Quality Payment Program Office Hours: QPP Changes You Should Know About in 2019

Presentation Overview General MIPS Updates MIPS Category-Specific Updates Advanced APM Updates Action Plan Resources

atom Alliance Partners Multi-state alliance for powerful change composed of three nonprofit, healthcare quality improvement consulting companies

Questions and Discussion If you have questions or comments please remember to: Press *9 to “Raise your Hand” Please introduce yourself and your facility Feel free to enter questions / comments directly into the chat at any time We will be asking the audience to participate in polling questions during the event. They will pop up on your WebEx screen. Please participate and remember to click the submit button to record your answer.

MIPS Advanced APM Both Unsure Poll: Which Quality Payment Program track (MIPS or Advanced APM) will you be participating in for 2019? MIPS Advanced APM Both Unsure

Poll: Do you know about the 2019 QPP changes? Yes, all of them Some of them No Unsure

Quality Payment Program 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: Two different pathways to participate in the Quality Payment Program: Merit-based Incentive Payment System MIPS Advanced Alternative Payment Models Advanced APMs OR Positive or negative adjustment based upon performance and applied to all Part B PFS allowable charges Receive greater financial reward for taking on some risk related to patient outcomes

Merit-Based Incentive Payment System (MIPS) Updates

Account Management System Change New name: From Enterprise Identity Data Management system (EIDM) to HCQIS Access Roles and Profile system (HARP) Benefit: Single location for registering/managing access and viewing/reporting data Doesn’t impact those with existing accounts

MIPS Eligible Clinician Type Updates Previous MIPS eligible clinicians: Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists AND Newly Included: Clinical Psychologists Physical Therapists Occupational Therapists Speech-Language Pathologists Audiologists Registered Dieticians or Nutrition Professionals

Change to the Payment Adjustment Amount Performance Period Also referred to as… Corresponding Payment Year Corresponding Adjustment 2017 2017 “Transition” Year 2019 Up to + or -4% 2018 “Year 2” 2020 Up to + or -5% “Year 3” 2021 Up to + or -7%

Exceptional Performance Threshold MIPS Performance Threshold Requirements Performance Period Minimum Performance Threshold Exceptional Performance Threshold 2017 3 70 2018 15 2019 30 75

MIPS Performance Threshold and Payment Adjustments Final Score 2019 Payment Adjustment 2021 >75 points Positive adjustment greater than 0% Eligible for additional payment for exceptional performance —minimum of additional 0.5% 30.01- 74.99 Not eligible for additional payment for exceptional performance 30 Neutral payment adjustment 7.51- 29.99 Negative payment adjustment is from less than 0% to -6.9% 0-7.5 Negative payment adjustment of -7%

Provide >200 Covered Professional Services Low-volume Threshold Determination Required to participate if the following are met: New Bill >$90,000 a year in allowed Medicare Physician Fee Schedule charges Furnish covered professional services to >200 Medicare Part B beneficiaries Provide >200 Covered Professional Services AND AND *Excluded from the MIPS in 2019 if all three criteria aren’t met

Voluntary Participation Excluded but Want to Participate Two options: New Opt-in Voluntary Participation If a MIPS eligible clinician and meet or exceed at least one of the low-volume threshold criteria Submit data to CMS and receive performance feedback You will receive a positive or negative MIPS payment adjustment You will not receive a positive or negative MIPS payment adjustment

New Opt-in Policy Important Things to Remember Once an election has been made, the decision to opt-in to MIPS would be irrevocable and could not be changed Clinicians or groups who opt-in are subject to all of the MIPS rules, special status, and MIPS payment adjustment APM Entities interested in opting-in to participate in MIPS under the APM Scoring Standard would do so at the APM Entity level

Change to the MIPS Determination Period First Determination: Changed from Sept. 1, 2016-Aug. 31, 2017 to Oct. 1, 2017-Sept. 30, 2018 (including a 30-day claims run out) Second Determination: Changed from Sept. 1, 2017 to Aug. 31, 2018 (including a 30-day claims run out) to Oct. 1, 2018-Sept. 30, 2019 (does not include a 30-day claims run out) * Multiple timeframes, to determine such things as special status, were consolidated and aligned with the fiscal year ** MIPS eligible clinicians with a special status designation are still included in MIPS but qualify for special rules.

New Terminology Collection Type: set of quality measures with comparable specs and data completeness criteria eCQMs, MIPS CQMs, QCDR Measures, Part B Claims Measures Submission Type: mechanism by which data gets submitted to CMS Direct, Login and upload, Part B claims, Login and Attest, CMS Web Interface (group of 25+) Submitter Type: the individual or entity that submits the data Individual, Group, Virtual Group, Third Party Intermediary

MIPS Category-Specific Updates

General Performance Category Weight Changes 2017 Category Weights 2018 Category Weights 2019 Category Quality 60% 50% 45% Cost 0% 10% 15% Improvement Activities Promoting Interoperability 25% -10% -5% +10% +5%

Quality Category Updates Topic What’s New? Meaningful Measures Removed 26 quality measures, Added 8 new measures (4 Patient-Reported Outcome Measures), 6 of which are high-priority. Total of 257 quality measures for 2019, as opposed to 275 in 2018. Small Practice Bonus Points Bonus of 6 points for MIPS eligible clinicians in small practices who submit data on at least 1 quality measure. *this replaces the previous 5 bonus points added to the final score for small practices. Scoring Considerations Measures impacted by clinical guideline changes will be given a score of zero, and the physician who reports the measure will have his or her quality performance category denominator score reduced by 10. Topped out Measures Continuation of 2018 policy plus Extremely Topped-Out Measures (average mean performance is within the 98th to 100th percentile range) can be proposed for removal during next rulemaking cycle. *QCDR measures are excluded from topped out measure and special scoring policies

Quality Category Updates cont. Topic What’s New? New Specialty Measure Sets Urgent Care – 15 measures, Skilled Nursing Facility – 13 measures Third-party Intermediaries All QCDR measure owners must now enter into license agreements permitting any approved QCDR to submit data on the QCDR measure (without modification) for purposes of MIPS, or risk having their measure rejected. – over 600 QCDR measures available

MIPS CQMs (Registry/QCDR) Quality Category Updates cont. Collection Type What’s New? Claims 65 measures – 7 measures removed, 34 are topped out with a 7 point cap applied, while another 9 measures are topped out without point cap, 13 measures are without benchmark data. Can no longer be reported by individual eligible clinicians in large groups (16+ clinicians) eCQMs (EHR) 50 measures – 4 measures removed, 5 are listed as topped out with a 7 point cap applied, while another 4 measures are topped out without point cap, 7 measures are without benchmark data. MIPS CQMs (Registry/QCDR) 233 measures, 15 less than 2018. 42 are topped out with a 7 point cap, while another 51 measures are topped out without point cap, 77 measures are without benchmark data. Web Interface High priority measure bonus removed. Submission deadline aligned with other submission types.

Facility-based Scoring Option Quality/Cost Category Updates cont. Topic What’s New? Facility-based Scoring Option Clinicians can be scored for purposes of the MIPS quality and cost performance categories based on their attributed hospital’s performance in the Hospital Value-Based Purchasing Program. Facility-based scores for the 2019 performance period/2021 payment determination are based on the 12 measures included in the fiscal year 2020 Hospital VBP Program.

Facility-based Scoring Details Hospital-based designation: Attribution: Individual EC: Provide 75% or more covered professional services in a hospital setting. Group: 75% or more of eligible clinicians billing under the group’s T IN are eligible for facility-based measurement as individuals Clinician would be attributed to hospital where most services provided. Group would be attributed to hospital where most clinicians are attributed. Election: Performance Score: Automatically applied. No submission requirements for individual clinicians but Groups would need to submit data for Improvement Activity and Promoting Interoperability categories to be measured as facility-based group. Based on attributed hospital’s performance in the Hospital Value-Based Purchasing Program.

Cost Category Updates 100 Total points: up to *previously 20 Topic What’s New? New Measures 8 episode-based measures; 5 procedural and 3 Acute inpatient medical condition. Measure Case Minimums TPCC still 20, MSPB still 35 and now with the addition of Episode-based measures Procedural ones are 10 and Acute Inpatient Medical Conditions are 20

Cost Category Updates cont. Measure Measure Type Maximum Points Medicare Spending Per Beneficiary (MSPB) N/A 10 points Total Per-Capita Cost for All Attributed Beneficiaries (TPCC) Episode-based Measures Elective Outpatient Percutaneous Coronary Intervention (PCI) Procedural Knee Arthroplasty Revascularization for Lower Extremity Chronic Critical Limb Ischemia Routine Cataract Removal with Intraocular Lens (IOL) Implantation Screening/Surveillance Colonoscopy Intracranial Hemorrhage or Cerebral Infarction Acute inpatient medical condition Simple Pneumonia with Hospitalization ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)

Improvement Activities Updates Topic What’s New? Measure Changes Added 6, modified 5 existing measures, and removed 1 for a total of 118 active measures. Bonus Removed CEHRT bonus for reporting certain measures that goes towards the Promoting Interoperability category score

Promoting Interoperability Updates Topic What’s New? Measurement Changes Eliminated base and performance score. Performance-based scored at individual measure level and must report the required measures under each Objective and submit a numerator of 1 or “yes” or claim an exclusion (where applicable). 4 Objective categories: eRx, HIE, Provider to Patient Exchange, Public Health and Clinical Data Exchange Measure Changes Added two new measures to the eRx Objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement. Both measures are optional for 2019. Bonus Removed bonus for reporting certain Improvement Activity measures that goes towards the Promoting Interoperability category score and for reporting one or more Public Health and Clinical Data Registry measure. 10 bonus points available for optionally reporting two new measures. CEHRT Requirement Must use 2015 Edition Certified EHR Technology (CEHRT)

Promoting Interoperability Updates cont. Objectives Measures Maximum Points e-Prescribing e-Prescribing* 10 points Query of Prescription Drug Monitoring Program (PDMP) (new and optional) 5 bonus points Verify Opioid Treatment Agreement (new and optional) Health Information Exchange Support Electronic Referral Loops by Sending Health Information (formerly Send a Summary of Care)* 20 points Support Electronic Referral Loops by Receiving and Incorporating Health Information* Provider to Patient Exchange Provide Patients Electronic Access to their Health Information (formerly Provide Patient Access) 40 points Public Health and Clinical Data Exchange Immunization Registry Reporting* Electronic Case Reporting* Public Health Registry Reporting* Clinical Data Registry Reporting* Syndromic Surveillance Reporting* *Exclusion available. Points reweighted to another measure.

Numerator/ Denominator Promoting Interoperability Updates cont. Objectives Measures Maximum Points Numerator/ Denominator Performance Rate Score e-Prescribing 10 points 200/250 80% 10 x 0.8 = 8 points Health Information Exchange Support Electronic Referral Loops by Sending Health Information 20 points 135/185 73% 20 x 0.73 = 15 points Support Electronic Referral Loops by Receiving and Incorporating Health Information 145/175 83% 20 x 0.83 = 17 points Provider to Patient Exchange Provide Patients Electronic Access to their Health Information 40 points 350/500 70% 40 x 0.70 = 28 points Public Health and Clinical Data Exchange Immunization Registry Reporting Public Health Registry Reporting Yes N/A Total: 78 Points

Reweighting Description Measure Exclusion Reweighting Measure Reweighting Description ePrescribing The 10 points will be redistributed equally among the measures associated with the Health Exchange objective. HIE Objective: …Sending Health Information An exclusion is available, but it was not address in the proposed rule how the points would be redistributed if an exclusion is claimed. “We intend to propose in next year’s rulemaking how the points will be redistributed if an exclusion is claimed.” HIE Objective: …Receiving and Incorporating Health Information The 20 points would be redistributed to the Send Health Information measure in the HIE Objective Public Health and Clinical Data Exchange If an exclusion is claimed for one measure, but the MIPS eligible clinicians submits a “yes” response for another measure, they would earn the 10 points for the Public Health and Clinical Data Exchange objective. If a MIPS eligible clinician claims exclusions for both measures they select to report on, the 10 points would be redistributed to the Provide Patients Electronic Access to Their Health Information measure

Promoting Interoperability Updates cont. Topic What’s New? Category Reweighting *Same as 2018 plus: Extended the automatic reweighting for: Physical Therapists Occupational Therapists Clinical Psychologists Speech-Language Pathologists Audiologists Registered Dieticians or Nutrition Professionals

Category Reweighting Scenarios Quality Cost Improvement Activities Promoting Interoperability No Reweighting Needed Performance Category Scores 45% 15% 25% Reweight One Performance Category No Cost 60% 0% No Promoting Interoperability 70% No Quality 40% No Improvement Activities Reweight Two Performance Categories No Cost and no Promoting Interoperability 85% No Cost and no Quality 50% No Cost and no Improvement Activities 75% No Promoting Interoperability and no Quality No Promoting Interoperability and no Improvement Activities No Quality and no Improvement Activities

Promoting Interoperability Alignment MIPS APM Updates Topic What’s New Criteria Reworded to emphasize importance of basing payment on quality measures and cost Promoting Interoperability Alignment Align MIPS so eligible clinicians in any MIPS APMs can report Promoting Interoperability at either the individual or group level

Advanced APMs

Advanced APM Updates Topic What’s New? CEHRT Increased CEHRT use requirement to 75% of eligible clinicians in each Medicare Advanced APM entity. *Required for Other Payer Advanced APMs in 2020. MIPS Comparable Measures 2020 quality measures must meet new standards; On MIPS final measure list, be endorsed by a consensus-based entity, or determined to be evidence-based, reliable, and valid by CMS New for 2019 *Other Payer Advanced APM QP status is achieved based upon a combination of participation in Medicare Advanced APM/s and Other Payer Advanced APMs – referred to as the All-Payer Combination. QP determinations made at the EC, APM Entity level, and at the TIN level (for cases where the entire TIN participates in a single APM Entity). QP Determination Must receive either 50 percent of Medicare Part B Payments or 35 percent of Medicare patients through an Advanced APM entity during a determination period. *Partial QP is 40 and 25, respectively.

Action Plan

2019 Action Plan Seek to better understand the QPP and MIPS Analyze current and future state Determine eligibility (https://qpp.cms.gov/participation-lookup) Prepare a plan for success Create a Team Assign responsibilities Assess areas to maximize performance and revenue Establish performance and financial goals Create an audit folder, both paper and electronic, where possible Get Started Monitor progress and make adjustments

Poll: Do you have any questions, comments, or concerns about the MIPS or Advanced APMs? Yes – please explain over phone or in chat No – please explain over phone or in chat

Quality Payment Program Technical Assistance Medicare Learning Network (select Quality Initiatives under the Training Catalog) https://learner.mlnlms.com/Default.aspx atom Alliance/Qsource Quality Payment Program Assistance Resource Center Website: Providers.Exchange Email Support: TechAssist@Qsource.org Toll-Free Phone Support: 1-844-205-5540 Quality Payment Program Service Center Phone: 866-288-8292 Email: qpp@cms.hhs.gov

Connect with Us Reminders Facebook www.facebook.com/atomalliance Twitter www.twitter.com/atom_alliance LinkedIn www.linkedin.com/company/atom-alliance Pinterest www.pinterest.com/atomalliance/ This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS policy. 19.SURS-QPP.01.008