1. MACRA: State Hospital Association Strategies for Physician Engagement, Lessons Learned, and CMS Outreach Next Steps
Kimberly Harris-Salamone, PhD
Vice President, Health Information Technology
Howard Pitluk, MD, MPH, FACS
Vice President Medical Affairs and Chief Medical Officer
Health Services Advisory Group (HSAG)
Allied Hospital Associations Accounting & Financial Specialist (A2HA)
San Diego, California
March 28, 2017
*Medicare Access & CHIP Reauthorization Act of 2015
**Centers for Medicare & Medicaid Services

2. Agenda Introduce HSAG MACRA overview
Merit-Based Incentive Payment System (MIPS) overview
Alternative Payment Programs (APMs)
Lessons learned in physician outreach
HSAG’s Quality Improvement Organization (QIO) and Quality Payment Program (QPP) Small, Underserved, and Rural Support (SURS) contract activities
Discussion:
How can the physician-hospital relationship be leveraged to support and align quality-based payment systems?
What is the role of hospitals in supporting the development of APMs with an emphasis on physician engagement?

3. HSAG: Your Partner in Healthcare Quality
HSAG is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.
Committed to improving healthcare quality for more than 35 years
QIN-QIOs in every state/territory are united in a network under CMS.
The Medicare QIO Program is the largest federal program dedicated to improving healthcare quality at the community level.

4. HSAG’s QIN-QIO Territory
Nearly 25 percent of the nation’s Medicare beneficiaries
Drives quality by providing technical assistance, convening LANs, collecting and analyzing data for improvement
Works on initiatives to improve patient safety, reduce harm, improve clinical care
Engages healthcare providers, stakeholders, and beneficiaries to improve health quality, efficiency, and value.
HSAG is the Medicare QIN-QIO for Florida, California, Ohio, Arizona, and the U.S. Virgin Islands.

5. MACRA Overview
MACRA stands for the Medicare Access & CHIP* Reauthorization Act of 2015, bipartisan legislation signed into law on April 16, 2015.
* Children’s Health Insurance Program

6. Overview: What Does MACRA Do?
Repeals the Sustainable Growth Rate (SGR) Formula
Changes the way that Medicare pays clinicians and establishes a new framework to reward clinicians for value over volume
Streamlines multiple quality reporting programs into one new system: MIPS
Provides bonus payments for participation in eligible APMs

7. Overview: Medicare Reporting Under MACRA
MACRA streamlines these programs into the Quality Payment Program.
Physician Quality reporting System (PQRS)
Medicare EHR* Incentive Program
Value-based Modifier (VBM)
Quality Payment Program
MACRA streamlines these programs into one new quality reporting system, known as The Quality Payment Program.
CMS has just released a proposed rule on April 27th with recommendations for what this change would look like. We’re going to discuss some of the major components of the Quality Payment Program today.
In addition, [transition]
MIPS
APMs or
Source: The Centers for Medicare & Medicaid Services
* Electronic health record

8. Merit-based Incentive Payment System
MIPS Overview
Merit-based Incentive Payment System

9. Overview: How Much Can MIPS Adjust Payments?
Based on a final score, clinicians will receive +/- or neutral adjustments up to the percentages below.
+7%+9%
+4%+5%
Adjusted Medicare Part B payment to clinician
+/-
Maximum Adjustments
-4% -5%
-7%
So what does this payment adjustment look like? MIPS will adjust payments positively OR negatively based on a composite performance score for each clinician. The potential maximum adjustment percentage begins at +/- 4% in 2019 and will increase each year from 2019 to In 2022, the adjustment will be as high as +/- 9% [TRANSITION]
-9%
The potential maximum adjustment % will increase each year from 2019 to 2022
onward
MIPS
Source: The Centers for Medicare & Medicaid Services

10. Overview: When Does the Merit-Based Incentive Payment System Officially Begin?
Performance year
Submit
Feedback available
Adjustment
2017
Performance Year
March 31, 2018
Data Submission
January 1, 2019
Payment Adjustment
Feedback
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 percent incentive payment for participating in an Advanced APM, just send your 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 a 5 percent incentive payment in 2019.
Source: The Centers for Medicare & Medicaid Services

11. Overview: Who Is Eligible?
Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients a year.
Quick Tip:
Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function.
These clinicians include:
Physicians
Physician
Assistants
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetists
Source: The Centers for Medicare & Medicaid Services

12. Overview: What Will Determine My MIPS Score?**
The MIPS Final Score will factor in four weighted categories:
MIPS
Final Score
Advancing care Information
Quality
Cost
Improvement activities
Many of you are probably wondering what will make up the MIPS final score. The exact measures will be defined in rule-making, but broadly speaking, the score will factor in performance in 4 weighted categories:
quality, resource use, clinical practice improvement activities, and use of certified electronic health record (EHR) technology.
Most of these categories aren’t new to clinicians, who may have seen them before in programs such as PQRS.
*EHR = electronic health record
** Beginning in 2018
Source: The Centers for Medicare & Medicaid Services

13. 2017 Is a Transition Year
Special Options

14. Quality Payment Program: 2017 Pick Your Pace
Clinicians will pick their pace for the first year – both in how they participate and when.  We expect that everyone who is eligible for the Quality Payment Program will participate.
Test
Participation or
Partial
Participation or
Full Participation or
Advanced APMs

15. For 2017, There Are Four Options For Participating in MIPS
Not participating in the Quality Payment Program: If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment.
Test: If you submit a minimum amount of data to Medicare (for example, one quality measure or one improvement activity), you can avoid a downward payment adjustment.
Partial: If you submit 90 days of 2017 data to Medicare, you may earn neutral or small positive payment adjustment.
Full: If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment.
Source: The Centers for Medicare & Medicaid Services

16. Individual vs Group Reporting
Options
Individual
Group
1. Individual—Under an National Provider Identifier (NPI) number and Tax Identification Number (TIN) where they reassign benefits
2. As a Group
a) 2 or more clinicians (NPIs) who have reassigned their billing rights to a single TIN*
b) As an APM Entity
* If clinicians participate as a group, they are assessed as a group across all four MIPS performance categories.

17. Overview: How are MIPS Performance Categories Weighted?
Weights assigned to each category is based on a 1 to 100 point scale.
Transition Year Weights
Advancing care Information
Quality
Cost
Improvement activities
60% 0%
15%
25%
Note: These are defaults weights; the weights can be adjusted in certain circumstances.

18. Advanced Payment Models
APMs
Advanced Payment Models

19. Advanced APMs Are a Subset of APMs
APMs may offer practices opportunities that are not immediately able to take on the risk and requirements of Advanced APMs.
The QPP does not change how any particular APM rewards value.
APMs
Advanced APMs

20. Requirements for Advanced APMs
Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR
(2) requires participants to bear a more than nominal amount of financial risk
Financial Risk
Bearing financial risk means that the Advanced APM may do one or more of the following if actual expenditures exceed expected expenditures:
Withhold payment for services to the APM Entity and/or the APM Entity’s eligible clinicians
Reduce payment rates to the APM Entity and/or the APM Entity’s eligible clinicians
Require direct payments by the APM Entity to CMS.
Total Amount of Risk
The total amount of that risk must be equal to at least either:
8% of the average estimated total Medicare Parts A and B revenues of participating APM Entities; OR
3% of the expected expenditures for which an APM Entity is responsible under the APM.
Source: CMS

21. Advanced APMs in 2017
For the 2017 performance year, the following models are Advanced APMs:
Comprehensive End Stage Renal Disease Care Model (Two-Sided Risk Arrangements)
Comprehensive Primary Care Plus (CPC+)
Shared Savings Program Track 2
Shared Savings Program Track 3
Next Generation ACO Model
Oncology Care Model (Two-Sided Risk Arrangement)
Source: CMS

22. Physician outreach, concerns, and a path forward
Lessons Learned:
Physician outreach, concerns, and a path forward

23. Lessons Learned: Physician Outreach
Small (<15), Rural, and Underserved Providers
Are overwhelmed by the computer aspect of reporting
Many do not have functional EHRs
Participated in PQRS through Claims
Did not participate in Meaningful Use (MU)
Providers employed by hospitals are far less worried and frustrated by the QPP.
Many physicians still want to remain independent from large health systems.

24. Lessons Learned: Physician Outreach
Larger physician groups (>15)
Not as overwhelmed
Have EHR in place with IT support
Quality and IT departments help with reporting requirements of various tasks.
More likely to participate in APMs
Have access to the hospital’s EHR through contractual arrangements

25. Lessons Learned: Concerns
Reimbursement will suffer.
Losing autonomy in the decision-making process for their patients
Losing control over the care of their patients
Time is taken up by administrative tasks (EHR data entry, check boxes, reporting and communication requirements).

26. Lessons Learned: Path Forward
Assess where practices are with regard to health IT (ACI capabilities)
Prepared a 2017 transition year implementation plan for providers without ACI capabilities
Facilitate communication and transitions of care between hospitals and providers
Multiple, overlapping programs need coordination at the federal level: TCPI, PTNs, QIN QIOs, QPP-SURs, and HIINs.*
*Transforming Clinical Practice Initiative (TCPI); Practice Transformation network (PTN); Hospital Improvement Innovation Network (HIIN)

27. HSAG’s QIN-QIO, QPP-SUR, and HIIN Contract Activities
Care coordination
Assist providers (>15) in MIPS or APM reporting
Workflow analysis
Quality measure monitoring and reporting
Quality Improvement interventions
Patient engagement—patient portal
ACI facilitation
Antibiotic stewardship
Million Hearts® quality measures

28. HSAG’s QIN-QIO, QPP-SUR, and HIIN contract activities: Care Coordination
Assist providers (<15) in MIPS or APM reporting
Similar to large practices, but with more in-depth, direct technical assistance
Just-in-time technical assistance
Regularly scheduled technical assistance
Assist in picking measures for MIPS or APM submission

29. HSAG’s QIN-QIO, QPP-SUR, and HIIN contract activities: HIIN Details
HSAG HIIN
HIINs are across state borders, with no specific geographic boundaries.
Help engage hospitals and hospital associations in hospital associated infections (HAI) prevention and readmission reduction
20 percent reduction in HAIs by 2021
12 percent readmission reduction by 2021

30. Resources
Providers who want to transform their practice so they can be part of an APM
Contact your local Practice Transformation Network (PTN)
Providers who want help with MIPS and APM reporting
More than 15 providers in a practice, call your QIN-QIO
15 or fewer providers in a practice, call your QPP-SURs
Coordinate with the HIINs to reduce HAIs and readmissions.

31. Engage Physicians Support providers in the development of APMs.
Role of hospitals in the development of APMs
Facilitate communication between providers and patients
Ensure that the hospital’s secure direct addresses are provided to referring providers.
Measure readmission reduction and care coordination in APM.

32. Discussion
How can hospital associations support physicians in supporting these new models?
Guidance on development of APMs that streamlines the various reporting requirements of the QPP and quality-based payment for hospitals
Guidance on how to transition an APM into an Advanced APM

33. Thank you! Kimberly Harris-Salamone, PhD|
Howard Pitluk, MD, MPH, FACS |

34. CMS Disclaimer
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-D