: Proposed Changes to PI Final Score: Measures: Requirements: Submission: Contributes up to 25% of final score Reweight for: PAs, NPs, CNS, CRNA, PT, OT, CSW, Clinical Psychologists Eliminates old scoring methods Proposes new performance-based scoring at measure-level 2 – 5pt bonuses under e-RX Use of 2015 CEHRT Four objectives: e-RX HIE Provider to Pt Exchange Public Health & Clinical Data Exchange Direct Log-in & Upload Log in & Attest Weight to final score: 25% in Year 3 Maintains the same reweighting criteria and extends to additional clinician types Certification Requirements: Eligible clinicians must use 2015 Edition CEHRT in Year 3 Scoring: CMS is proposing major changes to the method of scoring in addition to the Objectives for Y3 of QPP for this category. Eliminating base, performance, and bonus scores   Proposing a new scoring methodology: Performance-based scoring at the individual measure-level. Each measure would be scored based on the MIPS eligible clinician’s performance for that measure based on the submission of a numerator or denominator, or a “yes or no” submission, where applicable The scores for each of the individual measures would be added

QPP NPRM Y3: PI Proposed Measure Changes Measure Status Measure Measures retained – No modifications* ● e-Prescribing *Security Risk Analysis is retained, but not included as a measure under the proposed scoring methodology. Measures retained with modifications ● Send a Summary of Care (name proposal - Support Electronic Referral Loops by Sending Health Information) ● Provide Patient Access (name proposal - Provide Patients Electronic Access to Their Health Information) ● Immunization Registry Reporting ● Syndromic Surveillance Reporting ● Electronic Case Reporting ● Public Health Registry Reporting ● Clinical Data Registry Reporting Removed measures ● Request/Accept Summary of Care ● Clinical Information Reconciliation ● Patient-Specific Education ● Secure Messaging ● View, Download or Transmit ● Patient-Generated Health Data New measures ● Query of Prescription Drug Monitoring Program (PDMP) ● Verify Opioid Treatment Agreement ● Support Electronic Referral Loops – Receiving and Incorporating Health Information e-Prescribing :10 points Bonus: Query of Prescription Drug Monitoring Program (PDMP): 5 bonus points Bonus: Verify Opioid Treatment Agreement: 5 bonus points Health Information Exchange: Support Electronic Referral Loops by Sending Health Information: 20 points Support Electronic Referral Loops by Receiving and Incorporating Health Information: 20 points Provider to Patient Exchange: Provide Patients Electronic Access to Their Health Information: 40 points Public Health and Clinical Data Exchange: Choose two of the following: Immunization Registry Reporting Electronic Case Reporting Public Health Registry Reporting Clinical Data Registry Reporting Syndromic Surveillance Reporting 10 points

QPP NPRM Y3: PI Proposed Scoring Methodology Objectives Measures Maximum Points e-Prescribing 10 pts Bonus: Query of Prescription Drug Monitoring Program 5 pts bonus Bonus: Verify Opioid Treatment Agreement Health Information Exchange Support Electronic Referral Loops by Sending Health Information 20 pts Support Electronic Referral Loops by Receiving and Incorporating Health Information Provider to Patient Exchange Provide Patients Electronic Access to Their Health Information 40 pts Public Health and Clinical Data Exchange Choose two of the following: Immunization Registry Reporting Electronic Case Reporting Public Health Registry Reporting Clinical Data Registry Reporting Syndromic Surveillance Reporting

QPP NPRM Y3: Proposed Advanced APM Summary Increasing the CEHRT use criterion threshold for Advanced APMs Must require at least 75% of ECs in each APM Entity use CEHRT Minimum CEHRT Threshold: Effective CY 2020, quality criteria to state that at least one of the quality measures upon which an Advanced APM bases payment must be: On the MIPS final list Endorsed by a consensus-based entity Otherwise determined to be evidence-based, reliable, and valid by CMS MIPS Comparable Measures: APMs: Advanced APMs Minimum CEHRT Use Threshold Proposed Changes: Increasing the CEHRT use criterion threshold for Advanced APMs so that an Advanced APM must require at least 75 % of ECs in each APM Entity use CEHRT document and communicate clinical care with patients and other health care professionals APMs: MIPS Comparable Measures Proposed Changes: Amending the Advanced APM quality criteria to state that at least one of the quality measures upon which an Advanced APM bases payment must be (1) on the MIPS final list, (2) endorsed by a consensus-based entity, or (3) otherwise determined to be evidence-based, reliable, and valid by CMS to be considered MIPS comparable, beginning in 2020 for both Advanced APMs and Other Payer Advanced APMs

QPP NPRM Y3: Proposed Advanced APM Summary Effective CY 2020, quality criterion to require that the outcome measure used must be: On the MIPS final list Endorsed by a consensus-based entity Otherwise determined to be evidence-based, reliable, and valid by CMS Outcome Measures: Maintain 8% revenue-based nominal amount standard through 2024 Revenue-based Nominal Amount Standard: Effective CY 2020, quality criteria to state that at least one of the quality measures upon which an Advanced APM bases payment must be: Payer-Initiated Process for Remaining Other Payers: APMs: Outcome Measures Proposed Changes: Amending the Advanced APM quality criterion to require that the outcome measure used must be (1) on the MIPS final list, (2) endorsed by a consensus-based entity, or (3) otherwise determined to be evidence-based, reliable, and valid by CMS effective in 2020 for both Advanced APMs Other Payer Advanced APMs. APMs: Revenue-Based Nominal Amount Standard: CMS is maintaining the revenue-based nominal amount standard for Advanced APMs at 8 percent through performance year 2024 APMs: Payer-Initiated Process for Remaining Other Payers : CMS is implementing the previously finalized policy and allowing all payer types to be included in the 2019 Payer Initiated Process for the 2020 QP Performance Period. Moving forward with the policy in the current rule will offer additional flexibilities for payers and reduce burdens for eligible clinicians

QPP NPRM Y3: Proposed All-Payer Combination All-Payer combination option is available in the 2019 QP performance period All-Payer Combination Option is one of two pathways through which ECs can become a QP or partial QP Option for ECs to achieve QP status based on a combination of participation in: Advanced APMs w/ Medicare, and Other Payer Advanced APMs offered by other payers Proposing to request QP Determinations at the TIN level & individual EC level for All-Payer Option Beginning in 2019, we will allow for QP determinations under the All-Payer Option to be requested at the TIN level in addition to the APM Entity and individual eligible clinician levels. This was a change made as a result of public comment and subsequent listening sessions with the payer community about how contracting is executed in the commercial, non-Medicare space

QPP NPRM Y3: Proposed All-Payer Combination All-Payer Combo Highlights Keeping Annual Submissions - streamlining process Revenue-based Nominal Amount for Other Payer Advance APMs = 8% thru 2024 Increasing CEHRT use criterion threshold to 75% Payers or ECs submit evidence to demonstrate CEHRT is at required threshold, rather than the Other Payer Advanced APM Updating the Advanced APM CEHRT threshold so that an Advanced APM must require that at least 75 percent of eligible clinicians in each APM Entity use CEHRT. • Extending the 8% revenue-based nominal amount standard for Advanced APMs through performance year 2024. • Increasing flexibility for the All-Payer Combination Option and Other Payer Advanced APMs for non-Medicare payers to participate in the Quality Payment Program. o Establishing a multi-year determination process where payers and eligible clinicians can provide information on the length of the agreement as part of their initial Other Payer Advanced APM submission, and have any resulting determination be effective for the duration of the agreement. We propose this streamlined process to reduce the burden on payers and eligible clinicians. o Allowing QP determinations at the TIN level, in addition to the current options for determinations at the APM entity level and the individual level, in instances when all clinicians who bill under the TIN participate as a single APM Entity. This will provide additional flexibility for eligible clinicians under the All-Payer Combination Option. o Moving forward with allowing all payer types to be included in the 2019 Payer Initiated Other Payer Advanced APM determination process for the 2020 QP Performance Period. • Streamlining the definition of a MIPS comparable measure in both the Advanced APM criteria and Other Payer Advanced APM criteria to reduce confusion and burden among payers and eligible clinicians submitting payment arrangement information to CMS. • Clarifying the requirement for MIPS APMs to assess performance on quality measures and cost/utilization. • Updating the MIPS APM measure sets that apply for purposes of the APM scoring standard.

2019 Physician Fee Schedule (PFS) Overview

Patients Over Paperwork CMS initiative focused on reducing administrative burden while improving care coordination, health outcomes and patients’ ability to make decisions about their own care. Proposed changes to the Physician Fee Schedule (PFS) address those problems by streamlining documentation requirements to focus on patient care and proposing to modernize payment policies. The patients over paperwork initiative is the catalyst for change from CMS Intent is to reduce administrative burden while improving care coordination, health outcomes and patients’ ability to make decisions about their own care. Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care and CMS Administration has listened and is taking action. The proposed changes to the Physician Fee Schedule are meant to address those problems head-on, by proposing to streamline documentation requirements to focus on patient care and proposing to modernize payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need.

Current State: Documenting E/M Currently, documentation requirements differ for each level and are based on either the 1995 or 1997 E/M documentation guidelines. Patient type (new v. established) Setting of service (e.g. outpatient setting or inpatient setting) Level of E/M service performed Billing Medicare for an Evaluation and Management (E/M) visit requires the selection of a Current Procedural Terminology (CPT) code that best represents: In general, the more complex the visit, the higher the level of code a practitioner may bill within the appropriate category. Code sets to bill for E/M services are organized into various categories and levels. For visits that consist predominantly of counseling and/or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M services. Three key components when selecting the appropriate level of E/M services provided are history, examination, and medical decision making. This slide shows the current state of Evaluation & Management, or E & M, codes. Current guidelines based on 1995 or 1997 guidelines – so outdated Code sets to bill for E/M services are organized into different categories and levels (more complex visits billed at higher level) All based on medical record documentation.

Proposed Payment for Outpatient Based E/M Visits Proposing a single PFS payment rate for E/M visit levels 2-5 (physician and non-physician in office based/outpatient setting for new and established patients). Proposing a minimum documentation standard where, for Medicare PFS payment purposes for an office/outpatient based E/M visit, practitioners would only need to document the information to support a level 2 E/M visit (except when using time for documentation). Biggest changes proposed for Year 3 PFS are related to E/M visits. Changes proposed currently apply to Medicare only-so be mindful that QPP program focuses on Medicare Part B so we don’t know if other payers will adopt these same changes. Reducing E/M visit levels from 5 down to 2 Would reduce the amount of documentation needed from physician (level 2 vs level 5)-so sticking with that “theme” of patients over paperwork

Why Change? Stakeholders have said that the Documentation Guidelines for E/M visits are clinically outdated. According to stakeholders, some aspects of required documentation are redundant. Current documentation requirements may not account for changes in care delivery. Stakeholders have said that the 1995 and 1997 Documentation Guidelines for E/M visits are clinically outdated and may not reflect the most clinically meaningful or appropriate differences in patient complexity and care. Furthermore, the proposed CY 2019 Physician Fee Schedule would help to free EHRs to be powerful tools that would actually support efficient care while giving physicians more time to spend with their patients, especially those with complex needs, rather than on paperwork. Specifically, this proposal would: Simplify, streamline and offer flexibility in documentation requirements for Evaluation and Management office visits — which make up about 20 percent of allowed charges under the Physician Fee Schedule and consume much of clinicians’ time; According to stakeholders, some aspects of required documentation are redundant- In response to stakeholder feedback suggesting that this process is duplicative and burdensome, CMS is proposing to change the requirements so that the medical record must only document that the teaching physician was present at the time the service was furnished. Under the proposed rule, the teaching physician does not have to be the one to document this information. Use of technology and maximizing EHR benefits

Proposed Payment for Outpatient Based E/M Visits **I showed this table and just said here are the proposed payment rates based on the CY2018 conversion factor (CF). Below provides additional info if you wanted to talk thru this more. Since the 2019 conversion factor (CF) has not been finalized, CMS modeled this proposed change based on the 2018 CF. If the standardized E/M reimbursement was in place in 2018, E/M levels two through five would be paid at $135 for new patients and $93 for established patients. The proposed 2019 CF update is only a slight change ($0.06) from the finalized 2018 rate. Therefore, assuming the proposed 2019 CF is finalized, the rates outlined in the 2018 model should be an accurate indication of what the actual rates will be under the proposed rule. Reimbursement proposal for office/outpatient EM services: 99201 and 99211 would be reimbursed at the following rates: 99201 = $44.00 99211 = $24.00 99202 – 99205 would be reimbursed at a fixed rate of $135.00 99212 – 99215 would be reimbursed at a fixed rate of $93.00 For both sets of codes starting at level 2, payment will be made at the same rate regardless of the code billed. Time based coding has not been decided. * Current Payment for CY 2018 ** Proposed Payment based on the CY2019 proposed relative value units and the CY2018 payment rate

E/M Summary Practitioners may use either the current E/M standards for coding office visits, may use strictly time spent with the patient, or may use solely Medical Decision Making. CMS proposing to adopt a single payment for every new patient visit and a single payment for every established patient visit. Practitioners would not be required to document extensively for those higher acuity patients. Practitioners would no longer be required to personally document the patient history, as they do now. They may review a history entered by “ancillary staff or the patient” and indicate they verified it. Summarizing the two biggest changes Reducing E/M levels Reduction in documentation efforts, including physicians being able to verify information such as patient history, which could be documented by ancillary staff or the patient (via a patient portal).

Advancing Virtual Care To support access to care using communication technology, CMS is proposing: Pay clinicians for virtual check-ins – brief, non-face-to-face assessments via communication technology. Pay Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit. Pay clinicians for remote evaluation of patient-submitted photos or recorded video. Expand Medicare telehealth services to include prolonged preventive services. In response to the CY 2018 PFS Proposed Rule, CMS received feedback from stakeholders supportive of expanding access to services that support technological developments in healthcare. CMS interested in recognizing changes in healthcare practice that incorporate innovation and technology in managing patient care. CMS is proposing payment for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit. Historically CMS has bundled "routine non-face-to-face communication" into the payment for the in-person visit, but in cases where a video or audio check-in doesn't lead to an office visit, there would be no office visit to bundle that payment to. The new payment system would also allow physicians to be paid for consultations with patients with whom they don't have a prior relationship. For instance, a patient could share videos or photos of a skin condition with a dermatologist to figure out if they need an in-person visit.  Expansion of prolonged preventive service codes for telehealth services

Part B Drugs Consistent with section 1847A(c)(4) of MACRA (Medicare Access and CHIP Reauthorization Act), CMS is proposing that effective January 1, 2019, wholesale acquisition cost payments for Part B drugs made under section 1847A(c)(4) of the Act, utilize a 3 percent add-on in place of the 6 percent add-on that is currently being used. The proposed change for 2019 would reduce the wholesale acquisition cost add-on from 6% to 3%, decreasing the amount of money Medicare and beneficiaries pay for in-office drugs. This aligns with the Trump Administration’s commitment to lowering prescription drug prices.

Support & Assistance

Value-Based Payment Support Services QPP SURS Technical Assistance: Free, high-level resources for organizations with 15 or fewer eligible clinicians as they navigate the Quality Payment Program. The Resource Center include: straightforward, self-directed resources and tools, up-to-date materials, and access to expert Quality Improvement Advisors. Sign up: www.qppresourcecenter.com VBP Individualized Assistance: 12 months of planning and transformation support tailored to meet specific client needs and support success in value-based payment. This includes current state analysis, recommendations for action, collaborative goal setting and project planning, education, strategic decision support and ongoing advisory services. Advanced APM Support: Ongoing support, research, work plan development and application support for transition to advanced alternative payment models (APM).

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QPP NPRM Y3: Questions