1. Medicare Access and Chip Reauthorization Act of 2015 (MACRA)
Paul A. Martin DO FACOFP dist.
CMO/VP
Grandview/Southview Medical Centers

2. Which current physician payment adjustment will sunset after December 31, 2018?
Medicare Shared Savings Program (MSSP)
Comprehensive Primary Care Initiative (CPCI)
EHR Meaningful Use program (MU)
Comprehensive Primary Care Plus (CPC+) 10

3. By not participating in the MIPS Quality Payment Program in the 2017 transition year, what negative payment adjustment would eligible physicians incur?
Negative .5% payment adjustment
Negative 4% payment adjustment
Negative 1% payment adjustment
Negative 9% payment adjustment 10

4. MACRA Background

5. Medicare Payment Prior to MACRA
Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value.
The Sustainable Growth Rate (SGR)
Established in 1997 to control the cost of Medicare payments to physicians
> IF
Overall physician costs
Target Medicare expenditures
Physician payments cut across the board
Each year, Congress passed temporary “doc fixes” to avert cuts (no fix in would have meant a 21% cut in Medicare payments to clinicians)

6. MACRA Background
Goal – Move physician payment from volume-based to value-based
Signed into law April 2015
Supported by organized medicine
Passed with over 90 percent support in both the House and Senate
Rare example of bi-partisan legislation
Strong indication Medicare value-based payment is here to stay
Value Driven. Health Care. Solutions. 6 6

7. Impact on the MPFS Instead of a 21 percent payment cut
No increase in MPFS (January – June 2015)
Increase 0.5 percent (July 2015 – December 2015)
Increase 0.5 percent per year (2016 – 2019)
No increase (January 2020 – December 2025)
2026 and beyond:
APM participants – percent annual increase
MIPS participants – percent annual increase
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8. Impact on Current Medicare Payment Adjustments
Sunsets current payment adjustments after December 31, 2018
Physician Quality Reporting System (PQRS)
EHR Meaningful Use (MU) program
Value-based Payment Modifier (VBM)
Some features of PQRS, MU, and VBM are part of the new MIPS criteria
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9. MACRA created the Quality Payment Program
The Quality Payment Program policy will:
Reform Medicare Physician Fee Schedule payments for more than 600,000 clinicians
Improve care across the entire health care delivery system
Clinicians have two tracks to choose from:
The Merit-based Incentive Payment System (MIPS)
If you decide to participate in traditional (fee-for-service) Medicare, you may earn a performance-based payment adjustment through MIPS.
Advanced Alternate Payment Models (APMs)
If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model.
OOR

10. Quality Payment Program Strategic Goals
Improve beneficiary outcomes
Enhance clinician experience
Increase adoption of Advanced APMs
Maximize participation
Improve data and information sharing
Ensure operational excellence in program implementation
For additional information on the Quality Payment Program, please visit QPP.CMS.GOV

11. Here is a graphical representation of the MACRA path you will be venturing on.11 11

12. Alternative Payment Models (APMS)

13. What are APMs?
Payment approachs that incent clinicians to provide high- quality, cost-effective care
Examples:
Medicare Shared Savings Program (MSSP)
CMS Innovation Center Models
CMS Demonstration Programs
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14. 2017 Advanced APMs MSSP Track 2 MSSP Track 3
Comprehensive Primary Care Plus (CPC+)
Next Generation ACO
Comprehensive ESRD Care Model
Two sided
Oncology Care Model-Two sided
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15. Advanced APMs Eligibility Criteria
At least half of the clinicians must use certified electronic health record technology (CEHRT)
Base payment on quality measures comparable to MIPS quality measures
Be a medical home model or require participants to bear more than a nominal amount of financial risk
Only medical home that qualifies for Advanced APM (AAPM) is CPC+
Value Driven. Health Care. Solutions. 15 15

16. Payment and Patient Thresholds for AAPMs
Participants earn an annual lump sum payment of 5 percent of the MPFS from if they receive at least 25 percent of their Medicare Part B payments OR see at least 20 percent of their Medicare patients through an AAPM
Participation requirements increase in 2019 and 2021
Performance Year
2017
2018
2019
2020
2021
2022 and later
Percentage of Medicare payments through an Advanced APM
Percentage of Medicare patients through an Advanced APM
25%
25%
50%
50%
75%
75%
20%
20%
35%
35%
50%
50%
Value Driven. Health Care. Solutions. 16 16

17. Merit-Based Incentive Payment System (MIPS)

18. MIPS Overview First MIPS performance year-2017
First MIPS payment year-2019
Combines three current Medicare performance incentive programs
PQRS MU
VBM
New measure: Improvement activities
Provides both upside and downside adjustments to the MPFS
Maximum adjustments:
2019: 4 percent
2020: 5 percent
2021: 7 percent
2022 & beyond: 9 percent
4x% 5x% 7x% 9x%
Threshold
-4x% -5x% -7x% -9x%
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19. MIPS Eligible Clinicians (ECs)
Physicians (MDs and DOs)
Podiatrists
Optometrists
Chiropractors
MIPS applies to individual ECs and group practices
Dentists
Physician Assistants
Nurse Practitioners
Clinical Nurse Specialists
Certified Registered Nurse Anesthetists
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20. Who is excluded from MIPS?
Clinicians who are:
Significantly participating in Advanced APMs
Newly-enrolled in Medicare
Below the low-volume threshold
Medicare Part B allowed charges less than or equal to $30,000 a year OR
See 100 or fewer Medicare Part B patients a year
Enrolled in Medicare for the first time during the performance period (exempt until following performance year)
Receive 25% of your Medicare payments OR
See 20% of your Medicare patients through an Advanced APM

21. When Does the Merit-based Incentive Payment System Officially Begin?
submit
adjustment
Performance year
Feedback available
2017
Performance Year
March 31, 2018
Data Submission
Feedback
January 1, 2019
Payment Adjustment
Performance: The first performance period opens January 1, 2017 and closes December 31, During 2017, you will record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can provide care during the year through that model.
Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, In order to earn the 5% incentive payment for participating in an Advanced APM, just send quality data through your Advanced APM. 
Feedback: Medicare gives you feedback about your performance after you send your data. 
Payment: You may earn a positive MIPS payment adjustment beginning January 1, 2019 if you submit 2017 data by March 31, If you participate in an Advanced APM in 2017, then you could earn 5% incentive payment in 2019.

22. Reporting Individual – defined as a single NPI tied to a single TIN
CEHR
Registry
Qualified clinical data registry
Group – must share a common TIN
CMS web interface – must register by June 30, 2017
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23. What is the Merit-based Incentive Payment System?
Performance Categories
Quality
Cost
Improvement Activities
Advancing Care Information
Moves Medicare Part B clinicians to a performance value-based payment system
Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice
Reporting standards align with Advanced APMs wherever possible

24. MIPS Category Measures Over Time
A score of developed for each eligible clinician based on performance in four categories:
Quality
Advancing Care Information
Improvement Activities
Cost
Replaces PQRS
Replaces MU
New (PCMH)
Replaces VBM
2017
60%
25%
15% 0%
2018
50%
10%
2019+
30%
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25. Flexible Start for Clinicians: Pick Your Pace
MIPS
Participate in an Advanced Alternative Payment Model
Test Pace
Partial Year
Full Year
Some practices may choose to participate in an Advanced Alternative Payment Model in 2017
Submit some data after January 1, 2017
Neutral or small payment adjustment
Report for 90-day period after January 1, 2017
Small positive payment adjustment
Fully participate starting January 1, 2017
Modest positive payment adjustment
Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment.

26. MIPS: Choosing the Test Pace for 2017
Submit minimum amount of 2017 data to Medicare
Avoid a downward adjustment
You Have Asked: “What is a minimum amount of data?” OR OR
4 or 5
Required Advancing Care Information Measures 1
Quality
Measure
1 Improvement Activity

27. MIPS: Partial Participation for 2017
Submit 90 days of 2017 data to Medicare
May earn a positive payment adjustment
If you’re not ready on January 1, you can start anytime between January 1 and October 2
Need to send performance data by March 31, 2018

28. MIPS: Full Participation for 2017
Submit a full year of 2017 data to Medicare
May earn a positive payment adjustment
Best way to earn largest payment adjustment is to submit data on all MIPS performance categories

29. Quality – 60% 60
Points
Select 6 measures to report on from about 300 quality measures
Or choose to report on a set of specialty specific measures
Group practices using the web interface will report on 15 set measures
Must report for at least 90 days to be eligible for a positive adjustment
Physicians receive points for each measure based on performance against a benchmark
60 possible points
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30. MIPS Scoring for Quality (60% of Final Score)
Bonus Points
Clinicians receive bonus points for either of the following:
Submitting an additional high-priority measure
Using CEHRT to submit measures to registries or CMS 1 2
1 bonus point for submitting electronically end-to-end
2 bonus points for each additional outcome and patient experience measure
1 bonus point for each additional high-priority measure

31. MIPS Scoring for Quality (60% of Final Score in Transition Year)
Points earned on required 6 quality measures
Any bonus points
Total Quality Performance Category
Score + =
Maximum number of points*
Quick Tip: Maximum score cannot exceed 100% *Maximum number of points = # of required measures x 10

32. Quality: Requirements for the Transition Year
Test Pace means...
Submitting a minimum amount of data for one measure set for 2017.
Partial and Full Participation means…
Submitting at least six quality measures, including at least one outcome measures, for a full year.
For a full list of measures, please visit qpp.cms.gov

33. MIPS Performance Category: Advancing Care Information
Promotes patient engagement and the electronic exchange of information using certified EHR technology
Ends and replaces the Medicare EHR Incentive Program for eligible professionals (not for Medicaid or hospitals)
Greater flexibility in choosing measures
In 2017, there are 2 measure sets for reporting based on EHR edition:
2017 Advancing Care Information Transition Objectives and Measures
Advancing Care Information Objectives and Measures

34. MIPS Performance Category: Advancing Care Information
Advancing Care Information Objectives and Measures:
Base Score Required Measures
2017 Advancing Care Information Transition Objectives and Measures:
Base Score Required Measures
Objective
Measure
Protect Patient Health Information
Security Risk Analysis
Electronic Prescribing
e-Prescribing
Patient Electronic Access
Provide Patient Access
Health Information Exchange
Send a Summary of Care
Request/Accept a Summary of Care
Objective
Measure
Protect Patient Health Information
Security Risk Analysis
Electronic Prescribing
e-Prescribing
Patient Electronic Access
Provide Patient Access
Health Information Exchange

35. MIPS Performance Category: Advancing Care Information
Advancing Care Information Objectives and Measures:
Performance Score Measures
2017 Advancing Care Information Transition Objectives and Measures
Performance Score Measures
Objective
Measure
Patient Electronic Access
Provide Patient Access*
Patient-Specific Education
Coordination of Care through Patient Engagement
View, Download and Transmit (VDT)
Secure Messaging
Patient-Generated Health Data
Health Information Exchange
Send a Summary of Care*
Request/Accept a Summary of Care*
Clinical Information Reconciliation
Public Health and Clinical Data Registry Reporting
Immunization Registry Reporting
Objective
Measure
Patient Electronic Access
Provide Patient Access*
View, Download and Transmit (VDT)
Patient-Specific Education
Secure Messaging
Health Information Exchange
Health Information Exchange*
Medication Reconciliation
Public Health Reporting
Immunization Registry Reporting

36. Advancing Care Information Requirements for the Transition Year
Test pace means…
Partial and full participation means…
Submitting 4 or 5 base score measures
Depends on use of 2014 or 2015 Edition
Submitting more than the base score in year 1
Reporting all required measures in the base score to earn any credit in the advancing care information performance category
For a full list of measures, please visit qpp.cms.gov

37. MIPS Scoring for Advancing Care Information Bonus Score
for reporting on any of these Public Health and Clinical Data Registry Reporting measures:
Syndromic Surveillance Reporting
Specialized Registry Reporting (14)
Electronic Case Reporting (15)
Public Health Registry Reporting (15)
Clinical Data Registry Reporting(15) 5%
BONUS
for using CEHRT to report certain Improvement Activities
10%
BONUS

38. MIPS Scoring for Advancing Care Information (25% of Final Score)
Advancing Care Information Performance Category Score =
Base Score
Performance Score
Bonus Score
Quick Tip: Maximum score will be capped at 100%

39. Advancing Care Information – 25%50 90 15
Required base score (50)
Performance score (up to 90)
Bonus score (up to 15)
Security risk analysis
e-Prescribing
Provide patient access
Send summary of care
Request/accept summary of care
Submit nine measures for 90 days for performance credit
5 percent per measure for public health/clinical data registry reporting
10 percent for improvement activity alignment
Category score includes:
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40. MIPS Performance Category: Improvement Activities
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 (4 activities)
Population Management (16)
3. Care Coordination (14)
4. Beneficiary Engagement (23)
5. Patient Safety and Practice Assessment (21)
Participation in an APM
Achieving Health Equity (4)
8. Integrating Behavioral and Mental Health (8)
9. Emergency Preparedness and Response (2)

41. Examples of Improvement Activities
After hours access to care
Same day appointments
Extended office hours
Test tracking system
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42. Improvement Activity Requirements for the Transition Year
Partial and full participation means…
Choosing 1 of the following combinations:
2 high-weighted activities
1 high-weighted activity and 2 medium-weighted activities
At least 4 medium-weighted activities
Test Pace means…
Submitting 1 improvement activity
Activity can be high weight or medium weight

43. Improvement Activities – 15%
Full credit for clinicians in CPC+, in a certified PCMH, or in similar specialist practice
PCMH certifications for MIPS include: a national program, a regional or state program, a private payer, or other body that certifies at least 500 practices
Participation in the Transforming Clinical Practice Initiative grant is a high-weighted activity earning 20 points
40 possible points
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44. Cost – 0% Clinicians are not required to submit cost data to CMS
CMS assesses clinicians based on Medicare claims data
CMS compares resources used to treat similar care episodes and clinical condition groups across practices
Cost measures adjusted for geographic payment rates and beneficiary risk factors
ECs earn a maximum of 10 points per episode cost measure
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45. MIPS Final Score for 2017 Performance Year
Payment Adjustment
Positive adjustment
Eligible for exceptional performance bonus – minimum of additional 0.5%
4-69 points
Not eligible for exceptional performance bonus
3 points
Neutral payment adjustment
0 points
Negative payment adjustment of -4%
0 points = does not participate
MIPS 2017 performance year and 2019 payment year:
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46. Additional Incentive Payments and Support
For , maximum of $500 million per year in additional incentive payments may be available to distribute to ECs who have “exceptional performance”
Final score of 70 or higher qualifies for an additional payment in 2017 (2019 payment year)
Not budget neutral
Technical support for small and rural practices
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47. Performance Adjustments After 2017
CMS will publish a “performance threshold” score at the start of each year
Each EC’s final score compared to the performance threshold score
No MIPS adjustment made to ECs with a score exactly at threshold
ECs with a score below threshold receive a negative payment adjustment
ECs with a score above threshold receive a positive payment adjustment factor
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48. MIPS Adjustments to the MPFS
Final score based on:
Quality measures
Cost
Improvement activities
Advancing care information
THRESHOLD 0% 0%
Final Score
100%
-9%
-7%
-5%
-4%
4x%
5x%
7x%
9x%
2022+
2021
2020
2019
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49. Budget Neutrality
>> Amounts accrued from penalties assessed against ECs with scores below the threshold will fund payments for ECs with scores above the threshold
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50. (MIPS) APM Scoring Standard
Quality
Measures report through APM
Cost
0% Indefinitely
ACI
Must report – same as all eligible physicians
Improvement Activities
Automatic 100% (annual review of model)
*CMS will calculate the final score for MIPS APM at the APM Entity level.
MIPS APMs are MSSP (All Tracks), Next Gen ACO and CPC+
All advanced APMs could be a MIPS APM but not all MIPS APM can’t be a advanced APM
Still get credit –but fall back into MIPS –
Different Scoring Mechanism within MIPS
Use Measure reported to APM models as Quality, Cost is zero percent now and in the future
2017 will get 100% in IA - Will review model annually against improvement activities and score – possibly to attest to get higher score
Only required to report ACI – will aggregate all score ups to APM entity level 50 50

51. Physician Compare Website
MIPS composite scores and individual performance category scores available on the CMS Physician Compare website
Patients can see health care providers rated on a scale of 0 to 100 and how physician compares to peers nationally
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52. paulfcc@aol.com pmartin@ketteringhealth.org
Thank You!!! Questions???