1. What Ob-gyns Need to Know about the MACRA Quality Payment Program
ACOG Grand Rounds Slide Deck

2. What Is MACRA?
The Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act of 2015 (MACRA) replaced the faulty sustainable growth rate (SGR).​
MACRA passed with near-unanimous bipartisan support in both the House and the Senate.​
The intent of the law is to move physicians and other providers to deliver care that is reimbursed through an alternative payment model (APM) and ensure that payments are tied to quality
Last updated 2/7/2017.

3. Quality Payment Program
CMS has renamed MACRA the Quality Payment Program (QPP).  ​
The final rule was released on October 14 and is more than 2,000 pages.​
ACOG submitted comments in response to the proposed rule and provided suggestions of how CMS can improve its proposal.
Some of ACOG’s recommendations have been incorporated into the final version of the QPP.
Last updated 2/7/2017.

4. Two Different Tracks Merit-based Incentive Payment System (MIPS)
Sunsets current Meaningful Use (MU), Value-based Payment Modifier (VM), and Physician Quality Reporting System (PQRS) programs at the end of 2018, rolling requirements into a single program.​
Adjusts Medicare payments beginning in 2019.
Advanced Alternative Payment Models (APMs)
Requires significant share of provider revenue or patients seen in APM with two- sided risk, quality measurement, and use of certified EHR technology (CEHRT) or a federal medical home model demonstration​.
Provides financial incentives (5% annual bonus in ) and exemption from MIPS requirements.
Last updated 2/7/2017.

5. Key Changes in the Final Rule
Transition period for MIPS
Different low-volume threshold for individuals and groups: ≤$30,000 in Medicare Part B allowed charges or ≤100 Medicare patients
No cost measurement in the first performance period
Fewer required improvement activities
Fewer required measures in the Advancing Care Information category
Shortens reporting period for Advancing Care Information to 90 days for future reporting periods
Allows obstetrics and gynecology practices to be considered medical homes in future models under the Advanced APM track
Last updated 2/7/2017.

6. Pick Your Pace: What to Expect in MACRA’s 2017 Transitional Year
Source: Centers for Medicare & Medicaid Services’ final rule for implementing Quality Payment Program under the Medicare Access and CHIP Reauthorization Act of 2015
By Janie Boschma, POLITICO Pro DataPoint
2 3 1
Submit at least 90 days of data
Earn at least a neutral, if not a positive, adjustment for submitting three months of data and meeting requirements for any one of three categories (quality, improvement activities, and advancing care information).
Submit nothing
Receive the full
4 percent negative adjustment.
Submit something
Avoid a negative payment adjustment for submitting partial 2017 data, such as complete data for one quality measure or one improvement activity.
MIPS submission options for transition year:
2017
Submit a full year of data
Earn a positive adjustment of up to 4 percent — and potentially an additional
positive adjustment depending on performance — for submitting a full year’s data
in all three categories.
Receive payment adjustment for performance on or after Jan. 1, (and begin collecting 2019 data)
Dec. 31, 2017
First performance period ends
March 31, Deadline to submit MIPS data
Oct. 2, 2017
Last day to begin MIPS data collection
Jan. 1, 2018
Begin collecting MIPS data
2017: CMS outlines parameters for 2018 period and payments for 2020 and after
KEY DATES
Jan. 1, 2017
First day to begin collecting MIPS data
CMS provides feedback on 2017 performances TR A
NSI
TIO N
YEA R
Last updated 2/7/2017.

7. MIPS
Merit-based Incentive Payment System
Last updated 2/7/2017.

8. Merit-based Incentive Payment System (MIPS) Summary
Sunsets current Meaningful Use (MU), Value-based Payment Modifier (VM), and Physician Quality Reporting System (PQRS) programs at the end of 2018, rolling requirements into a single program.
Adjusts Medicare payments based on performance on a single budget- neutral payment beginning in 2019.
Applies to physicians, NPs, clinical nurse specialists, physician assistants, and certified nurse anesthetists.
Providers that meet a low-volume threshold or who are new to billing Medicare do not have to participate.
Last updated 2/7/2017.

9. Low-volume Threshold
Low-volume threshold: ≤100 Medicare patients or ≤$30,000 Medicare Part B allowed charges
Examples
If a practice sees 90 Medicare patients and submits $50,000 in allowed Medicare charges, it is exempt from MIPS.
If a practice sees 120 Medicare patients and submits $28,000 in allowed Medicare charges, it is exempt from MIPS.
Last updated 2/7/2017.

10. MIPS Performance Categories
20%
40%
60%
80%
2019
2020
2021+
MIPS Score Components
50%
30%
10%
25%
15%
Quality Measures
Cost
Improvement Activities
Advancing Care
Information
MIPS is made up of 4 performance categories
Quality
Cost
Improvement Activities
Advancing Care Information
The categories’ weight will change during the first 3 years of the program to give less weight to quality scores and more weight to cost over time.
Last updated 2/7/2017.

11. Quality Performance Category
The quality category accounts for 60 percent of the MIPS score in the first year.
Clinicians choose 6 measures to report.
For groups with 16 clinicians or more, CMS will automatically calculate all-cause hospital readmission based on claims.
When selecting the 6 quality measures, you must choose 1 outcome measure (if available) or another high-priority quality measure.
If fewer than 6 measures apply to the individual MIPS eligible clinician or group, you will only be required to report on each measure that is applicable.
Last updated 2/7/2017.

12. Cost Performance Category
The cost category will not be scored in the first year.
In future performance periods, CMS calculates scores based on Medicare claims, meaning there are no additional reporting requirements for clinicians under this category.
Measures will be based on total per capita cost, total spending per Medicare beneficiary, and episode groups.
For the 2017 performance period, physicians will receive feedback on their performance in this category, but no score.
Last updated 2/7/2017.

13. Advancing Care Information Performance Category – Base Score
The base score accounts for 50 points of the total Advancing Care Information category score.
To receive the base score, clinicians must provide the numerator/denominator or yes/no for each objective and measure.
Last updated 2/7/2017.

14. Advancing Care Information Performance Category – Base Score – cont’d
For ob-gyns using an EHR certified to the 2015 standard, there are 5 objectives and associated measures:
Security Risk Analysis
Electronic Prescribing
Provide Patient Access
Send a Summary of Care Record
Request/Accept a Summary of Care
Last updated 2/7/2017.

15. Advancing Care Information Performance Category – Performance Score
Accounts for up to 90 points of the total Advancing Care Information score.
Select measures that best fit your practice from these objectives:
Provide Patient Access
Patient-specific Education
View, Download, and Transmit (VDT)
Secure Messaging
Patient-generated Health Data
Send a Summary of Care
Request/Accept a Summary of Care
Clinical Information Reconciliation
Immunization Registry Reporting
Last updated 2/7/2017.

16. Advancing Care Information Performance Category – Combining Base and Performance Scores
The clinicians’ base score, performance score, and bonus points (if applicable) are added together for a total of up to 155 points.
If clinicians earn 100 points or more then they receive the full 25 points in the Advancing Care Information performance category.
If clinicians earn less than 100 points, their overall score in MIPS declines proportionately.
Last updated 2/7/2017.

17. Improvement Activities Performance Category
Accounts for 15 percent of the MIPS score in the first year.
Clinicians will have more than 90 options to choose from in the following categories:
Expanded practice access
Beneficiary engagement
Achieving health equity
Population management
Patient safety and practice assessment
Emergency preparedness and response
Care coordination
Participation in an APM, including a medical home model
Integrated behavioral and mental health
Last updated 2/7/2017.

18. Improvement Activities Performance Category – cont’d
The maximum total points in this category will be 40 points. There are different weights for the activities.
Highly-weighted activities are worth 20 points
Other activities are worth 10 points.
Last updated 2/7/2017.

19. Improvement Activities Performance Category – cont’d
MACRA statute requires that clinicians receive credit toward scores in this category for participating in Alternative Payment Models (APMs) and Patient-Centered Medical Homes (PCMH).
APMs do not have to meet the same standard as an Advanced APM to get credit under this performance category.
Clinicians participating in an accredited PCMH will get full credit under this category and do not have to attest to any other activities.
Last updated 2/7/2017.

20. Reporting Mechanisms for MIPS
Physicians who report as individuals can report quality measures through claims.
Physicians can report data via third parties for the quality, advancing care information, and improvement activities performance categories:
Qualified Registries
Qualified Clinical Data Registries (QCDRs)
Electronic health records (EHRs)
Certified survey vendors
Within each performance category, you must use the same reporting mechanism, but you can use different mechanisms for different categories.
Last updated 2/7/2017.

21. MIPS Payment Adjustments
In the first year, adjustments are calculated so that:
Non-exempt ob-gyns and other providers who do not submit data will be subject to a negative penalty of 4 percent.
Non-exempt ob-gyns who submit at least one measure in quality or improvement activity or the 4/5 required advancing care information measures will not be subject to any negative adjustments.
Non-exempt providers who submit at least 90 consecutive days of data on more than one measure in the quality or improvement activities or more than the required advancing care information measures may be eligible for a small positive payment adjustment.
Non-exempt providers who submit a full year of data on quality, advancing care information, and improvement activities may be eligible for a positive payment adjustment of up to 4 percent. Exceptional performers may be eligible for even higher payment adjustments.
Last updated 2/7/2017.

22. MIPS Payment Adjustments – cont’d
Currently, the first performance year will be calendar year (CY) 2017 and the first payment adjustment year will be CY2019.
In the first five payment years of the program, $500 million is available for performance bonuses that are exempt from budget neutrality for exceptional performance.
Last updated 2/7/2017.

23. Advanced APMs Advanced Alternative Payment Models
Last updated 2/7/2017.

24. Advanced APM Bonus Rewards Participation in New Models
Requires significant share of provider revenue in APM with two-sided risk and quality measurement or a federal medical home model demonstration
Provides financial incentives (5% annual bonus in ) and exemption from MIPS requirements
Includes partial qualifying mechanism that allows providers that fall short of APM requirements to report MIPS measures and receive corresponding incentives or to decline to participate in MIPS
Last updated 2/7/2017.

25. What Counts As an Advanced APM?
Model approved by the Physician-Focused Payment Models Technical Advisory Committee (PTAC)
Model developed by the Centers for Medicare and Medicaid Innovation (CMMI)
Medicare Shared Savings Accountable Care Organization (ACO)
Demonstration under the Medicare Health Care Quality Demonstration Program
Any demonstration required by Federal law
Last updated 2/7/2017.

26. What APMs Currently Exist That Qualify As Advanced?
Comprehensive End-stage Renal Disease Care Model for Large Dialysis Organizations with 2-sided Risk
Comprehensive Primary Care Plus
Medicare Shared Savings Program – Track 2 and Track 3
Next Generation ACO Model
Oncology Care Model with 2-sided Risk
Last updated 2/7/2017.

27. Advanced APM Standards
Bear a certain amount of financial risk.
An Advanced APM will meet the financial risk requirement if CMS withholds payment, reduces rates, or requires the entity to make payments to CMS if its actual expenditures exceed expected expenditures.
The amount of risk that an APM Entity potentially owes to CMS must be at least equal to:
For performance periods 2017 and 2018, 8 percent of the estimated average total Medicare Part A and B revenues of participating APM Entities, or
3 percent of the expected expenditures for which an APM Entity is responsible under the APM.
Base payments on quality measures comparable to those used in the MIPS quality performance category.
Require participants to use certified EHR technology (CEHRT).
Last updated 2/7/2017.

28. Medical Home Model Standards
Medical home models that have been expanded under the Innovation Center authority qualify as Advanced APMs regardless of whether they meet the financial risk criteria.
Medical home models must focus on primary care and accountability for empaneled patients across the continuum of care.
Advanced APM that are medical homes have financial risk standards that are somewhat less stringent.
Last updated 2/7/2017.

29. Additional Requirements
To qualify for incentive payments, clinicians will have to receive enough of their payments or see enough of their patients through Advanced APMs.
In 2019 and 2020, the participation requirements for Advanced APMs are only for Medicare payments or patients.
Starting in 2021, the participation requirements for Advanced APMs may include non- Medicare payers and patients, including those with Medicare Advantage plans.
Payment Year
2019
2020
2021
2022
2023
2024 and beyond
Percentage of Payments
25%
50%
75%
Percentage of Patients
20%
35%
Last updated 2/7/2017.

30. Looking Forward What ACOG Is Doing to Help Fellows
Last updated 2/7/2017.

31. What ACOG Is Doing to Help Fellows Get Ready
On ACOG’s MACRA QPP webpages you can find a range of materials on requirements for ob-gyns and how Medicare payment has changed under MACRA. Go to
Attend our in-person workshops in Tampa, Albuquerque, or Atlanta. Check out the Education and Events section for more details and registration.
If you have questions, you can
You can also visit CMS’ webpage
Last updated 2/7/2017.

32. What ACOG Is Doing to Help Fellows Get Ready
We are continuing to partner with other medical associations to improve and simplify these regulations
We have convened taskforces to work on creating alternative payment models for maternity care and gynecologic procedures
We are working to define quality measures that matter - including meaningful patient-reported outcomes so that participation in the QPP will enhance and improve our practices.
Last updated 2/7/2017.

33. Last updated 2/7/2017.