1. How to Succeed under the New Medicare Quality Payment Program
MACRA:
How to Succeed under the New Medicare Quality Payment Program

2. April 2015 – Congress Passed Landmark, Bipartisan Law – MACRA…
Medicare Access and CHIP Reauthorization Act of (MACRA) – focused on Part B Medicare
Congressional Intent of MACRA:
Sustainable Growth Rate repeal
Improve care for Medicare beneficiaries
Change our physician payment system from one focused on volume to one focused on value
MACRA has been recast as the Quality Payment Program - NPRM April 27, 2016

3. Quality Payment Program In a Nutshell
Law intended to align physician payment with value
The Medicare Access and CHIP Reauthorization Act of (MACRA)
Or now the…
Quality Payment Program
Merit-Based Incentive Payment System (MIPS)
Advanced Alternative Payment Models (APMs)

4. Quality Payment Program: Are you “in” or are you “out”?
YES NO
Medicare Part B payments
Medicare Part A (e.g., hospital payments)
Physicians, Pas, NPs, CNSs, and CRNAs
Clinicians that fall below the low-volume threshold (see below)
Groups that include the above clinicians
Clinicians billing Medicare for the first year (for MIPS)
Low Volume Threshold *– if below this, you are not included:
If you bill Medicare less than or equal to $30,000 a year OR
Provide care for less than or equal to 100 Medicare patients a year.
THIS WAS A BIG WIN for ACP!
Final Rule Published on October 14, 2016:

5. Merit-based Incentive Payment System (MIPS)

6. This new MIPS “report card” will replace current Medicare reporting programs
There are currently multiple individual quality and value programs for Medicare physicians and practitioners:
Physician Quality Reporting Program (PQRS)
Value-Based Payment Modifier (quality and cost of care)
“Meaningful use” of EHRs
MACRA streamlines those programs into MIPS:
Merit-Based Incentive Payment System
(MIPS)
Source:

7. How Will Clinicians Be Scored Under MIPS?
A single MIPS composite performance score will factor in performance in 4 weighted performance categories:
MIPS Composite
Performance Score
Clinical practice improvement activities
15%
Quality
50%
Advancing Care Information
25%
Cost
10%
Year 1 or 2019*
Cost 0%
Quality
60%
* Based on reporting data in 2017
Getting cost down to 0% in the first year is a BIG WIN for ACP! Exactly what we asked for.

8. How Much Can MIPS Adjust Payments?
Based on the MIPS composite performance score, physicians and practitioners will receive positive, negative, or neutral adjustments up to the percentages below.
MIPS adjustments are budget neutral.
MAXIMUM Adjustments
Merit-Based Incentive Payment System (MIPS) 5% 9%
-9%
onward
-7%
-5%
-4% 7% 4%
Adjustment to provider’s base rate of Medicare Part B payment
Those who score in top 25% are eligible for an additional annual performance adjustment of up to 10%, (NOT budget neutral)

9. Timing of QPP Implementation
Source:

10. “Pick Your Pace” for 2017 Reporting
Source:

11. Overview of Quality Performance Category
Most participants: Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days.
Three population measures automatically calculated from administrative claims, but only one* used for performance score.
Groups using the web interface: Report 15 quality measures for a full year.
Groups in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: Report quality measures through your APM. You do not need to do anything additional for MIPS quality.
CAHPS for MIPS reporting is voluntary (and credit is provided under Improvement Activities)
NOTE: Key Change from Current Program (PQRS): reduced from 9 measures to up to 6 measures with no domain requirement
Year 1 Weight: 60%
Population measure to be kept: all-cause hospital readmissions (ACR) measure and will apply it to groups with 16 or more clinicians instead of the proposed approach of groups of 10 or more. A 200 case minimum must be met for the measure to count as part of a group’s quality performance score.
* All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases.

12. Quality Performance Scores

13. Improvement Activities
Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.
Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.
Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.
Participants in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: Automatically receive points based on the requirements of participating in the APM.
Part of an advanced APM, but not a qualifying participant - full credit.
Other APMs will get half credit.
Year 1 Weight: 15%
The law required CMS to give ECs in APMs at least half credit in the CPIA category (for those that are not qualified/partial qualified participants in Advanced APMs) -- these are the practices/clinicians that CMS deemed to be MIPS APMs. For the first performance period, CMS determined that participants in the MIPS APMs pathway will receive full CPIA credit rather than at least half credit. ECs who are in MIPS APMs are not required to submit/attest to any anything in the CPIA category to get credit.
The MIPS APMs are essentially those that are considered Advanced APMs (for ECs who don't reach the qualified participant threshold) as well as MSSP Track 1 and the Oncology Care Model (which does not qualify as an Advanced APM until the second year).
The APM scoring standard is a separate standard for MIPS APMs. CPIA is worth more than 15 percent for MIPS APMs based on which APM you are in.

14. Improvement Activities = 15%
Attest to participation in activities that improve clinical practice
Examples: Shared decision making, patient safety, coordinating care, increasing access
Clinicians choose from 90+ activities under 9 subcategories:
1. Expanded Practice Access
2. Population Management
3. Care Coordination
4. Beneficiary Engagement
5. Patient Safety and Practice Assessment
6. Participation in an APM
7. Achieving Health Equity
8. Integrating Behavioral and Mental Health
9. Emergency Preparedness and Response

15. Advancing Care Information
Fulfill the required (i.e., base) 5 measures for a minimum of 90 days:
Security Risk Analysis
e-Prescribing
Provide Patient Access
Send Summary of Care
Request/Accept Summary of Care
Choose to submit up to 9 measures for a minimum of 90 days for additional credit.
For bonus credit, you can:
Report Public Health and Clinical Data Registry Reporting measures
Use certified EHR technology to complete certain improvement activities in the improvement activities performance category OR
You may not need to submit advancing care information if these measures do not apply to you.
Year 1 Weight: 25%

16. Advancing Care Information
These are the 4 or 5 required measures (depending on which set of objectives you use in 2017):
The base score accounts for 50% of the overall category score and includes the following measures:
Protect Patient Health Information
Electronic Prescribing
Patient Electronic Access
Health Information Exchange: Send Summary of Care
Health Information Exchange: Request/Accept Summary of Care
As we learned earlier, clinicians must submit a numerator/denominator OR yes/no combination for each respective measure. Failure to meet the reporting requirements will result in the base score being zero.

17. ACI Performance Score

18. ACI Bonus Score

19. Cost (aka Resource Use)
No data submission required. Calculated from adjudicated claims.
Year 1 Weight: 0%
This is exactly what ACP asked for… the measures are not yet proven to be reliable and validated in their application to physicians.

20. ACP’s Recommended Scoring Approach… CMS Response
Total points for Quality = 60
Total points for Cost = 0
Total points for IA = 15
Total points for ACI = 25
While CMS did reduce the reporting requirements in most performance categories, the methodology has not been simplified sufficiently and the points available with each measure are not reflective of the value a measure has in the overall composite performance score in most cases.

21. CMS Scoring Approach for MIPS
MIPS Category
Measures
Top Score
Total Percentage Weight
Quality
Each measure worth up to 10 points and evaluated based on performance relative to benchmarks
Bonus for reporting additional outcome or high-priority measures and for end-to-end reporting
60 + more for bonus reporting
60%
Advancing Care Information
Base score 0-50 points +
Performance score 0-90 points +
Bonus points 0-15 points
100 (even though you can actually get up to 155)
25%
Improvement Activities
High weighted activities = 20 points
Medium weighted activities = 10 points
40 (small practices or those in rural or HPSA areas 20)
15%

22. Advanced Alternative Payment Models (APMs)

23. Advanced Alternative Payment Models (APMs)
As defined by MACRA, advanced APMs must meet the following criteria:
The APM requires participants to use certified EHR technology.
The APM bases payment on quality measures comparable to those in the MIPS quality performance category.
The APM either: (1) requires APM Entities to bear more than nominal financial risk for monetary losses; OR (2) is a Medical Home Model expanded under CMMI authority.
Initial definitions from MACRA law, APMs include:
CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)
MSSP (Medicare Shared Savings Program)
Demonstration under the Health Care Quality Demonstration Program
Demonstration required by Federal Law

24. Advanced APMs include:
Comprehensive Primary Care Plus (CPC+)
Medicare Shared Savings Programs – Tracks 2 & 3
Next Generation ACO Model
Comprehensive End-Stage Renal Disease Care Model (Two- Sided Risk Arrangements)
Oncology Care Model (Two-Sided Risk Arrangement)
Comprehensive Care for Joint Replacement (CJR) Model – Track 1
Vermont Medicare ACO Initiative (as part of the Vermont All- Payer ACO Model)
Coming soon: MSSP Track 1+ and possibly other models??

25. How does MACRA Provide Additional Rewards for Participation in Advanced APMs?
Most clinicians who participate in APMs will be subject to MIPS and will receive favorable scoring under the MIPS improvement activities performance category – these are called MIPS APMs.
APM
participants
Those who participate in the most Advanced APMs may be determined to be qualifying APM participants (“QPs”). As a result, QPs:
Are not subject to MIPS
Receive 5% lump sum bonus payments for years
Receive a higher fee schedule update for 2026 and onward
Advanced APMs
QPs
The 2019 APM Incentive Payment will be based on 2017 services

26. Are you a Qualifying Participant?
Patients
Payments QP
25%
20%
Partial QP
10%
QPs are eligible to receive a 5% bonus payment plus any rewards associated with the APM, and are excluded from MIPS.
Partial QPs have the option to participate in MIPS, and are eligible for APM rewards.
If in an APM that is advanced OR in an advanced APM but do not meet the thresholds to be excluded from MIPS, you are in a MIPS APM with favorable scoring and APM rewards.

27. How does a MIPS APM help me?
Streamlines MIPS reporting & scoring for ECs in certain APMs (e.g., no add’l quality reporting beyond APM)
MIPS scores aggregated at the APM entity level
All ECs in an APM receive the same MIPS final score
Full credit in the Improvement Activities category
Continued participation in APM’s reward program

28. Independent PFPM Technical Advisory Committee (PTAC)
Physician-Focused Payment Model
Goal to encourage new APM options for Medicare clinicians
Technical Advisory Committee 
Submission of model proposals by Stakeholders
 
Secretary comments on CMS website, CMS considers testing proposed models
11 appointed care delivery experts that review proposals, submit recommendations to HHS Secretary
For more information on the PTAC, go to: physician-focused-payment-model-technical-advisory-committee

29. Proposed FINAL Rule (and beyond) Advanced APMs
Proposed in 2017
New for 2017
New for 2018
Shared Savings Program (Tracks 2 and 3)
Track One Plus (details recently released)
Next Generation ACO Model
Adding new participants (applications in 2017)
Comprehensive ESRD Care (CEC) (large dialysis organization)
CEC for non-LDOs with 2-sided risk
Comprehensive Primary Care Plus (CPC+)
Adding more payers & practices (applications in 2017)
Oncology Care Model (OCM) announced to start in 2018
OCM – 2-sided risk (now starting in 2017)
Comprehensive Care for Joint Replacement Payment Models (originally planned for 2018)
 Vermont Medicare ACO Initiative
Advancing Care Coordination through Episode Payment Models Track 1
Cardiac Rehabilitation (CR) Incentive Payment Model
Source:

30. Comprehensive Primary Care Plus
Two primary care practice tracks, with different practice expectations and payment levels.
CPC+ is a five-year model:
Round 1 began in January 2017 and
Round 2 will begin in January 2018
Round 1 - CMS is partnering with 54 payers in the 14 CPC+ regions – practices recently announced
Round 2 – will include 10 new regions, new payers, new practices

31. ACP Resources to Help

32. ACP Resources for MACRA/QPP – and Value-Based Payment Overall
ACP’s MACRA webpage:
Quality Payment Advisor – (members only)
Top 10 Things to Do Today to Prepare – UPDATED!!!
Questions & Answers
Glossary of Terms
Recorded webinar and downloadable slides
4-Pager Handout
Links to Tools and Resources
*New* Member Forum for MACRA/QPP:
Questions:

33. ACP Resources for MACRA/QPP – and Value-Based Payment Overall
ACP’s Practice Transformation webpage:
ACP’s Support and Alignment Network Grant
High Value Care Resources
HVC Care Coordination Toolkit
Practice Redesign Support
Quality Improvement and Registries
Engaging Patients and Families

34. ACP Resources for MACRA – and Value-Based Payment Overall
Physician & Practice Timeline (text alerts–acptimeline to ) -
Will help you to know key deadlines and prepare for them!
ACP Practice Advisor® -
Interactive web tool to assist with quality improvement, practice transformation, and more
AmericanEHR Partners -
Data from physicians for physicians on EHR selection and usability, including MU certification

35. ACP Resources for MACRA – and Value-Based Payment Overall
MIPSwizard (coming soon) and ACP Genesis Registry
Registry software option to assist with reporting to CMS on PQRS and/or MU.
Submit 2016 PQRS data by February 28, 2017
AND, it will be designed to meet quality, improvement activities, and ACI requirements of MIPS
Questions:

36. Centers for Medicare and Medicaid Learning Collaborative
>$785 million
Prepare 140,000+ clinicians for value-based payments
↑health outcomes for millions of patients
↓unnecessary hospitalization, tests and procedures
Generate $1-$4 billion in savings
Build evidence base for practice transformation
Two Major Parts:
Practice Transformation Networks
Support and Alignment Networks
One of many but the most broad reaching and inclusive (small rural underserved practices)
>$785 million in funding from CMMI
Prepare 140,000+ clinicians for value-based payments
↑health outcomes for millions of patients
↓unnecessary hospitalization, tests and procedures
Generate $1-$4 billion in savings
Build evidence base of practice transformation

37. ACP Support and Alignment Network (SAN)
Recruit practices into networks (PTNs)
Enhance and promote ACP Practice Advisor®
Integrate patient/family partnership
Support and prepare clinicians
Build evidence base

38. ACP Practice Advisor® Improve process and structure of care
Spotlighted practices
Practice biopsy
Links to tools based on biopsy results
CME and MOC
New Modules
Avoid Unnecessary Testing
Improve Patient Access
Improve Care Coordination
Improve Medication Adherence
Patient Experience
Patient Engagement
Advanced Care Planning

39. What is the Genesis Registry?
National, “EHR-Ready”, CMS Qualified Clinical Data Registry (QCDR)
Supports continuous exchange of standard EHR
data
Pulls data to populate eMeasures aligned w/ EHR data readiness
64 eMeasures 2016 / All NQS Domains/ All MIPS measures
Benchmarks Across Multiple Specialties
User friendly and approved feedback reports to drive continuous practice improvement and high quality scores on measures
30,000+ Providers
21,000,000+ Patients

40. Genesis Registry Quality Reporting
Meets reporting requirements for MIPS composite score
Quality (60%)
Continuous Practice Improvement Activity (CPIA) ( 15%)
Advancing Care Information (ACI) (25%)
Gap analysis performance results and measure feedback
Comparisons by practice and
specialty to:
National benchmarks
Peer comparators

41. Electronic algorithm/ practice readiness assessment–practice characteristics, quality measurement experience, quality improvement activities, and readiness
Algorithm does NOT result in a single answer (of MIPS vs APMs)–but rather analyzes the challenges and opportunities with each option–and identifies gap areas (e.g., are you doing care coordination, population management, etc.)
The user identifies their pathway–and is then directed to tailored resources to help them succeed. ACP resources such as Practice Advisor®, Genesis Registry, AmericanEHR, etc.

42. Step-by-Step Guide to QPP Readiness:

43. Quality Payment Advisor

44. Maximize your MIPS reporting

45. Contact Information
member forum: webpage:
ACP can help you navigate upcoming payment changes