Quality Payment Program

Quality Payment Program
November 7, 2016

Topics What is the Quality Payment Program?
Who participates in the Quality Payment Program? How does the Quality Payment Program work? What is the Merit-based Incentive Payment System (MIPS) What are Advanced Alternative Payment Models (APMs) Where can I go to learn more?

What is the Quality Payment Program?

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 2015 would have meant a 21% cut in Medicare payments to clinicians)

The Quality Payment Program
The Quality Payment Program policy will reform Medicare Part B payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system. Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population. Two tracks to choose from:

Who participates in the Quality Payment Program?

Who participates in the Quality Payment Program?
Medicare Part B clinicians billing more $30,000 a year and providing care for more than 100 Medicare patients a year. These clinicians include: Physicians Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse Anesthetists Years 1 and 2

Who is excluded from the Quality Payment Program?
Newly-enrolled Medicare clinicians Clinicians who enroll in Medicare for the first time during a performance period are exempt from reporting on measures and activities for MIPS until the following performance year. Clinicians below the low-volume threshold Medicare Part B allowed charges less than or equal to $30,000 OR 100 or fewer Medicare Part B patients Clinicians significantly participating in Advanced APMs

How does the Quality Payment Program work?

Transition Year— Pick Your Pace
MIPS Test Pace Partial Year Full Year 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 Clinicians: Should assess readiness and decide how and when they’ll participate. Can choose to participate in 2017 as a test year by submitting a minimum amount of 2017 data to Medicare. Can choose to partially participate by submitting 90 days of 2017 data to Medicare. With this option, you may earn a small bonus. Can choose full participation by submitting a full year of data to Medicare. With this option, you may earn a moderate bonus. **Note: Not participating in the Quality Payment Program: If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment. MIPS Pick Your Pace for Participation Options: Test Pace An effort to help clinicians “experiment” with the program Preparing clinicians for broader reporting in 2018 and 2019 Clinicians must submit some data after January 1, 2017 What does “some” data mean? Eligible for a neutral or small payment adjustment Partial Year Clinicians report for a period of 90-days anytime after January 1, 2017 October 2, 2017 is the last day to begin reporting for the 90-day option Eligible for a small positive payment adjustment Full Year Option is for clinicians/practices that are prepared to fully participate starting on January 1, 2017 Eligible for a modest positive payment adjustment Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment.

Choosing to Test for 2017 If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity), you can avoid a downward adjustment For Test Participation: Submit 1 quality measure or 1 Improvement activity or 5 advancing care information measures

Partial Participation for 2017
If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment. That means if you’re not ready on January 1, you can choose to start anytime between January 1 and October 2, Whenever you choose to start, you'll need to send in performance data by March 31, 2018. For Partial Participation: Clinicians can choose to report to MIPS for a period of time less than the full year performance period 2017 but for a full 90-day period at a minimum. They must report more than one quality measure, more than one improvement activity, or more than the 5 required measures in the advancing care information performance category in order to avoid a negative MIPS payment adjustment and to possibly receive a positive MIPS payment adjustment.

Full Participation for 2017
If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment. The best way to earn the largest positive adjustment is to participate fully in the program by submitting information in all the MIPS performance categories. Key Takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted. For Full participation: Clinicians should report to MIPS for a full 90-day period or, ideally, the full year, and maximize the MIPS eligible clinician’s chances to qualify for a positive adjustment. In addition, MIPS eligible clinicians who are exceptional performers in MIPS, as shown by the practice information that they submit, are eligible for an additional positive adjustment for each year of the first 6 years of the program. Full participation in the MIPS would mean that clinicians should, at least, meet the following criteria: Report 6 Quality Measures Report 4 medium weighted or 2 high-weighted improvement activities Report 5 advancing care information measures

The Merit-based Incentive Payment System (MIPS)

The Merit-based Incentive Program
One path of the Quality Payment Program that streamlines 3 legacy reporting programs (PQRS, Value Modifier and the Medicare EHR Incentive Program) Moves Medicare Part B clinicians to a performance-based payment system MIPS provides clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance There are four MIPS performance categories: Quality, Advancing Care Information, Improvement Activities, and Cost.

MIPS Performance Category: Quality
Category Requirements Replaces PQRS and Quality Portion of the Value Modifier 60% of final score Select 6 of about 300 quality measures (minimum of 90 days); 1 must be: Outcome measure OR High-priority measure – defined as outcome measure, appropriate use measure, patient experience, patient safety, or care coordination May also select specialty-specific set of measures Readmission measure for group submissions that have > 16 clinicians and a sufficient number of cases (no requirement to submit) Different requirements for groups reporting CMS Web Interface or those in MIPS- APMs The Quality performance category, worth 60%, was created to add clinician flexibility to focus on the measures that are truly important to beneficiaries. Each eligible clinician will select six measures, which is a current decrease from what is required under PQRS. Additionally, under PQRS, clinicians are required to report on nine measures that cover three national quality strategy domains. Within MIPS, there is no requirement that clinicians would have to choose measures that cover a certain number of domains; rather, they are encouraged to choose measures that span as many domains as possible. Of those six measures, one must an outcome measure. If an outcome measure is not available, clinicians would need to select from another high priority measure. A high priority measure is defined as an outcome measure, appropriate use measure, patient experience, patient safety, or care coordination measure. Clinicians can either select from the approximately 300 measures that will be available, or select a specialty specific set of measures that the CMS created together with multiple specialty societies. There are three additional population health measures that are automatically calculated for all clinicians.

Advancing Care Information
Promotes patient engagement and interoperability using certified EHR technology Replaces the Medicare EHR Incentive Program Greater flexibility in choosing measures In 2017, there are 2 measure sets for reporting based on EHR edition: Advancing Care Information Objectives and Measures 2017 Advancing Care Information Transition Objectives and Measures Clinicians may be more familiar with the components of the Advancing Care Information category, as it is similar to the EHR Incentive Program. As an example, the measures found within the Advancing Care Information category are based on the measures adopted by the EHR Incentive Programs for Stage 3 in There are, however, some important changes that you as a trainer need to discuss. For instance, the category is not exclusive to physicians. In fact, it applies to all eligible clinicians participating in the MIPS program either as an individual or group. Additionally, Advancing Care Information eliminates the all-or-nothing reporting criteria that was found under the EHR Incentive Program and replaces it with a greater degree of flexibility for clinicians to choose the measures that fit their practice and patients.

Advancing Care Information: Reporting
Clinicians must use certified EHR technology to report. Reporting requirements are dependent on your version of Certified EHR Technology If you’re reporting via EHR technology certified to the 2015 Edition: Option 1: Advancing Care Information Objectives and Measures Option 2: Combination of the two measure sets If you’re reporting via EHR Technology certified to the 2014 Edition: Option 1: 2017 Advancing Care Information Transition Objectives and Measures Option 2: Combination of the two measure sets or Clinicians need to understand that in order for them to report any of the measures under the Advancing Care Information category, they must use certified EHR technology. Depending on the EHR edition, there will be different objectives from which the clinician may choose to report.

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

Advancing Care Information Objectives and Measures 2017 Advancing Care Information Transition Objectives and 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

Advancing Care Information: Flexibility
Clinicians recognized as participating in a MIPS-APM entity will automatically receive a 50% score in the category Clinicians need to earn the remaining 50% to receive full credit in the category CMS will automatically reweight the Advancing Care Information performance category to zero for Hospital-based MIPS clinicians, clinicians with lack of Face-to-Face Patient Interaction, NP, PA, CRNAs and CNS Reporting is optional although if clinicians choose to report, they will be scored. If clinician faces a significant hardship and is unable to report advancing care information measures, they can apply to have their performance category score weighted to zero

+ + = BASE SCORE BONUS SCORE FINAL SCORE PERFORMANCE SCORE Account for 50% of the total Advancing Care Information Performance Category Score Account for up to 90% of the total Advancing Care Information Performance Category Score Account for up to 15% of the total Advancing Care Information Performance Category Score Earn 100 or more percent and receive FULL 25 points of the total Advancing Care Information Performance Category Final Score The overall Advancing Care Information score would be made up of a base score, a performance score, and a bonus score for a maximum score of 100 percentage points

MIPS Performance Category: Improvement Activities
Assesses participation in activities that improve clinical practice Examples: Shared decision making, patient safety, coordinating care, increasing access Clinicians choose from about 90+ activities under 9 subcategories: Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Participation in an APM Achieving Health Equity Integrating Behavioral and Mental Health Emergency Preparedness and Response The Improvement Activities performance category will be new to most clinicians. This category, worth 15% of the clinician’s Final Score, assesses how much a clinician participates in activities that improve clinical practice. Examples of these activities include how well a clinician shares in decision making with the patient, improves patient safety, coordinates care, and increases access for patients. The Improvement Activities category also includes incentives that help drive participation in certified Patient-Centered Medical Homes and Alternative Payment Models. Clinicians will have the flexibility to choose from approximately 90 activities under nine subcategories. These include Expanded Practice Access, Population Management, Care Coordination, Beneficiary Engagement, Patient Safety and Practice Assessment, Participation in an APM, Achieving Health Equity, Integrating Behavioral and Mental Health, and Emergency Preparedness and Response.

Improvement Activities: Flexibilities
Groups with 15 or fewer participants, non-patient facing clinicians, 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 under the APM scoring standard, such as Shared Savings Program Track 1 or the Oncology Care Model: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit. Since this category will be new to most clinicians, there will be many questions around the requirements. The Improvement Activities category requires that no clinician or group has to report more than four activities. Additionally, there are special considerations for: Practices with 15 or fewer clinicians Rural or geographic Health Professional Shortage Areas (HPSAs) Non-patient facing APM Certified Medical Home Practices with 15 or Fewer Clinicians, Rural or Geographic HPSA, and Non-patient Facing Choose 1 of the following combinations: 1 high-weighted activity OR 2 medium-weighted activities

MIPS Performance Category: Cost
No reporting requirement; 0% of final score in 2017 Clinicians assessed on Medicare claims data Uses measures previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR), but scoring is different The Cost performance category is worth 0% of a clinician’s Final Score for the first performance year. Clinicians will be assessed based on administrative Medicare claims data, including specific episode measures, for Medicare patients only and only for patients that are attributed to them. Therefore, there is no reporting requirement necessary for clinicians.

Cost: Reporting Cost Measures from VM
Medicare Spending Per Beneficiary (MSPB) Total Per-Capita Cost for All Attributed Beneficiaries For the transition year, there are no requirements for the Cost Performance Category Although there is not a reporting component to the Cost category, there are certain measures to which clinicians should become familiar, as these will be used to evaluate their Cost performance. The cost measures are divided into two groups, and all are risk-adjusted to accommodate for differences in patients. The first group focuses on cost measures from VM and includes: Medicare Spending Per Beneficiary (MSPB) Evaluates the costs of care related to inpatient hospital visits Total Per-Capita Cost for All Attributed Beneficiaries Evaluates the annual overall patient costs Episode Group The episode group includes 10 measures: Aortic/Mitral Valve Surgery Cholecystectomy and Common Duct Exploration Colonoscopy Coronary Artery Bypass Graft (CABG) Hip Replacement or Repair Inpatient Hip/Femur Fracture or Dislocation Treatment Knee Arthroplasty (Replacement) Lens and Cataract Procedures Mastectomy for Breast Cancer Transurethral Resection of the Prostate

Cost: Flexibilities For the transition year, the cost performance category will not impact payment in 2019 Clinicians’ Cost performance (episode groupers measures) will be included in 2018 performance feedback to help clinicians gauge performance and prepare for year 2 of the program. For data submission, no action is needed from the clinician.

Example of MIPS Participation for a Cardiologist
Sample Quality Measures: Closing the referral loop with referring provider Documentation of current medications Statins for primary prevention in high-risk patients and for treatment in patients with known CVD Beta blockers in patients with LV systolic dysfunction ACE-Inhibitor or ARB in patients with LV systolic dysfunction Antiplatelet therapy in patients with CAD *Chronic anticoagulation therapy for patients with non-valvular atrial fibrillation (AFib) based on CHADS2 risk score *Avoidance of inappropriate cardiac stress imaging in low-risk patients Sample Improvement Activities: Telehealth services that expand access to care Participation in a qualified clinical data registry (QCDR), for example: American College of Cardiology Foundation – CathPCI Registry American College of Cardiology Foundation (ACCF)-PINNACLE Registry American Society of Nuclear Cardiology ImageGuide Registry Implementation of specialist reports back to referring provider Implementation of processes for timely communication of test results Use of certified EHR technology (CEHRT) Advancing Care Information (Use of Technology): Electronic Prescribing Patient Electronic Access Health Information Exchange Exchange of patient care records Reconciliation of clinical information Flexibility to CHOOSE WHAT and HOW you report Payment adjustments according to composite score *measure supported by American College of Cardiology

Alternative Payment Models (APMs)
We have reviewed aspects of the Quality Payment Program and the Merit-based Incentive Payment System (MIPS), but now it is important for us to shift our focus towards Advanced Alternative Payment Models. However, first we should familiarize ourselves with Alternative Payment Models (APMs) in general.

What is an Alternative Payment Model (APM)?
Alternative Payment Models (APMs) are new approaches to paying for medical care through Medicare that incentivize quality and value. The CMS Innovation Center develops new payment and service delivery models. Additionally, Congress has defined – both through the Affordable Care Act and other legislation – a number of demonstrations that CMS conducts. 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 As defined by MACRA, APMs include: What is an Alternative Payment Model? Alternative Payment Models (APMs) are new approaches (payment models) to paying for medical care through Medicare that incentivize quality and value. APMs are developed in partnership with the clinician community and offer added incentives to clinicians to provide high-quality and cost-efficient care. The CMS Innovation Center develops new payment and service delivery models in accordance with the requirements of the Social Security Act. Additionally, Congress has defined – both through the Affordable Care Act and previous legislation – a number of specific demonstrations to be conducted by CMS. These include: CMS Innovation Center Model (other than a Health Care Innovation Award) Medicare Shared Savings Program (MSSP) Demonstration under the Health Care Quality Demonstration Program Demonstration required by Federal law

Alternative Payment Models
An Alternative Payment Model (APM) is a payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. APMs may offer significant opportunities to eligible clinicians who are not immediately able or prepared to take on the additional risk and requirements of Advanced APMs. Advanced APMs are a Subset of APMs APMs Advanced APMs

Advanced Alternative Payment Models (Advanced APMs) Benefits

Advanced Alternative Payment Models
Advanced Alternative Payment Models (Advanced APMs) enable clinicians and practices to earn greater rewards for taking on some risk related to their patients’ outcomes. It is important to understand that the Quality Payment Program does not change the design of any particular APM. Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs. Advanced APMs Advanced APM- specific rewards + 5% lump sum incentive

What are the Benefits of Participating in an Advanced APM as a Qualifying APM Participant (QP)?
Are excluded from MIPS QPs: Receive a 5% lump sum bonus So, what are the benefits of participating in an Advanced APM? For payment years 2019 through 2024, clinicians who meet these requirements is excluded from MIPS adjustments and receives a 5 percent lump sum incentive payment for their Part B professional services furnished during the calendar year immediately prior to the payment year for payment years 2019 through Please bear in mind that there is not an explicit incentive in 2025, however Qualifying APM Participants would be excluded from MIPS reporting requirements and payment adjustments and would, as always, have the potential for rewards under the Advanced APMs in which they participate. For payment years 2026 and later, an eligible clinician who meets these requirements is excluded from MIPS reporting requirements and payment adjustments each year, and receives a higher Physician Fee Schedule (PFS) update than those clinicians who are not qualifying APM participants. The PFS update following beginning in 2026 will be: 0.75% annual update for services furnished by Qualifying APM Participants 0.25% annual update for services furnished by non-Qualifying APM Participants We will talk about what it means to be a Qualifying APM Participant shortly. Receive a higher Physician Fee Schedule update starting in 2026

The Quality Payment Program provides additional rewards for participating in APMs.
Potential financial rewards In Advanced APM Not in APM In APM MIPS adjustments MIPS adjustments + APM-specific rewards APM-specific rewards What about those who are in “Advanced” APMs –i.e. the ones that meet the criteria we described earlier? Like those in “regular” APMs, these individuals will receive APM-specific rewards, and some individuals (called “qualifying APM participants”) will be eligible for a 5% lump sum bonus. + If you are a Qualifying APM Participant (QP) = 5% lump sum bonus

Advanced APM Criteria

Medical Home Model A Medical Home Model is an APM that has the following features: Participants include primary care practices or multispecialty practices that include primary care physicians and practitioners and offer primary care services. Empanelment of each patient to a primary clinician; and At least four of the following additional elements: Planned coordination of chronic and preventive care. Patient access and continuity of care. Risk-stratified care management. Coordination of care across the medical neighborhood. Patient and caregiver engagement. Shared decision-making. Payment arrangements in addition to, or substituting for, fee-for-service payments.

Advanced APMs Must Meet Certain Criteria
To be an Advanced APM, the following three requirements must be met. The APM: Requires participants to use certified EHR technology; Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and 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. 1 2 3 To be an Advanced APM, the following three requirements must be met. The APM: Requires participants to use certified EHR technology; Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR requires participants to bear a more than nominal amount of financial risk. Be aware that the Final Rule updated the risk requirement for an Advanced APM, so that it can be defined in terms of either total Medicare expenditures or participating organizations’ Medicare revenue (which may be significantly lower for small practices). “So what?” – This update provides needed flexibility to allow for the creation of more Advanced APMs tailored to small practice participation 38

Advanced APM Criterion 1: Requires use of Certified EHR Technology
1. Requires participants to use certified EHR technology Requires that at least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other health care professionals. Shared Savings Program requires that clinicians report at the group TIN level according to MIPS rules. Include SSP exception Clinicians must use certified EHR technology. To meet this requirement, an Advanced APM must require that at least 50% of the clinicians use certified EHR technology to document and communicate clinical care information with patients and other health care professionals.

Advanced APM Criterion 2: Requires MIPS-Comparable Quality Measures
2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category. Ties payment to quality measures that are evidence-based, reliable, and valid. At least one of these measures must be an outcome measure if an appropriate outcome measure is available on the MIPS measure list. Include SSP exception Clinicians must use certified EHR technology. To meet this requirement, an Advanced APM must require that at least 50% of the clinicians use certified EHR technology to document and communicate clinical care information with patients and other health care professionals.

Advanced APM Criterion 3: Medical Home Expanded Under CMS Authority
3. 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. Medical Home Model Expansion Medical Home Models tested under section 1115A of the Act has an alternate pathway to meet the financial risk criterion through expansion under section 1115A(c) of the Act Medical Home Model Financial Risk While no medical home models have yet been expanded, medical home models can still be Advanced APMs if they include financial risk for participants. The medical home model financial risk standard acknowledges that risk under the terms of an APM can be structured uniquely for smaller entities in a way that offers the potential of losses without threatening their financial viability. 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. 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.

Advanced APM Criterion 3: Bear a More than Nominal Amount of Financial Risk
3. 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. 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. 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.

Advanced APMs in 2017 For the 2017 performance year, the following models are Advanced APMs: The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements on an ad hoc basis. 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) For the 2017 performance year, the following models are considered Advanced APMs: Comprehensive End Stage Renal Disease Care Model (Large Dialysis Organization arrangement) Comprehensive Primary Care Plus (CPC+) Model Shared Savings Program Track 2 Shared Savings Program Track 3 Next Generation Accountable Care Organization (ACO) Model Quick Tip: Encourage clinicians to check back with CMS periodically, as a final list of Advanced APMs for the first performance year will be posted by January 1, 2017.

Future Advanced APM Opportunities
MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and assess Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee. In future performance years, we anticipate that the following models will be Advanced APMs: Comprehensive Care for Joint Replacement (CJR) Payment Model (CEHRT) New Voluntary Bundled Payment Model The initial list is expected to grow over the coming years, and CMS anticipates that these following models would qualify as Advanced APMs in the future performance years: Comprehensive Care for Joint Replacement (CJR) Payment Model (CEHRT) New Voluntary Bundled Payments for Care Improvement Advancing Care Coordination through Episode Payment Models Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model) ACO Track 1+ Quick Tip: Be sure clinicians review the final list that is scheduled to be published on or before January 1, 2018. Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT) Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model) ACO Track 1+

Qualifying APM Participants (QPs)

What is a Qualifying APM Participant (QP)?
Qualifying APM Participants (QPs) are clinicians who have a certain % of Part B payments for professional services or patients furnished Part B professional services through an Advanced APM Entity. Beginning in 2021, this threshold % may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid.

How do Eligible Clinicians become Qualifying APM Participants? – Step 1
Qualifying APM Participant determinations are made at the Advanced APM Entity level, with certain exceptions: individuals participating in multiple Advanced APM Entities, none of which meet the QP threshold as a group, and eligible clinicians on an Affiliated Practitioner List when that list is used for the QP determination because there are no eligible clinicians on a Participation List for the Advanced APM Entity. For example, gain sharers in the Comprehensive Care for Joint Replacement Model will be assessed individually. 1

CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods (payment amount and patient count). Methods are based on Medicare Part B professional services and beneficiaries attributed to Advanced APM CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity. 2 Attributed (beneficiaries for whose cost and quality of care the APM Entity is responsible) These definitions are used for calculating Threshold Scores under both methods. Attribution-eligible (all beneficiaries who could potentially be attributed) 48

The two methods for calculation are Payment Amount Method and Patient Count Method. 2 Payment Amount Method Patient Count Method $$$ for Part B professional services to attributed beneficiaries $$$ for Part B professional services to attribution-eligible beneficiaries # of attributed beneficiaries given Part B professional services # of attribution-eligible beneficiaries given Part B professional services Threshold Score % = Threshold Score % = 49

The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result. Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements) Performance Year 2017 2018 2019 2020 2021 2022 and later Percentage of Payments through an Advanced APM Percentage of Patients through an Advanced APM 50

Advanced APM Advanced APM Entities Eligible Clinicians All the eligible clinicians in the Advanced APM Entity become QPs for the payment year. Threshold Scores above the QP threshold = QP status 4 Threshold Scores below the QP threshold = no QPs 51

What is the Performance Period for QPs?
The QP Performance Period is the period during which CMS will assess eligible clinicians’ participation in Advanced APMs to determine if they will be QPs for the payment year. The QP Performance Period for each payment year will be from January 1 – August 31st of the calendar year that is two years prior to the payment year. The Qualifying APM Participant Performance Period is the period during which CMS will assess eligible clinicians’ participation in Advanced APMs to determine if they will be Qualifying APM Participants for the payment year. The QP Performance Period for each payment year will be from January 1-August 31st of the year that is two years prior to the payment year. For example, the first QP Performance Period will be from January 1, 2017 through August 31, 2017 for the 2019 payment year. Performance Period: QP status based on Advanced APM participation Incentive Determination: Add up payments for Part B professional services furnished by QP Payment: +5% lump sum payment made (excluded from MIPS adjustment)

What are the three “Snapshots” for QPs during the Performance Period?
During the QP Performance Period (January – August), CMS will take three “snapshots” (March 31, June 30, August 31) to determine which eligible clinicians are participating in an Advanced APM and whether they meet the thresholds to become Qualifying APM Participants. MAR 31 JUN 30 AUG 31 53

How are QPs determined during the Performance Period?
For each of the three QP determinations, CMS will use claims data from period “A” for the APM Entity participants captured in the snapshot at point “B.” CMS then allows for claims run-out during period “C” and finalizes QP determinations at point “D.” If an APM Entity meets the QP threshold, subsequent eligible clinician additions to the Participation List do not automatically confer QP status to those eligible clinicians. If the group meets the QP threshold for a subsequent QP determination, then the new additions become QPs. Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Jan 2017 Dec 2017 B C D #1 #2 #3 A

When Will Clinicians Learn their QP Status?
Reaching the QP threshold at any one of the three QP determinations will result in QP status for the eligible clinicians in the Advanced APM Entity Eligible clinicians will be notified of their QP status after each QP determination is complete (point D). Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Jan 2017 Dec 2017 B C D #1 #2 #3 A

What if Clinicians do not Meet the QP Payment or Patient Thresholds?
Clinicians who participate in Advanced APMs, but do not meet the QP threshold, may become “Partial” Qualifying APM Participants (Partial QPs). Partial QPs choose whether to participate in MIPS. Medicare-Only Partial QP Thresholds in Advanced APMs Payment Year 2019 2020 2021 2022 2023 2024 and later Percentage of Payments Percentage of Patients If they opt in to MIPS, they receive a MIPS Final Score and a MIPS payment adjustment. If they opt out of MIPS, they are exempt from MIPS reporting requirements and payment adjustments but do not receive the 5% APM Incentive Payment.

Other Payer Advanced APMs

Do payments from other payers apply to QP determination?
Starting in the 2019 QP Performance Period, participation in payment arrangements with other, non-Medicare payers can contribute to meeting the QP threshold. The “All-Payer Combination Option” will be based on a combination of Advanced APM participation and participation in “Other Payer Advanced APMs.” To be considered under the All-Payer Combination Option, eligible clinicians must also participate in an Advanced APM but not meet the QP threshold under the Medicare Option. Other Payer Advanced APMs must meet criteria similar to those for Advanced APMs.

What is the Performance Period for QPs?
The QP Performance Period is the period during which CMS will assess eligible clinicians’ participation in Advanced APMs to determine if they will be QPs for the payment year. The QP Performance Period for each payment year will be from January 1 – August 31st of the calendar year that is two years prior to the payment year. The Qualifying APM Participant Performance Period is the period during which CMS will assess eligible clinicians’ participation in Advanced APMs to determine if they will be Qualifying APM Participants for the payment year. The QP Performance Period for each payment year will be from January 1-August 31st of the year that is two years prior to the payment year. For example, the first QP Performance Period will be from January 1, 2017 through August 31, 2017 for the 2019 payment year. Performance Period: QP status based on Advanced APM participation Incentive Determination: Add up payments for Part B professional services furnished by QP Payment: +5% lump sum payment made (excluded from MIPS adjustment)

All-Payer Combination Option How do Eligible Clinicians become Qualifying APM Participants? – Step 1
Qualifying APM Participant determinations are made at the Advanced APM Entity level, with certain exceptions: individuals participating in multiple Advanced APM Entities, none of which meet the QP threshold as a group, and eligible clinicians on an Affiliated Practitioner List when that list is used for the QP determination because there are no eligible clinicians on a Participation List for the Advanced APM Entity. For example, gain sharers in the Comprehensive Care for Joint Replacement Model will be assessed individually. 1

All-Payer Combination Option How do you calculate Threshold Scores
All-Payer Combination Option How do you calculate Threshold Scores? – Step 2 CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods (payment amount and patient count). Methods are based on payments from and patient furnished services through agreements with all payers, with certain exceptions. CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity. 2 The aggregate of all payments (or all patients given services) under the terms of the payment arrangement These definitions are used for calculating Threshold Scores under both methods. The aggregate of all payments (or all patients given services) from the payer 61

2 All-Payer Combination Option
How do you calculate Threshold Scores? – Step 2 Calculate the Threshold Score under the All-Payer Combination Option. 2 PAYMENT AMOUNT METHOD PATIENT COUNT METHOD # of patients given services under Advanced APMs and Other Payer Advanced APMs # of patients given services under all payers $$$ the terms of Advances APMs and Other Payer Advanced APMs $$$ from all payers = Threshold Score % = Threshold Score % 62

All Payer Combination Option How do you calculate Threshold Scores
All Payer Combination Option How do you calculate Threshold Scores? – Step 2 Payments from the following sources are excluded from the calculation under the All-Payer Combination Option: Department of Defense Health Care Programs Department of Veterans Affairs Health Care Programs Title XIX in a state with no Medicaid Medical Home Model or APM. In order not to adversely impact physicians who have no opportunity to participate, Title XIX payments or patients would be excluded unless: a state had at least one Medicaid Medical Home Model or APM in operation that is determined to be an Other Payer Advanced APM; and the relevant Advanced APM Entity is eligible to participate in at least one such Other Payer Advanced APM, regardless of whether the Advanced APM Entity actually participates in such Other Payer Advanced APMs. 2 New sentence in bubble has to be formatted. Add “2” to slide as with earlier slides

All-Payer Combination Option
How do Eligible Clinicians become Qualifying APM Participants? – Step 3 The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result. 3 All-Payer Combination Option Payment Year 2019 2020 2021 2022 2023 2024 and later QP Payment Amount Threshold N/A QP Patient Count Threshold Total Medicare

QP Determination Tree Payment Years 2021 - 2022
YES YES Is All-Payer Threshold Score > 50% Is Medicare Threshold Score > 50% PARTIAL QP NO YES YES NO Is All-Payer Threshold Score > 40% OR is Medicare Threshold Score > 40%? Is Medicare Threshold Score > 25% All-Payer Combination Option slide. Thresholds and process flow from rule. NO YES NO Is Medicare Threshold Score > 20% MIPS Eligible Clinician NO MIPS Eligible Clinician

ADVANCED APM OTHER PAYER All the eligible clinicians in the Advanced APM Entity become QPs for the payment year. 4 ADVANCED APM ENTITY ELIGIBLE CLINICIANS OR Entity-level Threshold Score below the QP threshold = no QPs Entity-level Threshold Score above the QP threshold = QPs 66

APM Scoring Standard

What are MIPS APMs? APMs Goals
Reduce eligible clinician reporting burden. Maintain focus on the goals and objectives of APMs. How does it work? Streamlined MIPS reporting and scoring for eligible clinicians in certain APMs. Aggregates eligible clinician MIPS scores to the APM Entity level. All eligible clinicians in an APM Entity receive the same MIPS final score. Uses APM-related performance to the extent practicable. MIPS APMs are a Subset of APMs APMs MIPS Certain Alternative Payment Models (APMs) include MIPS eligible clinicians as participants and hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. This type of APM is called a “MIPS APM,” and participants in MIPS APMs receive special MIPS scoring under the “APM scoring standard.”

What are the Requirements to be Considered a MIPS APM?
The APM scoring standard applies to APMs that meet these criteria: APM Entities participate in the APM under an agreement with CMS; APM Entities include one or more MIPS eligible clinicians on a Participation List; and APM bases payment incentives on performance (either at the APM Entity or eligible clinician level) on cost/utilization and quality.

What are key dates for the APM scoring standard?
To be considered part of the APM Entity for the APM scoring standard, an eligible clinician must be on an APM Participation List on at least one of the following three snapshot dates (March 31, June 30 or August 31) of the performance period. Otherwise an eligible clinician must report to MIPS under the standard MIPS methods. MAR 31 JUN 30 AUG 31 For example, if OCM is determined to be a MIPS APM, a MIPS eligible clinician who is part of an OCM practice from January 15 through April 25 of the MIPS performance year would be on the Participation List on March 31 and therefore would be included in the APM Entity for that performance year.

To which APMs does the APM Scoring Standard apply in 2017?
For the 2017 performance year, the following models are considered MIPS APMs: The list of MIPS APMs is posted at QPP.CMS.GOV and will be updated on an ad hoc basis. Comprehensive ESRD Care (CEC) Model (All Arrangements) Comprehensive Primary Care Plus (CPC+) Model Shared Savings Program Tracks 1, 2, and 3 Next Generation ACO Model Oncology Care Model (OCM) (All Arrangements) For the 2017 performance year, the following models are considered Advanced APMs: Comprehensive End Stage Renal Disease Care Model (Large Dialysis Organization arrangement) Comprehensive Primary Care Plus (CPC+) Model Medicare Shared Savings Program (MSSP) Track 2 Medicare Shared Savings Program (MSSP) Track 3 Next Generation Accountable Care Organization (ACO) Model Quick Tip: Encourage clinicians to check back with CMS periodically, as a final list of Advanced APMs for the first performance year will be posted by January 1, 2017.

Shared Savings Program (All Tracks) under the APM Scoring Standard
REPORTING REQUIREMENT PERFORMANCE SCORE WEIGHT ACOs submit quality measures to the CMS Web Interface on behalf of their participating MIPS eligible clinicians. The MIPS quality performance category requirements and benchmarks will be used to score quality at the ACO level. MIPS eligible clinicians will not be assessed on cost. N/A No additional reporting necessary. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the Shared Savings Program. All ACO participant TINs in the ACO submit under this category according to the MIPS group reporting requirements. All of the ACO participant TIN scores will be aggregated as a weighted average based on the number of MIPS eligible clinicians in each TIN to yield one APM Entity group score. Quality Cost Improvement Activities Performance Year 2017 Payment Year 2019 Advancing Care

Next Generation ACO Model under the APM Scoring Standard
REPORTING REQUIREMENT PERFORMANCE SCORE WEIGHT ACOs submit quality measures to the CMS Web Interface on behalf of their participating MIPS eligible clinicians. The MIPS quality performance category requirements and benchmarks will be used to score quality at the ACO level. MIPS eligible clinicians will not assessed on cost. N/A No additional reporting necessary. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the Next Generation ACO Model. Each MIPS eligible clinician in the APM Entity group reports advancing care information to MIPS through either group reporting at the TIN level or individual reporting. CMS will attribute one score to each MIPS eligible clinician in the APM Entity group. This score will be the highest score attributable to the TIN/NPI combination of each MIPS eligible clinician, which may be derived from either group or individual reporting. The scores attributed to each MIPS eligible clinicians will be averaged to yield a single APM Entity group score. Quality Cost Improvement Activities Advancing Care Performance Year 2017 Payment Year 2019

All Other APMs under the APM Scoring Standard
REPORTING REQUIREMENT PERFORMANCE SCORE WEIGHT The APM Entity group will not be assessed on quality under MIPS in the first performance period. N/A MIPS eligible clinicians will not be assessed on cost. No additional reporting necessary. CMS will assign the same improvement activities score to each APM Entity group based on the activities required of participants in the MIPS APM. Each MIPS eligible clinician in the APM Entity group reports advancing care information to MIPS through either group reporting at the TIN level or individual reporting. CMS will attribute one score to each MIPS eligible clinician in the APM Entity group. This score will be the highest score attributable to the TIN/NPI combination of each MIPS eligible clinician, which may be derived from either group or individual reporting. The scores attributed to each MIPS eligible clinician will be averaged to yield a single APM Entity group score. Quality Cost Improvement Activities Advancing Care Performance Year 2017 Payment Year 2019

Physician-Focused Payment Model Technical Advisory Committee

Physician-Focused Payment Model Technical Advisory Committee
MACRA established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and assess Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee. The PTAC is a federal advisory committee that provides independent advice to the Secretary. The PTAC is supported by HHS Office of the Assistant Secretary for Planning and Evaluation. This committee provides a unique opportunity for stakeholders to participate in the development of new models and to help determine priorities for the physician community

PFPM Technical Advisory Committee (PTAC)
Physician-Focused Payment Model Goal to encourage new APM options for Medicare clinicians Technical Advisory Committee Secretary comments on CMS website, CMS considers testing proposed models Submission of model proposals by Stakeholders Models with favorable response go to CMS Innovation Center 11 appointed care delivery experts that review proposals, submit recommendations to HHS Secretary

How Does the PTAC Work? 78 Proposed model is submitted to the PTAC.
PTAC reviews and provides comments and recommendations on proposals to the Secretary. Secretary of the Department of Health and Human Services reviews the recommendations of PTAC and posts a detailed response on the CMS website. Models that receive a favorable response will go to the CMS Innovation Center. Models that are implemented will go through the CMS developmental process for APMs. 78

Where can I go to learn more?

qpp.cms.gov Help Is Available
CMS has organizations on the ground to provide help to clinicians who are eligible for the Quality Payment Program: Transforming Clinical Practice Initiative (TCPI): TCPI is designed to support more than 140,000 clinician practices over the next 4 years in sharing, adapting, and further developing their comprehensive quality improvement strategies. Clinicians participating in TCPI will have the advantage of learning about MIPS and how to move toward participating in Advanced APMs. Click here to find help in your area. Quality Innovation Network (QIN)-Quality Improvement Organizations (QIOs): The QIO Program’s 14 QIN-QIOs bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality. More information about QIN-QIOs can be found here. If you’re in an APM: The Innovation Center’s Learning Systems can help you find specialized information about what you need to do to be successful in the Advanced APM track. If you’re in an APM that is not an Advanced APM, then the Learning Systems can help you understand the special benefits you have through your APM that will help you be successful in MIPS. More information about the Learning Systems is available through your model’s support inbox.

When and where do I submit comments?
The final rule with comment includes changes not reviewed in this presentation. We will not consider feedback during the call as formal comments on the rule. See the proposed rule for information on submitting these comments by the close of the 60-day comment period on December 19, When commenting refer to file code CMS-5517-F. Instructions for submitting comments can be found in the proposed rule; FAX transmissions will not be accepted. You must officially submit your comments in one of the following ways: electronically through Regulations.gov by regular mail by express or overnight mail by hand or courier For additional information, please go to: QPP.CMS.GOV

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