1. THE RELEVANCE OF MACRA TO CME AND HOW TO ENGAGE IN THE CMS COMMENT PROCESS June 16, 2016

2. Shea McCarthy, Moderator
Policy Analyst, CME Coalition
Vice President, Thorn Run Partners
Andrew Rosenberg, JD
Senior Advisor, CME Coalition
Founding Partner Thorn Run Partners
20 years of experience as a lobbyist, Capitol Hill staffer and former congressional candidate
Thomas Sullivan
President Rockpointe, Inc. , Potomac Center for Medical Education
Editor, Policy and Medicine, Life Science Compliance Update
Founder CME Coalition

3. Agenda Review MACRA and implications on physicians
Discuss MACRA, MIPS and CPIA’s – Where CME Fits in
Evaluate the Timeline of MACRA
Explain how to submit comments to CMS

4. Medicare Access and CHIP Reauthorization (MACRA)
Enacted in April 2015
House Passed , Senate Singed by President 4/2015
Eliminates SGR; Requires EHR interoperability by 2018
Clear Timelines for Implementation
MIPS 2017 performance measures determines 2019 Payments
APM selection is necessary before 2019

5. Goal of MACRA
HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.
HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.
This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.

6. In the HIMSS analysis of results, only 3 percent of respondents said they believe their organization is highly prepared to make the transition to pay for value from the current reimbursement approach of fee-for-service.

7. Payment Evolution Today – MACRA → Two Payment Paths
Alternative Payment Model
Differential FFS based on measured performance (MIPS)

8. Path 1: Alternative Payment Models (APMs)
→ 5% Medicare Bonus
Under MACRA, APM includes the following for Medicare patients:
Medicare Shared Savings Program (two-sided models: Tracks 2 and 3)
Next Generation ACO Model
Comprehensive ESDR Care (CEC) (large dialysis organization arrangement)
Comprehensive Primary Care Plus (CPC+)
Oncology Care Model (OCM) (two-sided risk track available in 2018)
APM must accept more than nominal risk for financial losses
Must use MIPS Quality Measures and Certified EHR.
Mix of Patients Change over Time – To Medicare and All Payers
CMS Estimates 30,000 to 90,000 Clinicians will qualify in 2019

9. Path 2: Merit Based Incentive Payment System (MIPS)
Incorporates three existing programs into one program
Meaningful Use (Started in 2011)
Physician Quality Reporting System (Started in 2007)
Value Based Modifier (First applied in 2015)
Adds an additional category “Clinical Practice Improvement Activities” (CPIA)
MIPS Composite Scores will
Drive reimbursement levels, and
Posted publicly on Physicians Compare Website
CMS Estimates 687,000 to 746,000 Clinicians will be MIPS eligible

10. Eligible Professionals in MIPS
Eligible professionals (EPs) for 2017 and include:
Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists.
In 2019, more professionals become eligible for MIPS, including:
Physical or occupational therapists, speech language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dieticians or nutrition professionals.

11. Some Providers Exempt from MIPS
Providers who do not meet the "low volume threshold"
Medicare Shared Savings Program Accountable Care Organization providers and other participants in alternative payment models and
First Year Medicare providers
The aforementioned "low volume threshold" can be one of three things:
The minimum number of individuals enrolled under Medicare who are treated by the EC for the performance period; <100 Medicare Patients
The minimum number of items and services furnished to individuals enrolled under Medicare by the EC for the performance period or;
The minimum amount of allowed charges billed by the EC under Medicare for the performance period. (<$10,000)

12. Difficult for Small Practices and Some Specialties
Losers 
 Negative Adjustments
Chiropractors 
-98.4% 
Dentists 
-68.9% 
General Practice 
-69.4% 
Optometry 
-79.7% 
Podiatry 
-78.0% 
Plastic Surgery 
-65.4% 
Psychiatry  
-68.8% 
Physical Medicine 
-57.9% 
Winners 
Positive Adjustment 
Cardiology 
62.1% 
Endocrinology 
67.3%
Emergency Medicine 
64.0% 
Colorectal Surgeons 
59.7% 
Family Practice 
59.5% 
Gastroenterology 
61.5% 
Nurse Practitioners 
62.0% 
Pediatrics 
79.3%
Source CMS MACRA Proposed Rule, Table 63, pages

13. Performance Category - 2017
Points Need to Get a Full Score
Maximum Possible Points per Performance Category
Quality: Clinicians choose six measures to report to CMS that best reflect their practice. One of these measures must be an outcome measure or a high quality measure and one must be a crosscutting measure. Clinicians also can choose to report a specialty measure set.
80 to 90 points depending on group size
50%
Advancing Care Information: Clinicians will report key measures of interoperability and information exchange. Clinicians are rewarded for their performance on measures that matter most to them.
100 points
25%
Clinical Practice Improvement Activities: Clinicians can choose the activities best suited for their practice; the rule proposes over 90 activities from which to choose. Clinicians participating in medical homes earn full credit in this category, and those participating in Advanced APMs will earn at least half credit.
60 points
15%
Cost: CMS will calculate these measures based on claims and availability of sufficient volume. Clinicians do not need to report anything.
Average score of all resource measures that can be attributed.
10%

14. Year
Meaningful Use – Advancing Care Information
Quality – PQRS
Resource Use - VBM
Clinical Practice Improvement
Total Points
2017 Reporting
2019 Payments
25 Pts
50 Pts
10 Pts
15 Pts
100 Pts
2018 Reporting
2020 Payments
45 Pts
2019 Reporting
2021 Payments and Beyond
30 Pts

15. 2020
2021
2022
2023 and Beyond
Positive Adjustments Include up to 3x payment multiplier +10% Bonus for Exemplary Performance

16. Total Incentive Performance
Program
Participation
Incentive Payment
No Difference
Penalties
PQRS
51%
39%
12%
49%
Meaningful Use
48%
48% Stage 1
6% Stage 2
52%
Value Based Modifier
61%
01%
60%

17. Clinical Practice Improvement Activity (CPIA)
Brand New Measurement Category
Definition: The term "Clinical Practice Improvement Activity" is defined as an activity that relevant eligible professional organizations and other stakeholders identify as one that improves clinical practice or care delivery and that the Secretary determines is likely to result in improved outcomes.
Desired Results: The CPIA will assess healthcare professionals on their effort to engage in continuing education and working to improve their practices and facilitate future participation in APMs.

18. CPIA Categories Expanded Practice Access Beneficiary Engagement
Patient Safety and Practice Assessment
Participation in an APM, including a medical home
Achieving Health Equity
Emergency Preparedness and Response
Integrated Behavioral and Metal Health
Expanded Practice Access
Population Management
Care Coordination

19. Proposed CPIA’s Scoring
Category
Total Points Needed
60 Points
High Rated Activity
20 Points
Medium Rated Activity
10 Points
Participation in Certified (AAAHC, NCQA, URAC, Joint Commission)
Medicare Medical Home or Medical Home Model
Alternative Payment Model (APM) Participation (ACO, Bundled Payment, PCMH (not certified)…
30 Points + Combination of High and Medium Rated Activities
Large Groups 16+
Can use any combination of High and Medium Rated Activity to get to 60 points
Groups of 15 or eligible clinicians and non patient facing clinicians
One Medium or High Weighted provides 50% of Score
Two Medium or High Weighted Activities 100% of Score

20. Examples of Current CPIA’s

21. Reasons To Have CME Recognized In MIPS
CME has long been recognized as a means by which physicians (aka Eligible Providers) demonstrate that they are engaging in Continuing Professional Development (CPD) to maintain the knowledge, skills, and practice performance that lead to optimal patient outcomes.
Lifelong learning, assessment and improvement are integrally related. Learning is a necessary component of the change process that results in meaningful, sustained Clinical Performance Improvement.
Without learning, assessment and professional development, the measurement of adherence to quality metrics, and health information technology usage on their own are insufficient to produce clinical performance improvement.

22. More Reasons
Society will continue to need Health Care Professionals (HCPs), also known as Eligible Clinicians (EC’s) to engage in lifelong learning, assessment and improvement in practice. Thus, it is important that those activities be recognized and rewarded in the value-based payment constructs that are increasingly being promulgated by private payers and by CMS (MACRA).
If CME/CE is not recognized within the new Value Based Payment constructs, there is a real risk that CME/CE/CPD may become a defacto “unfunded mandate” – a professional obligation without incentives or other reinforcing mechanisms.
EC’s should be credited for their efforts to stay current with clinical practice and quality measures by utilizing CME. The inclusion of CME as a Clinical Practice Improvement Activity recognized by CMS will help EP’s retain credit for the time EP’s invest in learning about practice improvement.
EC’s Sources of Information on QI requirements are limited and participation can only be increased with education.
Failure to learn about rampant change afoot under healthcare reform will place HCPs at risk financially, operationally and clinically
Accredited Education is an understandable, predefined measure.

23. Another Key Reason: Accredited CME in MIPS Utilizes Existing Structures for Change
There are mechanisms in place to ensure that accredited/certified CME activities are:
Designed to address clinicians’ practice- relevant learning needs and practice gaps;
Evaluated to measure the educational and clinical impact of those learning activities;
Planned and provided independent from commercial influence or other biases.

24. MACRA Implementation Timeline
Important Event
Dates
MACRA Draft Rule
Comments Due June 27th
MACRA Final Rule 
4th Qtr. 2016
MIPS Initial Reporting Period (Application Year 2019)
2017 
MIPS Initial Feedback – Confidential Quarterly Reporting
July 1, 2017
Information about Plurality of Care and Medicare Spending Per Beneficiary (MSPB)
July 1, 2018
Payment Adjustment – 1st Year
2019
APM Election deadline for 2019
TBD

25. Public Comments
Public comments are encouraged – over 500 submitted on the rule so far, including approximately 80 on the importance of including a role for CME
Easiest way is via
Draft template comment letter
Editable, one-button to send
Also, directly at ent;D=CMS
Background material and CME Coalition comments available at

26. The Goal of Public Comments
Drive CMS awareness and attention to the importance of annunciating a clear role for CME
500 comments is our goal
Generate enough public comment to put this on the radar of media, thought leaders and policy makers at CMS
Ultimately – the goal is to drive explicitly recognition of a role for CME in driving physician adherence to clinical practice improvement activities, as defined MACRA

27. The CME Coalition’s Comments (key points)
“Because CME has the ability to make a measurable difference in the way physicians practice their trade, accredited CME activities that are designed to further the objectives of MACRA, the “three aims,” and the NQS should result in credit as clinical practice improvement activities within the MIPS.”
PARS Reporting System
Can be augmented to assist CMS in tracking compliance
“90-day” Rule Compliance
Approved CME activities that incorporate a 90-day survey or evaluation period into the program should be considered to have met the proposed rule’s 90-day activity threshold

28. The CME Coalition Comments (continued)
In specific, we seek explicit credit for certain defined CME activities in two of the CMS designated clinical practice improvement activities, namely:
Accredited CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, such as Performance Improvement CME, Quality Improvement CME.
Accredited CME that teaches the principles of quality improvement and the basic tenets of MACRA implementation, including application of the “three aims,” the NQS, and the CMS Quality Strategy, with these goals being incorporated into practice.

29. Proposed Table H Subcategory Activity Weight
Patient Safety and Practice Assessment
Accredited CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, such as Performance Improvement CME, Quality Improvement CME
Accredited CME activities that teaches the principles of quality improvement, explains MACRA or count towards MOC Part IV requirements such as MOC Part IV CME

30. Summary
MACRA is Complicated and will Need Significant Education to be Successful
CME has systems in place to ensure education and success of program
PI-QI CME Should be included
Speak with your organization about including CME in your overall MACRA Comments
Submit Comments to CMS Today
You Can Make A Difference

31. MACRA Resources CMS MACRA Proposed Rule - http://1.usa.gov/1PpBpMt
CMS MACRA Executive Summary -
CME Coalition -
American Medical Association -
American Academy of Family Physicians
Policy and Medicine – MACRA MIPS APM’s

32. Questions and Answers

33. For More Information CME Coalition www.cmecoalition.org
Andrew Rosenberg –
Thomas Sullivan –