Quality Payment Program Overview Kris Shay, HealthCare Data Systems Mona Mathews, MA, PMP, MetaStar Chris Becker, CPHIMS, CPHIT, MetaStar October 19, 2018

Lake Superior Quality Innovation Network The Lake Superior Quality Innovation Network (Lake Superior QIN) is comprised of three quality improvement organizations: Stratis Health in Minnesota MetaStar in Wisconsin MPRO in Michigan

Disclaimer Content provided in this presentation is based on the latest information made available by the Centers for Medicare & Medicaid Services (CMS) and is subject to change. CMS policies change, so we encourage you to review specific statutes and regulations that may apply to you for interpretation and updates.

Objectives Knowledge on 2018 Merit-Based Incentive Payment System (MIPS) Orthopaedic requirements for MIPS Tips and Tricks for participating successfully in MIPS .

Quality Payment Program The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) MIPS Merit-Based Incentive Payment System (MIPS) Performance-based payment adjustment Advanced APMs Advanced Alternative Payment Models (Advanced APM) Incentive payment for sufficiently participating in an innovative payment model The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program, that provides for two participation tracks:

2018 Year 2 MIPS Eligible Clinicians Low-volume threshold for 2018 Year 2 changes to INCLUDE MIPS eligible clinicians billing more than $90,000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare patients a year. 2017 Year 1 Bill > $30,000 Medicare Part B AND Provide care to > 100 beneficiaries 2018 Year 2 Bill > $90,000 to Medicare Part B AND Provide care to > 200 beneficiaries Revised from overview slides – which listed Non-patient facing clinicians as excluded from MIPS – they are only excluded from ACI *Voluntary reporting remains an option for clinicians exempt from MIPS

QPP Eligibility Look Up Results MIPS Participation Status Tool Source: https://qpp.cms.gov/participation-lookup

2018 Reporting Options Clinicians participating as a group are assessed as a group across all four MIPS performance categories. The same is true for clinicians participating as a Virtual Group. CMS-QPP-Year-2-Final-Rule-National Provider Call-Slides.2017.11.30

Focus on MIPS Reporting

Merit-Based Incentive Payment System (MIPS) Four MIPS category scores compiled for MIPS final score worth up to 100 points Quality Improvement Activities Promoting Interoperability Cost Previous Category – Year Physician Quality Reporting System (PQRS) New Category EHR Incentive Program Value Based Modifier (VBM) 2018 50 % 15 % 25 % 10 % 2017 60 % 15% 25% 0 % Replaces PQRS: Maximum score 60 Evolution of previous CMS programs: PQRS, VBM, MU Report six quality measures* from over 300 quality measures OR measures from Specialty set Report via Claims, EHR, Registry Benchmark scores differ between reporting methods Groups of 25+ can use CMS GPRO Web Interface Report 14 quality measures* APMs report quality as a groups *Measure must meet qualification criteria for all methods If reporting as a group, combine all EC scores Lisa The 2nd path of the QPP is the Merit Based Incentive Payment System or MIPS CMS has combined the legacy programs of PQRS, EHR incentive payment system and Value- Based Modifier into 1 program, renamed them and added a new category of Improvement Activities. This screen shows the 4 categories of MIPS which each contribute a certain weight to your MIPS Score. Your MIPS Score is based on the performance year, and impacts your payment 2 years later for Medicare Part B fee for service For 2017 performance year: Quality – accounts for 60% of the MIPS score Advancing Care Information accounts for 25% of your score New category of Improvement Activities accounts for 15% of your score Cost accounts for 0% of your score, but will be phased in in future years. Source: CMS Quality Payment Program – Train-the-Trainer

Quality Category: 50 percent of MIPS Score in 2018 Earn up to 60 Quality Category points Scored on the highest six quality measures from 277 measures May pick from specialty set Must include at least one outcome or high priority measure Earn three to 10 category points for measures with benchmarks Earn up to seven points for six measures - if “topped out*” two or more years* Must meet data completeness criteria (2018 increased to 60 percent) 2018 Earn one point for reporting if data completeness not met Small practices still earn three points Bonus points for reporting end to end electronically (electronic clinical quality measure (eCQM)) Bonus points for reporting additional outcome or high priority measures The six topped out measures include the following: Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin. (Quality Measure ID: 21) Melanoma: Overutilization of Imaging Studies in Melanoma.(Quality Measure ID: 224) Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients). (Quality Measure ID: 23) Image Confirmation of Successful Excision of Image-Localized Breast Lesion. (Quality Measure ID: 262) Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description (Quality Measure ID: 359) Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy (Quality Measure ID: 52) *Topped out measures have little room for improvement

Examples of Orthopedic Quality Measures Closing the referral loop Documentation of current medications in the medical record Functional status assessment for total knee replacement Body Mass Index (BMI) screening and follow up plan Pain assessment and follow up

Cost: 10 percent of MIPS Score in 2018 Category Performance Score included in composite MIPS score starting in 2018 TWO measure scores are averaged (or any one available) Medicare Spending per Beneficiary (MSPB) Total per capita cost measures Category score weight will increase to 30 percent by 2021 No data submission required; Calculated from administrative claims if meet case minimum of attributed patients Benchmark calculated using current year performance New: Scoring Improvement Bonus up to one percentage point Based on statistically significant changes at the measure level .Lisa Cost is not scored in 2017 and will be phased in either in 2018 or 2019 No data submission – calculated automatically from Adjudicated Part B claims

Improvement Activities: 15 percent of MIPS Score 2017-2018 Maximum Category score 40 points Help participants prepare to transition to APMs and Medical Home Models. Additional activities available in 2018, some changed Engage in up to four activities for at least 90 days Medium activity = 10 points High activity = 20 points Earn PI category Bonus points for using CEHRT for some IA Report by simple Yes/No attestation Special Scoring: Double points: clinicians in small underserved or rural settings, and non-patient facing clinicians/groups Double points for small, rural, underserved, and non-patient facing clinicians/groups Full credit for PCMH, MHM (MN model counts) APMs – choose activities based on model criteria *We have defined practice sites as the practice address that is available in PECOS *Changes: including credit for using Appropriate Use Criteria (AUC) through a qualified clinical support mechanism for all advanced diagnostic imaging services ordered.

Possible Improvement Activities in Orthopedics Annual registration in the Prescription Drug Monitoring Program (PDMP) Anticoagulant Management Improvements i.e.: Patients being managed by an anticoagulant management service Consultation of the PDMP Implementation of use of specialty report back to referring clinician or group to close the referral loop

Promoting Interoperability: 25 percent of MIPS Score in 2018 Maximum Category score 100 of 155 possible points Earn up to 25 MIPS points 2018: May use either 2014 or 2015 Certified EHR Technology (CEHRT) (or combination) 10 percent bonus for using only 2015 CERHT Base measures, required for any score in this category Earn 50 points Four base measures for 2014 CEHRT, five for 2015 CEHRT; some measures also earn performance scores Exclusions available for two base measures: e-Prescribing and Health Information Exchange: Send Summary of Care Performance measures Optional Earn up to 90 points Seven for 2014 CEHRT, nine for 2015 CEHRT Mention ACI Exclusions for Hospital-based, Non-patient facing, and some EC types: NP, CNS, CRNA, PA

2014 vs 2015 Certified EHR Four Base Measures = 50 points Seven Performance Measures Earn up to 10 points each Two worth 20 points each Five Base Measures = 50 points Nine Performance Measures Earn up to 10 points each 2015 CEHRT MEASURE NAME Security Risk Analysis (Base) e-Prescribing (Base) Send Summary of Care (Base) Request/Accept Summary of Care (Base) Provide Patient Access (Base) Clinical Information Reconciliation Patient-generated Health Data Immunization Registry Reporting Patient-Specific Education Secure Messaging View, Download, or Transmit (VDT) Clinical Data Registry Reporting Public Health Registry Reporting Electronic Case Reporting Syndromic Surveillance Reporting 2014 CEHRT MEASURE NAME Security Risk Analysis (Base) e-Prescribing (Base) Send Summary of Care (Base) Provide Patient Access (Base) Immunization Registry Reporting Medication Reconciliation Patient-Specific Education Secure Messaging View, Download, or Transmit (VDT) Specialized Registry Reporting Syndromic Surveillance Reporting 2016 Opportunity to reach 155 points with bonuses, but maximum category score is 100

Reporting Scenarios of Orthopaedics

Scenario One Background Reporting Options Solo Practice Surgeon Eligible Clinician (exceeds low volume threshold) Must report to avoid a negative penalty Does not utilize an EHR Reporting Options Needs to obtain 15 MIPS Points to remain Neutral Could attest to Improvement Activities Report Quality Category via claims or registry Note: Practices with 15 or less clinicians get some special scoring

Solo Surgeon Reporting with No EHR Clinician decides that she does not want to pay for a registry and go through the trouble of doing chart reviews to populate the registry Finds out that billers have been submitting some “G” Codes for Medication Reconciliation and Body Mass Index Screening but they did not meet the 60 percent data completeness for quality Attests to using the Prescription Drug Monitoring Program (PDMP)

Score for this Solo Clinician One Improvement Activity Two Quality Measures Five free points for being a small practice Small Practices receive double points for Improvement Activities and a minimum of three points for quality measures Source: Stratis Health MIPS Estimator https://www.mipsestimator.org/

Scenario Two Background Reporting Options Orthopaedics Group Practice with 16 Eligible Clinician Types Has EHR through the local hospital Two of the clinicians exceed the low Volume Threshold The remaining 14 are eligible at the group level but not individually Reporting Options Group Reporting Individual Reports (2 mandatory and 14 voluntary)

Scores for Mandatory Clinicians William White Patricia White Source: Stratis Health MIPS Estimator https://www.mipsestimator.org/

Group Score Source: Stratis Health MIPS Estimator https://www.mipsestimator.org/

Group versus Individual Reports Individual Report – The individual clinicians will receive a payment adjustment Group report – All eligible clinician types in the group will receive a payment adjustment In this example, the group score was greater than either of the mandatory reporters so if a group report was submitted, they would receive the higher of the two scores.

Important Information About the Scenarios Did not give any points for cost or complex patient bonus The scores were calculated based on the most current benchmarks (some benchmarks will be recalculated during the performance year)

Resources Stratis Health MIPS Estimator https://www.mipsestimator.org/ Quality Payment Program Website: https://qpp.cms.gov/

Questions? Kris Shay – HealthCare Data Systems (kshay@hcds.us) 262-369-3460 Mona Mathews, MA, PMP – MetaStar mmathews@metastar.com 608-441-8241 Chris Becker, CPHIMS, CPHIT – MetaStar cbecker@metastar.com 608-441-8217 www.lsqin.org www.metastar.com

This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-WI-D1-18-107 100518