1. © 2016 American Hospital Association
MACRA Final Rule
December 2016
© 2016 American Hospital Association 1

2. Physician Quality Payment Program
PQRS VM MU
Starting in 2019….
Just as a quick reminder, the MACRA passed last year. In addition to eliminating the deeply flawed SGR formula for physician payments, it established a new, two-track physician Quality Payment Program (QPP) in That program does two things:
Consolidates three previously separate programs into one (the Merit-Based Incentive Program, or MIPS) and;
Provides incentives for participation in APMs.
Taken together, these programs are an aggressive step in moving the field from volume to value.
MIPS
APM

3. Why MACRA Matters
Physicians: Impact on payment, performance measurement requirements
Hospitals: May defray cost of implementation and compliance by employed/affiliated physicians
Continued shift in hospital-physician relationships
Incentives to participate in alternative payment arrangements increasing interest in risk-bearing arrangements
We expect the new physician payment system will have a number of important impacts on hospitals in the coming years, and look forward to hearing your thoughts on these implications during the discussion. A few potential impacts have emerged from our early discussions with members.
The most directly impacted hospitals will be those that employ their physicians. Those hospitals will need to absorb the costs of compliance.
But we also expect this new payment system will impact the continued shift in hospital-physician relationships. For example, some physicians may find the stability of hospital employment more appealing.
And given the significant incentives to participate in APMs, there may be more pressure from physicians for hospitals to participate in risk bearing relationships.

4. MACRA Final Rule: Key Takeaways
Starts Jan. 1, 2017, but clinicians can “pick their pace”
Few advanced APMs qualify for incentives in the (but more may be coming)
More data reported in 2017 means better chance of payment increase
Fewer clinicians than expected subject to MIPS in the first year
Expectations will ramp up over time
Final rule released Oct. 14
Though the QPP will start in 2017, clinicians will be able to “pick their pace” of implementation in the first year. CMS adopted a number of policy changes intended to provide clinicians more flexibility in avoiding payment penalties and meeting QPP requirements. For example, instead of requiring the reporting of a full year of MIPS data during CY 2017, CMS will only require clinicians to report data from any continuous 90-day period in In addition, CMS will not score participating clinicians on the cost and resource performance in the first year of the program due to concerns about the readiness of the measures.
There remain few advanced APMs that qualify for bonuses in the first year, but CMS is considering more options for future years. CMS’s final criteria for advanced APMs exclude many models in which hospitals are participating, such as Track 1 of the Medicare Shared Savings Program, because they do not require downside risk. However, CMS has signaled its interest in offering an additional APM — called Track 1+ — that includes downside risk and would qualify for APM bonuses. CMS will provide more details soon. Additionally, CMS plans to add the Comprehensive Care for Joint Replacement and proposed cardiac bundled payment models to the advanced APM track. Less than 10 percent of clinicians will qualify.
The more MIPS data clinicians report in the first year, the better their chances of receiving positive payment adjustments. Eligible clinicians can get by with reporting only some data — for example, one quality measure or one clinical practice improvement activity — and avoid receiving a payment penalty. However, clinicians reporting more than the minimum amount of data will increase their chances of receiving a positive payment adjustment. Clinicians who meet or exceed the reporting requirements in all MIPS categories will have the best chance of receiving a positive payment adjustment.
Fewer clinicians than expected will be required to participate in MIPS in the first year. CMS modified several policies in a way that reduces the number of clinicians required to participate in the MIPS in the first year. For example, CMS raised the volume threshold below which clinicians are NOT required to participate in the MIPS. In the first year, clinicians billing $30,000 or less in Medicare charges, or that see 100 or fewer Medicare patients, will not be required to participate in the MIPS. This change resulted in 380,000 fewer clinicians being required to participate in the MIPS.
Expectations for participation will ramp up over time. CMS has indicated that it views the first year of the QPP as a “transition” period during which clinicians will become accustomed to the QPP requirements. The agency intends to require more clinicians to participate in the future, and to raise participation requirements (e.g., requiring a full year of data to be reported, rather than just 90 days' worth).

5. APM: Bonus of 5% of PFS payments annually
Payment Under MACRA
APM: Bonus of 5% of PFS payments annually
APM 0.75% annually; no bonus payments
0.0% annual update
MIPS OR APM
2021
2022
2024
2025
2023
2019
2020
2026
MIPS 0.25% annually, PLUS penalties/bonus up to ± 9%
This slide illustrates the payment impact under MACRA over the next several years. The middle line is the base annual payment update. As you can see, from 2020 through 2025, it is zero percent, and a physician’s payment updates depend on their MIPS and APM performance.
The amount at risk for MIPS goes up until it reaches 9 percent in 2022 and beyond.
APM bonuses available through 2024, then go away.
In 2026, higher base payment updates for APM participants, but no bonus.
±4%
±5%
±7%
±9%
±9%

6. Merit-based Incentive Payment System
MIPS is default payment system
Applicable to physicians, PAs, NPs, CNSs and CRNAs beginning in 2019
Others can be added in 2021
Participate as individual or group practice
Exemptions for:
Certain participants in alternative payment models
Clinicians in first year of Medicare
Low-volume threshold
The MIPS will be the default payment system for physicians, physician assistants, nurse practitioners, certified nurse specialists, and certified registered nurse anesthetists beginning in CMS may choose to expand the payment system to other professionals paid under the fee schedule (such as physical, occupational, speech therapists) beginning in 2021.
Clinicians may participate at individuals or as part of group practices. For the purposes of the MIPS, each unique combination of NPI and TIN is treated as an individual. Group practices are defined as multiple NPIs billing under a single TIN.
Certain professionals will be exempted from the MIPS and its associated reporting requirements. Those include:
Qualified APM participants, which will be physicians who receive a certain percentage of payments through the APM.
“Partial” APM participants, who receive some payments through an APM but not enough to qualify as APM participants, and who do not report measure data under the MIPS. CMS will need to provide more definition on who fits in to this category.
Professionals who do not meet a low-volume threshold that will be determined by CMS. We will talk about that in a minute.

7. MIPS: Performance Categories
Category
CY 2019
CY 2020
CY 2021 and beyond
Quality
60%
50%
30%
Resource use (Cost) NA
10%
Clinical practice improvement activities
15%
Advancing Care Information (i.e., Meaningful Use)
25%
The MIPS includes four categories of performance, each of which is assigned a weight (read the categories).
It is important to note that for the first year, cost performance will not be tied to MIPS incentives or penalties. CMS chose to invoke statutory authority to alter the weightings of the categories in specific circumstances. As a result, in the first year, 60% of performance is tied to quality, 15 percent is tied to improvement activities, and 25 percent to ACI.
Clinicians who fail to meet reporting requirements of a particular category receive the lowest possible score in that category. So for example, if a professional does not submit quality data, they would receive the lowest score in the quality category
CMS invoking statutory flexibility to not score cost category in first year

8. MIPS Flexibility for Year 1
Shortened reporting period for CY 2017
Continuous 90-day period across all MIPS categories
“Pick your pace” options that help clinicians avoid penalties
Increased low-volume threshold
Clinicians excluded from MIPS if they bill $30,000 or less of Medicare charges, OR see fewer than 100 patients
Threshold may change in future years
CMS initially proposed to require MIPS data reporting to begin on Jan However, a number of stakeholders, including the AHA, raised significant concerns about the readiness of the field to meet this timeline, especially since the final rule would be in place only about two months before reporting would need to begin.
As a result, CMS signaled its intention to provide further flexibility in September. The final rule includes several provisions intended to allow clinicians to avoid payment penalties and “pick their pace” of implementation.
First, CMS shortened the reporting period to a continuous 90-day period for CY 2017 across ALL MIPS categories. As a result, it is possible for clinicians to wait as late as Oct to begin reporting data.
Second, CMS provided flexibility in how much data would need to be reported to avoid penalties and potentially earn incentives. We’ll drill down on that in a minute
And finally, CMS increased the low-volume threshold (read from slide). This change excludes ~380,000 clinicians from the MIPS in the first year. And it addresses the concerns of many – especially small practices and rural practices – who expressed concern about the ability to meet these requirements.
It is important to note, however, that CMS views year 1 as a “transition year,” so this threshold may be raised.

9. MIPS Flexibility for Year 1
“Pick Your Pace”
Three options for 2017 MIPS participation:
Report “some” data to avoid penalty (but receive no incentive)
One measure, one improvement activity or meet base ACI requirements
Report more than minimum data for 90 days to avoid penalty and potentially receive small incentive
More than one measure, more than one improvement activity or meet more than base ACI requirements
Report all required data across all categories for at least 90 days to maximize opportunity for incentive
Just to drill down on “pick your pace,” there are three possibilities for avoiding penalties and potentially receiving incentives:
Report “some” data. This could be a measure, an improvement activity, or meeting all base ACI requirements. If you do one of these things, you will not incur a penalty, but you also won’t get a payment incentive.
Report more than the minimum required data for the full 90-day period to avoid penalty and potentially receive a small incentive.
So for example, meeting the requirements for more than one quality measure, more than one improvement activity or more than base ACI positions you to potentially receive an incentive. Not guaranteed – just increases chances.
Lastly, report all required data for at least 90 days to maximize opportunity for incentive. You may see that in some places CMS suggests benefit to reporting for the full calendar year. There is no explicit scoring bonus for reporting a full year of data – the requirement is 90 days. That being said, for some measures, you may need more than 90 days of data in order to meet the minimum volume requirement.

10. MIPS: Applicability to Rural Providers
CAHs: MIPS will apply to CAHs billing under Method II whose clinicians have reassigned their billing rights to the CAH
FQHCs/RHCs:
MIPS does not apply to clinicians billing under the payment systems for FQHCs/RHCs
However, MIPS may apply if FQHC/RHC clinicians bill services under the PFS (such as in moonlighting arrangements)
Note that there are some special considerations about how the MIPS applies to clinicians practicing in rural settings.
MIPS participation depends upon the billing approach used by the CAH. If the CAH uses Method II billing, AND if clinicians have reassigned their billing rights to the CAH, then MIPS applies. Note that the MIPS adjustment applies only to the professional services portion of the payment.
It’s important to note that clinicians practicing in CAHs billing under Method I who are billing Medicare directly, as well as those who have not assigned billing rights to their Method II CAH, may still be subject to the MIPS, but the CAH payments would NOT be subject to the payment adjustment.
In general, FQHCs and RHCs are NOT subject to the MIPS if the clinician is billing under those systems. However, MIPS adjustments may apply to any moonlighting payments.

11. MIPS: Data Reporting Mechanisms
There are a variety of mechanisms for submitting MIPS data. There is some slight variation depending on whether you report as an individual or as a group practice. We won’t get into the details of each mechanism here, but I would note that
You must pick one mechanism per category. You wouldn’t be allowed to, for example, report some quality measures on EHRs and others on a registry.
In general, data are due to CMS on Mar. 31, 2018
And data completeness thresholds apply. For registries, in the first year, you are required to report on at least 50 percent of patients eligible for the measure. You get credit for reporting the measure if you fall short of that requirement. But you increase your chances of getting an incentive by meeting the completeness criteria.
Must select one mechanism per category
Data requiring submission due to CMS by Mar. 31, 2018
Data completeness thresholds apply

12. MIPS: Quality Measure Requirements
For most reporting mechanisms, clinicians and groups would report at least 6 measures. Of the 6:
Report at least 1 outcome measure
Can choose any measure from list of available measures
Specialty measure sets also available
For groups of 16 or more clinicians, CMS also will calculate a claims-based hospital readmission measure
For most reporting mechanisms, the quality reporting requirements are as follows:
Report at least six measures, including at least one outcome measure. If no outcome measure available, report on one other ‘high priority’ measure (like safety, care coordination, etc.).
One can choose from any measures on the list. There also are specialty sets (grouped by specialty). If the set includes fewer than six measures, you simply report all of the applicable measures in that set.
Lastly, CMS will calculate an all-cause hospital readmission measure for groups of 16 or more clinicians. This measure currently is used in the value modifier.

13. MIPS – Cost Category
Category not counted towards MIPS score for CY 2019 (but will for CY 2020)
CMS will use:
Total costs per capita
Medicare spending per beneficiary for physicians
Clinical condition and procedure episode cost measures from a list of 10 measures
Cost score = average score of all the measures that can be attributed to clinician / group
Various attribution methodologies
As noted earlier, cost will NOT be included in MIPS performance in the first year. However, CMS did adopt several policies that will apply when it begins to score clinicians and groups on cost/resource use.
CMS will use two all-condition resource use measures from the value modifier program – total costs per capita, and Medicare spending per beneficiary. In addition, CMS adopts 10 condition and procedure-specific measures.
Clinicians will be score on all measures that can be attributed to them. The attribution methodologies vary somewhat, but focus on whether the clinician or group has provided the plurality of services within the measurement timeframe.

14. MIPS – Improvement Activities
List of 93 activities from which clinicians can choose
Each activity assigned a weight of “medium” or “high” towards score
Participate in up to 4 activities for full credit
Participation in certified PCMH automatically receives highest score
Participation in MIPS APM automatically receives at least half the highest score
CMS assesses APM requirements against improvement activities list
MSSP Track 1 and Next Generation ACO would receive full credit
The MACRA requires CMS to score clinicians on participation in so called “clinical practice improvement activities,” which CMS has shortened to just “improvement activities.” These are activities thought to improve patient safety, care coordination and patient engagement.
CMS has a list of 93 activities from which clinicians may choose. Each activity has a “weight” towards the category score. Clinicians generally expected to participate in up to 4 activities. This could include all medium activities (in which case you’d need 4 activities), high weight activities (in which case you’d need 2 activities), or a mix of both.
The law requires CMS to give certain activities particular weight. Patient-centered medical homes meeting CMS criteria automatically receive the highest score.
APM participation gets at least half the highest score. And CMS has provided a mechanism for clinicians to get the highest score.

15. Advancing Care Information
Continuous 90-day reporting period for 2017 and 2018 for the ACI category
Finalizes a Base Score, Performance Score and Bonus Point structure
Offers the 2017 ACI Transition objectives and measures with fewer reporting requirements
Modifies some measures in the ACI objectives available in 2017 and required in 2018
Reduction in the measure threshold for patient electronic access
Reporting public health and clinical data registry reporting measures available for Bonus Points
For the new ACI category, CMS will apply the same 90-day reporting requirement as the quality and improvement activity categories.
The general approach offers more flexibility than before, including an ACI transition objectives/measures portion for 2017 that includes fewer reporting requirements.
Some of the measures themselves also were scaled down. For example, the threshold for patient electronic access was lowered.

16. MIPS Alternative Payment Models
CMS will use alternative scoring approach for participants in “MIPS APMs”
Defined as APM with:
Participation agreement with CMS
One or more MIPS-eligible clinicians
Payment incentives based on quality and cost
As we will address later, CMS’s criteria for advanced APMs limit the number of models qualifying for a bonus. However, the agency sought to create a mechanism to both recognize participation in APMs in the context of the MIPS, and to limit inconsistency between performance assessment on the MIPS and the APMs. They did so by creating an alternative scoring approach for those in “MIPS APMs.”
Those APMs are defined as those meeting three criteria (listed on slide)
ACO participants can use quality data reported through CMS web interface for the quality category. Moreover, re-weights the scoring for participants. The agency specifically identified weights for participants in MSSP and Next Generation ACO. They are not scored on cost because mechanism for determining cost performance is different in those models.
MIPS Category
Weight for MSSP and Next Gen ACO
Weight for other MIPS APMs
Quality
50% 0%
Resource Use
CPIA
20%
25%
ACI
30%
75%

17. MIPS: Incentives and Penalties
Exceptional performance bonus (up to 10 percent)
MIPS Final Score
100
Exceptional performance threshold (2019 – 2024 only)
For CY 2019:
70 points
Positive adjustment on sliding scale
Performance Threshold
(Determined annually)
For CY 2019:
3 points
Negative adjustment on sliding scale
*******This slide contains animation*******
Once CMS has determined a composite score, it must then use that score to determine upward, neutral or downward adjustments.
FIRST CLICK:
CMS will first determine a “performance threshold” for each year of the program based on the performance of all providers in the MIPS. Professionals with MIPS Composite scores above the threshold receive positive payment adjustments on a sliding scale. Professionals with scores below the threshold receive negative payment adjustments on a sliding scale.
SECOND CLICK
CMS then will then determine what MIPS Score is 25 percent of the performance threshold score. Any professionals scoring below that threshold will receive the maximum possible negative payment adjustment. That starts at 4 percent in CY 2019, and goes all the way up to 9 percent in 2022 and beyond.
THIRD CLICK
As noted earlier, the MIPS is a budget-neutral program. CMS can pay no more out in incentives than it collects in incentives. However, for CYs 2019 through 2024, the MACRA authorizes an “exceptional performance bonus” for the top performers in the MIPS. This is funded separately from the other MIPS adjustments. Each year, CMS will need to determine a threshold score above which the bonus would apply.
FOURTH, FIFTH and SIXTH CLICKS
Note that CMS has established thresholds for CY CMS set the performance threshold very low – 3 points – to operationalize its ‘pick-your-pace’ approach. Reporting only one quality measure or improvement activity gets you 3 points. The exceptional performance threshold for CY 2019 is 70 points.
For CY 2019:
0.75 points
25 percent of performance threshold
Maximum Negative Adjustment

18. MIPS: Getting Started…
Determine whether to participate as individuals or group practice
Identify applicable quality measures and improvement activities
Determine a reporting mechanism (e.g., registry, EHRs)
Examine readiness of EHR systems
Here are some things that we suggest you do to get started on participating in the MIPS…

19. Advanced APMs: Incentives
MACRA provides incentives for qualifying professionals (QPs)
Lump-sum bonus payment of 5% of Part B payments for professional services
Exemption from MIPS reporting requirements and payment adjustments
Higher base rates beginning in 2026
Incentives in 2019 based on 2017 APM participation
As a reminder, the MACRA provides incentives for physicians who demonstrate significant participation in alternative payment models by meeting thresholds (either based on payments or patient counts) set in statute. Those incentives include (read from slide).
CMS has proposed to use a base performance year of 2017, which means that it will assess APM participation in 2017 for incentives in 2019.

20. Alternative Payment Model
Determining QP Status QP
Advanced APM Entity
Advanced APM
Alternative Payment Model
This slide shows how CMS will drill down to determine which clinicians qualify for advanced APM incentives
At the bottom is the universe of alternative payment models
Only some of those APMs will meet the requirements to be an advanced APM.
CMS will then look to the entity that is accountable for the cost and qualify of care under the APM – known as the APM entity – and identify the clinicians who have formally partnered in some way with the APM entity to advance the goals of the model.
Among professionals provide significant care through the APM entities:
- Some will meet the thresholds discussed on the prior slide and will be “qualifying professionals” and receive all APM incentives.
- Some may fall just short of the threshold, though they still provide a significant amount of care (exceeding slightly lower thresholds set in the statute). These physicians are considered “partial qualifying professionals.” They are exempt from the MIPS – though they can choose to participate – but do not get any other incentives for their participation in the APMs.

21. Require use of certified EHR technology
Advanced APM Criteria
Advanced APM
Require use of certified EHR technology
Tie payment to quality
Require downside risk
To be designated an advanced APM, a model must meet certain criteria.
The criteria were generally set in statute, those some details were up to interpretation by CMS in the final rule.
The model must:
Require use of certified EHR technology.
Tie payment to quality.
Require downside risk. Note that although the statute uses different language (require “more than nominal risk” for financial loss), CMS is interpreting this as downside risk.

22. Certified Use of EHR Technology
Advanced APM Criteria
Certified Use of EHR Technology
Require 50 percent of clinicians to use certified EHR technology
Or, hospital if APM entity
Quality Measurement
Base payment on at least one evidence-based, reliable and valid measure
At least one outcome measure
For EHR technology, to promote alignment across tracks, CMS adopted the definition of EHR technology used for the MIPS.
The model must require that 50 percent of eligible clinicians use certified health IT functions to document and communicate clinical care.
If the hospital is the APM entity, the hospital must use certified EHR technology.
For quality measures, CMS acknowledged that different measures may be appropriate for different models and set a somewhat flexible requirement.
The model must base payment on at least one measure that is evidence-based, reliable and valid.
At least one measure must be an outcome measure, unless there is not an applicable measure when the APM is developed.

23. Advanced APM Criteria Financial Risk
General Standard
Require repayment if actual spending exceeds expected
Required potential risk:
3% of APM entity’s expected spending, or
8% of total Parts A & B revenues of APM entity ( )
Medical Home Standard
Require repayment based on spending or performance
Currently only applies to CPC+ model
Limited applicability after 2017 (organizations with <50 clinicians)
With respect to the financial risk requirement, CMS has established two alternatives.
Most models must require downside risk.
This means that if an APM entity’s actual spending exceeds expected spending (through a benchmark or target price), the entity must repay at least part of that loss.
The amount the APM entity must be on the hook to repay is at least 3% of expected spending (so 3% of the benchmark or target price) – CMS calls this the “benchmark standard.”
Alternatively, the potential payback could be based on total Parts A & B revenue of the APM entity (the revenue standard). This would be 8% of total Parts A & B revenues in 2017 and 2018, though CMS intends to increase the percentage going forward.
CMS also created a less stringent standard that applies to medical home models.
Under this standard, the risk requirement would be met if repayment would be required based on either spending over a benchmark/target price OR failure to meet performance requirements.
Currently, this standard only applies to the Comprehensive Primary Care Plus (CPC+) program, which begins in 2017.
For 2017, all organizations in the CPC+ can qualify under this standard. However, beginning in 2018, CMS will limit it to organizations with fewer than 50 clinicians – which likely will exclude most hospital-employed physicians from receiving Advanced APM credit for participation.
Note that fully capitated arrangements would meet the risk requirements.

24. Limited Medicare Models Available
Models that qualify in 2017:
MSSP Track 2
MSSP Track 3
Next Generation ACO
Comprehensive ESRD Care
Oncology Care Model (two-sided track)
Comprehensive Primary Care Plus (as medical home)
Models that do not qualify in 2017:
MSSP Track 1
Bundled Payments for Care Initiative
Comprehensive Care for Joint Replacement
Applying CMS’s interpretation of the criteria to existing models, you will see that a very limited number of models qualify as advanced APMs for 2017.
The most common disqualifier is the financial risk standard. The Bundled Payments for Care Initiative (BPCI) would not qualify because it doesn’t tie payment to quality measures, and the Comprehensive Care for Joint Replacement (CJR) – the joint replacement bundle mandatory for hospitals in some markets – does not include an EHR requirement. The others are disqualified because of the financial risk standard.
In particular, there are very few options for hospital-driven models to qualify.
For example, though hospital-led ACOs make up about 50% of the MSSP, most participants are in Track 1. Similarly, a number of hospitals participate in BPCI – and some hospitals were mandated to take financial risk through the CJR. And as we discussed on the last slide, most hospital-driven medical homes that participate in the CPC+ program will not qualify after 2017.
We are disappointed that those efforts will not be recognized in the first year.
CMS has indicated an interest in expanding availability of advanced APMs going forward:
In the new hospital bundled payment rule released in August, CMS proposed to create two tracks for participation in the new cardiac and hip facture bundles, and to create two tracks in CJR. In each, Track 1 would allow qualification as an advanced APM by incorporating an attestation of certified EHR technology use.
CMS also is considering a new ACO model that would incorporate less downside risk than the models currently available (“Track 1+). Few details were provided, however.
Overall, CMS has projected that only between 5-8 percent of clinicians will qualify for the APM incentives in year 1.

25. Other Payer Option
Other payer APMs = Medicare Advantage, Medicaid, private payer arrangements
Applicable to performance year 2019
Advanced APM criteria parallel to those for Medicare advanced APMs
CMS would require clinicians to submit information to verify eligibility of arrangements
We are often asked whether Medicare Advantage arrangements qualify as advanced APMs, and the answer, at least at first, is no.
However, there is an option beginning in performance year 2019 to qualify based on participation in APMs with payers other than Medicare – known as the “other payer option.”
Other payers include Medicare Advantage, Medicaid, and private payers.
CMS proposes advanced APM criteria for other payers that parallel those in Medicare advanced APMs. In other words, arrangements with other payers would need to incorporate an EHR requirement, quality measurement, and financial risk requirements similar to those in Medicare APM arrangements.

26. APM Entity Determinations
APMs with Participation List = group assessment
APMs with Affiliated Practitioner List = individual assessment
So, now you know how to identify whether a model is an advanced payment model. The next step for CMS will be to identify the clinicians who are associated with advanced APM entities so that it can assess whether those clinicians have demonstrated sufficient APM participation. There are are a couple of different ways CMS will look at this.
CMS will do this by first looking to see whether the model requires the APM entity to submit a participation list (for example, the MSSP requires that ACOs submit and update lists of participating clinicians). If so, CMS will assess all clinicians on the participants list as a group when determining whether they meet the thresholds for participation.
Some models do not require a participants list, but APM entities submit a list of clinicians who are engaged with the model as an affiliated practitioner. An example would be the bundled payment programs, where the clinician does not directly contract with CMS but instead engages with the APM entity (the hospital) through gainsharing agreements. In this case, each affiliated practitioner would be assessed individually.
CMS also would do an individual assessment in the case where a clinician participates in more than one advanced APM, but does not qualify through any one APM entity.
Clinicians in more than one APM but no one APM entity qualifies = individual assessment

27. APM Participation Thresholds
QP Payment Amount Thresholds
2023 and beyond
Medicare Option QP
25%
50%
75%
Partial QP
20%
40%
All-payer Option
N/A
Medicare
Total
This slide shows the thresholds that clinicians must meet to be deemed QPs and receive the APM incentives. Key things to note here are:
In the first two years, only Medicare payments count.
The thresholds increase over time.
Starting in performance year 2019 (for payment year 2021), there are two ways to qualify, either through Medicare APMs alone or a combination of Medicare and other payer APMs. Regardless of path, though, there is a baseline requirement of that at least 25% of Medicare FFS payments must be made through an advanced APM to qualify for incentives. So even those clinicians in APMs with non-Medicare payers must still engage substantially in Medicare models.
The chart also shows the slightly lower thresholds to be deemed partial QPs. These are clinicians who have significant participation in advanced APMs but not enough to qualify for the APM incentives. They still get a bit of a favored status, though – they may choose whether to participate in the MIPS.

28. APM Participation Thresholds
QP Patient Count Thresholds
2023 and beyond
Medicare Option QP
20%
35%
50%
Partial QP
10%
25%
All-payer Option
N/A
Medicare
Total
As an alternative, CMS will assess patient counts. This slide shows the relevant thresholds.
CMS will calculate APM participation based on both payment amounts and patient counts and will use whichever is most favorable to the relevant clinicians.

29. QP Determinations: Timing
CMS will evaluate advanced APM participation based on “snapshots” of participation lists on:
March 31
June 30
August 31
Once clinician is included in an APM entity, will be included in later snapshots even if no longer on participation list
Subsequent snapshots allow APM entities to capture added clinicians
Now that we know how CMS will assess APM participation, let’s talk about when they will do it.
CMS will evaluate advanced APM participation based on “snapshots” of participation lists. The snapshots will be of the participants lists on March 31, June 30, and August 31, and CMS will notify entities whether they achieved QP status within four months of each snapshot.
Once an entity receives a QP determination, it will not be reassessed unless it adds additional clinicians to the participation list.
Clinicians will only be added, not dropped, at future snapshots. So once a clinician is included as part of an APM entity, that clinician will continue to be included even if later dropped from the participation list.
The benefit to this is that entities will likely receive their QP determinations earlier than CMS originally proposed, and so clinicians who do not achieve QP status will know that before deciding whether to participate in MIPS.

30. Advanced APMs: Key Considerations
Participating in Advanced APM:
Keep participation lists updated throughout year
Estimate whether APM volume will meet thresholds; if not, evaluate voluntary MIPS participation
Not Participating in Advanced APM:
For 2017, focus on MIPS reporting
Consider Medicare APM options for 2018, all-payer arrangements for 2019
Here are some of the key considerations relevant to the advanced APM track that organizations should keep in mind.
For those who are in a model that will qualify as an advanced APM in 2017:
It’s important to keep your participation lists updated throughout the year so that all eligible clinicians are counted for purposes of the QP determination.
The organization should project whether it will do enough volume of business through the advanced APM, using the thresholds set by CMS for patient count and payment amount. If it’s not clear the organization will qualify, it should evaluate whether or not it wants to elect voluntary MIPS participation.
For those who are not in an advanced APM in 2017:
Focus on MIPS for 2017.
Organizations should evaluate whether they want to pursue advanced APM participation in future years. As we have discussed, there may be new models and opportunities for advanced APM participation in Looking even further down the road, the all-payer option starts in 2019.

31.
The AHA offers a number of materials and resources to assist with understanding and implementing MACRA, available on a dedicated webpage,

32. Current/Planned Resources
Available now:
Coming soon:
Customizable PPT slides
Decision tree
Implementation toolkit
“MACRA Minutes” educational videos
Final rule advisory
Infographic
Current resources include (read from slide)
Please mention that slides are publically accessible and we encourage folks to download them and adapt them for their own educational efforts

33. © 2016 American Hospital Association
THANK YOU!
© 2016 American Hospital Association 33