1. MIPS and APM GURDEV SINGH MD CPHIMS CIO, Renal Care Organization
COO, Global Nephrology Solutions
WILLIAM A. ELLERT, MD, MSN, FAAFP
Chief Medical Officer
Tenet Healthcare, Arizona

2. Disclosure Gurdev Singh MD, CPHIMS
Has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Additional Disclosure:
Founder and Executive member of RCO Analytics, a healthcare analytics company that offers services to Nephrologists to help improve quality and cost.
Founder and Executive member of Global Nephrology Solutions, a physician practice management company.

3. Disclosure of Financial Relationships
William A. Ellert, M.D. Has no relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on, patients. Additional Disclosure: Member of the Board of Directors of Circle the City, a not-for-profit charitable organization which cares for the homeless during times of illness.

4. The Quality Payment Program
The Quality Payment Program policy will:
Reform Medicare Part B payments for more than 600,000 clinicians
Improve care across the entire health care delivery system
Clinicians have two tracks to choose from: OR
The Merit-based Incentive Payment System (MIPS)
If you decide to participate in traditional 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.

5. What is the Merit-based Incentive Payment System?
Quality Payment Program
What is the Merit-based Incentive Payment System?
Combines legacy programs into single, improved reporting program
PQRS VM EHR
Legacy Program Phase Out
Last Performance Period
PQRS Payment End
2016
2018

6. What are the Performance Category Weights?
Quality Payment Program
What are the Performance Category Weights?
Weights assigned to each category based on a 1 to 100 point scale
Transition Year Weights
Quality
60%
Cost 0%
Improvement Activities
15%
Advancing Care Information
25%

7. MIPS Performance Category: Quality
Quality Payment Program
MIPS Performance Category:
Quality
Category Requirements
Replaces PQRS and Quality Portion of the Value Modifier
Select 6 of about 300 quality measures (minimum of 90 days to be eligible for maximum payment adjustment); 1 must be:
Different requirements for groups reporting CMS Web Interface or those in MIPS APMs
Outcome measure OR
High-priority measure—defined as outcome measure, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination
May also select specialty-specific set of measures

8. MIPS Scoring for Quality (60% of Final Score in Transition Year)
Quality Payment Program
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

9. Transition Year 2017 >70 points 4-69 points 3 points 0 points
Quality Payment Program
Transition Year 2017
Final Score
Payment Adjustment
>70 points
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

10. HOW TO GET STARTED

11. STEP 1: Pick Your Measures
Reporting as individual
Define the specific activities that will qualify each eligible professional in your office for the maximum incentive payment for MIPS
Reuse activities related to other incentive programs aka MU
Reporting as a Group
Select measures that are common to > 50% Eps
Identify back up measures

15. Improvement Activities – Examples
Subcategory
Description
Weight
Expanded Practice Access
Provide 24/7 access to MIP’s EC’s or care teams, expanded evening or weekend hours, e-visits, group visit, home visits, same day access
High
Population Management
Patient with diabetes with meds – individualized care plan addressing comorbidities, risk for hypoglycemia and reassessed annually
60% of patients on anticoagulation participate in systematic anticoagulation program (coagulation clinic, patient self-reporting or management program)
Targeted patient population reports that show unique characteristics of eligible patients, identification of vulnerable patients and how treatment is tailored
Medium
Beneficiary Engagement
Collection and follow-up on patient experience and satisfaction data on patient engagement
Patient Safety and Practice Assessment
Consultation of a prescription drug monitoring program prior to the issuance of a controlled substance schedule II that will last more than three days
Care Coordination
Timely communication of test results defined as timely identification of abnormal test results with timely follow-up
NOTE: High – 20 points, Medium – 10 point; 60 points to max category

17. ACI: Domain Measures
Part of the base score

18. MEASURE NAME
MEASURE DESCRIPTION
MEASURE TYPE
HIGH PRIORITY MEASURE
Adult Kidney Disease: Blood Pressure Management
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care
Intermediate Outcome
Yes
Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated
Outcome
Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter
Adult Kidney Disease: Referral to Hospice
Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care
Process
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions
Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
Controlling High Blood Pressure
Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period
Diabetes: Foot Exam
The percentage of patients years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year No
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

19. Example of 2017 MIPS Participation for a Nephrologist
Quality Payment Program
Example of 2017 MIPS Participation for a Nephrologist
Sample Quality Measures (6, Including 1 Outcome):
Closing the referral loop with referring provider
Documentation of current medications
Hemoglobin A1c
Care Plan
Immunization
Controlling high blood pressure (outcome measure)
Catheter at start of Dialysis (Outcome measure)

20. Example of 2017 MIPS Participation for a Nephrologist
Quality Payment Program
Example of 2017 MIPS Participation for a Nephrologist
Sample Quality Measures (6, Including 1 Outcome):
Sample Improvement Activities (2 High-Weighted):
Closing the referral loop with referring provider
Documentation of current medications
Hemoglobin A1c
Care Plan
Immunization
Controlling high blood pressure (outcome measure)
Catheter at start of Dialysis (Outcome measure)
Provide 24/7 access to eligible clinicians or groups who have real- time access to patient’s medical record. (EHR)
Use of QCDR for feedback reports that incorporate population health. (RCO)

21. Example of 2017 MIPS Participation for a Nephrologist
Quality Payment Program
Example of 2017 MIPS Participation for a Nephrologist
Sample Quality Measures (6, Including 1 Outcome):
Sample Improvement Activities (2 High-Weighted):
Advancing Care Information (Use of Technology) Measures (5 Base Score and 1 Performance Score):
Closing the referral loop with referring provider
Documentation of current medications
Hemoglobin A1c
Care Plan
Immunization
Controlling high blood pressure (outcome measure)
Catheter at start of Dialysis (Outcome measure)
Provide 24/7 access to eligible clinicians or groups who have real- time access to patient’s medical record. (EHR)
Use of QCDR for feedback reports that incorporate population health. (RCO)
Security Risk Analysis
e-Prescribing
Provide Patient Access
Send a Summary of Care
Request/Accept a Summary of Care
Secure Messaging (performance score)

22. Example of 2017 MIPS Participation for a Nephrologist
Quality Payment Program
Example of 2017 MIPS Participation for a Nephrologist
Sample Quality Measures (6, Including 1 Outcome):
Sample Improvement Activities (2 High-Weighted):
Advancing Care Information (Use of Technology) Measures (5 Base Score and 1 Performance Score):
Closing the referral loop with referring provider
Documentation of current medications
Hemoglobin A1c
Care Plan
Immunization
Controlling high blood pressure (outcome measure)
Catheter at start of Dialysis (Outcome measure)
Provide 24/7 access to eligible clinicians or groups who have real- time access to patient’s medical record. (EHR)
Use of QCDR for feedback reports that incorporate population health. (RCO)
Security Risk Analysis
e-Prescribing
Provide Patient Access
Send a Summary of Care
Request/Accept a Summary of Care
Secure Messaging (performance score)
Flexibility to CHOOSE WHAT and HOW you report
Payment adjustments according to composite score

23. Change is Hard

24. STEP 2: Create Strategy
Create a strategy for ensuring initial and continued high performance in selected measures
Optimal use of EMR features or IT Tools to track progress on a regular basis
Monitor back up measures also

27. STEP 3: Transform Workflow redesign EHR optimization
Measure and monitor
Change management

28. Langley et al 1996 IHI What are we trying to accomplish?
How do we know that change is an improvement?
What change can we make that will result in an improvement?
PDSA Do
Study
Act
Plan
Langley et al 1996 IHI

29. Introduction to Advanced Alternative Payment Models
(APMs)

30. Alternative Payment Models (APMs)
A payment approach that provides added incentives to clinicians to provide high-quality and cost- efficient care.
Can apply to a specific condition, care episode or population.
May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs.
Advanced APMs are a Subset of APMs
APMs
Advanced APMs

31. Advanced Alternative Payment Models
Clinicians and practices can:
Receive greater rewards for taking on some risk related to patient outcomes. +
Advanced APMs
Advanced APM- specific rewards
5% lump sum incentive

32. Receive a higher Physician Fee Schedule update
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
Receive a higher Physician Fee Schedule update
starting in 2026

33. If you are a Qualifying APM Participant (QP)
The Quality Payment Program provides
additional rewards for participating in APMs.
Potential financial rewards
Not in APM
In APM
In Advanced APM
MIPS adjustments
MIPS adjustments +
APM-specific rewards
APM-specific
rewards +
5% lump sum bonus
If you are a Qualifying APM Participant (QP) =

34. Advanced APMs Must Meet Certain Criteria
To be an Advanced APM, the following three requirements must be met.
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.
Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and
Requires participants to use certified EHR technology;

35. 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
Oncology Care Model (Two-Sided Risk Arrangement)
Next Generation ACO Model

36. 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.

37. How do Eligible Clinicians become Qualifying APM Participants?—Step 3
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

38. Center for Healthcare Quality and Payment Reform