1. Unlocking the Door to the Quality Payment Program.
Sandy Swallow and Michelle Brunsen
HIMSS Iowa Chapter
September 13, 2017
This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, 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. 11SOW-IA-D1-08/08/

2. Learning Objectives Provide the background for payment reform
Review the details of the Quality Payment Program (QPP)
Consider impact on clinicians working in your environment
Explore changes “proposed” for Year Two
Describe the specialized programs and resources available to you

3. Payment Reform Background
We have a payment system that has rewarded more care, regardless of the value (or quality) of that care
Payment models have not promoted coordination of care across settings of care

4. Medicare Trust Fund is Unsustainable
Payment Reform Background
Medicare Trust Fund is Unsustainable

5. Payment Reform Background
Health spending grew 4.8 % in 2016, slightly less than the year before when it rose 5.8%. However, don't expect the expenditures to stall for long, the report found. They could account for nearly 20% of U.S. spending by 2025.

6. Payment Reform Background
Vision for the future
HHS announces vision for better, smarter healthcare
Set clear goals and timeline for shifting Medicare reimbursements from volume to value
Medicare Access and CHIP Reauthorization Act of (MACRA)
Signed into law April 2015 Notice of Proposed Rule Making
Final Rule released October 2016
MACRA: Gets us closer to meeting HHS payment reform goals
*HHS Press Release January 26, 2015

7. Payment Reform Background
Three most important need-to-know points about MACRA:
Passed with bipartisan Congressional support in 2015
Introduces the Quality Payment Program (QPP)
Pays clinicians for delivering best care and overall work with patients

8. Quality Payment Program (QPP)
Moving from Volume to Value
Transition to a new payment system that promotes high-quality efficient care
Streamlines legacy programs (PQRS, MU, VM) into a single quality program
Creates choice of 2 paths – APMs and MIPS
Provides incentives for worthy performance and negative payment adjustment to lower performance

9. Quality Payment Program Eligibility
Who is included?
Physicians
Physician Assistants
Nurse Practitioners
Clinical Nurse Specialist
Certified Registered Nurse Anesthetists
Who is excluded?
If 2017 is your first year of participation in Medicare
Low volume threshold
You have less than or equal to $30,000 in Medicare Part B allowed charges for the year
You care for less than or equal to 100 Medicare patients during the year
Note: Must be enrolled to participate in Medicare Part B

10. Categories of Medicare Part B Eligible Clinicians
MIPS
Traditional Medicare FFS providers
Eligible to receive performance-based payment incentives
Advanced APM
Providers significantly participating in a qualifying CMS Innovative alternative payment model
Exempt from MIPS
Eligible for 5% lump sum bonus
MIPS-APM
Participants participating in a non-qualifying CMS Innovative alternative payment model
Partial qualifying participant
Eligible for MIPS
Exempt
Traditional Medicare FFS providers exempt from quality reporting due to low-volume threshold or newly enrolled in Medicare
Option to participate in MIPS

11. QPP Transition Timeline
MACRA - QPP
Quality Payment Program
MIPS Merit-Based Incentive Payment System
APMs Alternative Payment Model
Legacy Program Timeline
Last Performance Year: 2016
Last Submission Date: Jan-Mar 2017
Last Payment Adjustment: 2018
QPP Timeline
First Performance Year: 2017
First Submission Date: Jan-Mar 2018
First Payment Adjustment: 2019

12. What Impact Does MACRA Have on Clinicians?
Repeals the Sustainable Growth Rate (SGR)
Incentivizes care that focuses on improved quality outcomes and higher provider performance rather than the volume of patients
Streamlines payment adjustments into a single structure
Reduces reporting burden with more flexibility

13. Which Path is Right for You?
Merit-Based Incentive System (MIPS)

14. Which Path is Right for You?
Merit-Based Incentive Payment System (MIPS)
Which Path is Right for You?
Replaces PQRS, VM and MU
ECs earn a performance-based payment adjustment on the Medicare Part B PFS
Adjusted either up, down, or neutral
Payment adjustment is based an EC’s Final Score
The Final Score is calculated from quality data submitted by the EC in 4 performance categories

15. MIPS Reporting Options
Type
Identification Mechanism
Individual
Single NPI tied to TIN
Submit individual-level data
Data submission via claims, EHR, registry or QCDR
Group
Set of clinicians identified by NPIs sharing common TIN
Submit group-level data
Register as a group by June 30, 2017
Data submission via CMS web interface (25+), EHR, registry or QCDR
APM Entity Group (MIPS-APM)
Collection of entities participating in an APM that don’t qualify for Advanced APM or meet thresholds
Submit MIPS data to avoid downward payment adjustment

16. QPP “Pick Your Pace in 2017” Test Pace Submit Something
Transition Year
Test Pace Submit Something
Neutral bonus
No penalty
Partial Year 90 day Submission
Neutral to small bonus
Full Year Submission
Neutral to moderate bonus
Participate in an Advanced Payment Model
Don’t Participate Receive -4% payment adjustment
Key Takeaway: Positive adjustments are based on performance data submitted, not the amount of information or length of time submitted.

17. MIPS Performance Categories for 2017
How Will ECs be Scored?
Quality ECs report on quality measures best reflecting their practice
Advancing Care Information ECs report customizable measures reflecting their EHR use
Improvement Activities ECs select practice improvement activities that match their practice’s goals; full credit if PCMH recognized
Cost Beginning 2018, CMS will calculate measures based on claims; no reporting requirements from ECs

18. Quality Category 2017 - 60% 271 available measures*
Participants report at least 6 measures, including one “Outcome” or “High Priority” measure (if no Outcome measure available)
If fewer than 6 measures apply, submit all that apply
Must submit all measures through the same method
CAHPS Survey measure is exception (if selected as one of the 6)
Groups 16+ ECs: All-Cause Hospital Readmission measure is automatically calculated/scored if there is at least 200 cases
Each measure is scored on decile ranking (3-10 points)
Measure assessed against benchmarks to determine points measure earns
Different requirements for CMS Web Interface or MIPS-APMs
*Refer to for full list of measures, which can be filtered based on high-priority, data submission method and specialty measure set

19. Number of Points Assigned for the 2017 MIPS Performance Period
2017 Quality Performance Scoring
Point Estimation
Decile
Number of Points Assigned for the 2017 MIPS Performance Period
Below Decile 3
3 points
Decile 3
3-3.9 points
Decile 4
4-4.9 points
Decile 5
5-5.9 points
Decile 6
6-6.9 points
Decile 7
7-7.9 points
Decile 8
8-8.9 points
Decile 9
9-9.9 points
Decile 10
10 points
Clinician can receive 3 to 10 points for each measure (not including bonus points)
3-point floor for new measures
Risk adjusted to Hierarchical Condition Codes (HCC)
>20 eligible instances to contribute
Zero percent performance not included
“Topped out” measures may skip deciles

20. Advancing Care Information 2017 – 25%
Fulfill the required measures for minimum of 90 days
Security Risk Assessment
E-Prescribing
Provide Patient Access
Send Summary of Care
Request/Accept Summary of Care*
Choose to submit up to 9 measures for additional credit
*2015 CEHRT
For bonus credit, you can:
Report participation with a Public Health and/or Clinical Data Registry
Use of certified EHR technology to complete certain Improvement Activities
Choice of 2 Measure Set Options
ACI
2017 Transition ACI

21. 2017 ACI Performance Scoring
Earn up to 155% of maximum score, which will be capped at 100%

22. How is the Performance Score Calculated?
2017 ACI Performance Scoring
How is the Performance Score Calculated?
Performance Rates for Each Measure Worth up to 10%
Performance Rate = 1%
Performance Rate = 2%
Performance Rate = 3%
Performance Rate = 4%
Performance Rate = 5%
Performance Rate = 6%
Performance Rate = 7%
Performance Rate = 8%
Performance Rate = 9%
Performance Rate = 10%
Numerators and denominators converted to percentage score
Most measures maximum of 10%
Transition set has two measures worth 20%
Provide Patient Access
HIE
Submit “Yes” for Immunization Registry to receive the full 10% for that measure

23. Attest to Participation in Activities that Improve Clinical Practice
Improvement Activity Category – 15%
Attest to Participation in Activities that Improve Clinical Practice
Choose from 93 activities from 8 different subcategories
Need 40 points for maximum score
Attest up to 4 activities
High- and medium weight activities
Weights can be adjusted for certain circumstances
Small, Rural, HPSA Practice
Patient Centered Medical Home (PCMH)
MIPS-APM participants

24. Cost Category 2017 – 0% No reporting requirements for clinicians
CMS calculates from claims over 40 episode-specific measures to account for differences among specialties
Cost measures previously used from the Value-Based Modifier Program by rolling up all cost of inpatient and outpatient care including imaging, lab, drugs, rehabilitation, etc.
Medicare Spending Per Beneficiary (MSPB)
Total Per Capita Cost for All Attributed Beneficiaries
Provide feedback on EC 2017 performance; will not affect 2019 payment adjustment

25. How Are Payments Adjusted Under MIPS?
MIPS: Financial Impact on Clinicians
How Are Payments Adjusted Under MIPS?
Calculate the final score by sum of performance categories
Positive, negative, neutral adjustments based on CMS- established threshold
Budget neutral program
Clinicians at or above performance threshold will receive a neutral or positive adjustment factor based on a linear sliding scale
Adjustments applied to a clinician’s Medicare Part B claims starting in
Reflects adjustment to provider’s base rate of Medicare Part B payments

26. MIPS Payment Adjustment
MIPS Payment Adjustment Thresholds in CY 2019
Based on Reporting for 2017
Final Score Points
MIPS Payment Adjustment
0 points
Does not participate
Negative payment adjustment of -4%
3 points
Neutral payment adjustment
4-69 points
Neutral to positive payment adjustment
Not eligible for Exceptional Performance Bonus
> 70 points
Positive payment adjustment
Eligible for Exceptional Performance Bonus – minimum of additional 0.5%

27. MIPS Applying the Payment Adjustments
Applied to:
Medicare Part B payments for items/services furnished by a MIPS EC
Items/services billed under Medicare PFS
Adjustment on a per claim basis (not lump sum)
TIN/NPI level

28. MIPS Payment Adjustment Exclusions
Does Not Apply To:
Medicare Part A, Medicare Advantage Part C, Medicare Part D
Services rendered by clinicians under RHC All-Inclusive Rate (AIR) payment methodology
Includes items/services billed by RHC
No impact to payment to the RHC itself
“Method I’ CAH facility payments
“Method II” when the clinician has not reassigned their billing to the hospital
If they do not reassign, the CAH is only billing for facility services so not impacted
When EC does reassign rights to the hospital, these payments are subject to MIPS
Facility payments under facility-based payment methodology

29. What Impact Does MACRA Have on Clinicians?
Comparison to other MIPS Eligible Clinicians, regardless of specialty and against a performance threshold
If they choose to report as a group, the whole group gets the same Final Score, but the payment adjustment will be applied at the TIN/NPI level
The Final Score will be shared on Physician Compare

30. What Impact Does QPP Have on You?
What is your current role?
Will you have any new responsibilities because of QPP?
Are you familiar with the requirements of QPP?

31. Which Path is Right for You?
Alternative Payment Models (APMs)

32. Alternative Payment Model
Impact to YOU?
Does your organization participate in an alternative payment model such as a Medicare Shared Savings Program (MSSP) ACO?

33. Alternative Payment Model (APMs)
Which Path is Right for You?
Create the adoption of payment models that move away from FFS
Tie payment to value and focus on better care, smarter spending and healthier people
Must meet specific requirements
Must be in an Advanced APM to participate
Receive 5% lump sum bonus for
Receive higher fee schedule update for 2026 and beyond

34. Requirements to be Considered an Advanced APM
What are Advanced APMs?
The Basics of Advanced APMs
Requirements to be Considered an Advanced APM
Uses certified EHR technology
Collects quality measures data comparable to MIPS
Either:(1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear more than a nominal amount of financial risk
APM
Advanced APM

35. Eligible Advanced APMs Include:
What are Advanced APMs?
Impact on Eligible Clinicians
Eligible Advanced APMs Include:
Comprehensive ESRD Care Model
Comprehensive Primary Care Plus (CPC+)
Medicare Shared Savings Program Track 2 and 3
Next Generation ACO Model
Oncology Care Model Two- Sided Risk Arrangement
May be determined as qualifying APM participants (QPs) if they meet proposed thresholds
QPs:
Are not subject to MIPS
Receive 5 percent lump sum bonus payments for years
Receive a higher fee schedule update for 2026 and beyond

36. APMs: Scoring Standards
Category
Reporting Requirements
Category Scoring
Category Weight
Quality (PQRS)
The ACO submits Medicare Shared Savings Program quality measures on behalf of ACO participant TINs and their MIPS eligible clinicians via the CMS Web Interface.
Data is submitted on the first 248 consecutively ranked and assigned Medicare beneficiaries.
The ACO submits this information once for purposes of both the Medicare Shared Savings Program and MIPS.
MIPS benchmarks will be used to assign one score at the APM Entity Group (ACO) level. In other words, all MIPS eligible clinicians on the certified ACO Provider/Supplier list will receive the same score (unless they are excluded from MIPS).
Note that the performance of all clinicians in the ACO will contribute to this score, even if they are not subject to MIPS payment adjustments.
50%
Cost (VM)
MIPS eligible clinicians participating in the MSSP will not be assessed on cost. No reporting necessary.
N/A 0%
Improvement Activities (new)
No additional reporting necessary.
Full credit for the APM Entity group by virtue of MSSP participation.
20%
Advancing Care Information (MU)
ACO participant TINs will submit directly to MIPS via a MIPS data submission mechanism.
ACO participant TIN scores will be aggregated as a weighted average to yield one score for the APM Entity group.
30%

37. Quality Payment Program Proposed Rule for Year Two
Looking Ahead!
Quality Payment Program Proposed Rule for Year Two

38. Proposed Rule Year Two Highlights
Increase low-volume threshold so more small, rural and HPSA practices are exempt
< $90,000 or < 200 Medicare beneficiaries
Add new ACI hardship for small practices
Allow use of 2014 certified EHR system
Add bonus point opportunities to scoring methodology
Caring for Complex Patients
Using 2015 Edition CEHRT only
Reward improvement in performance
Award small practices 3 points for quality measures that don’t meet data completeness requirements

39. Proposed Rule Year Two Highlights
Offer Virtual Group participation option
Incorporate option to use facility-based scoring for facility-based clinicians
Change report period
Full year for Quality and Cost
Minimum of 90-days for ACI and IA
Gives more details about the APM All-Payer Combination
Extend the revenue-based nominal standard through 2020 for APMs

40. Resource Library QPP Proposed Rule Quality Payment Program
Fact Sheet: CY 2018 Updates to QPP PROPOSED RULE
CY 2018 Updates to QPP PROPOSED RULE (CMS-5522-P)
Quality Payment Program

41. What Support is Available for Clinicians?

42. Telligen QIO and SURS - We Are Here to Help!
QPP Coffee Talks with subject matter experts:
Open discuss with Q & A – dedicated to your questions
2nd Thursday every month
11:00 a.m. CST for 1 hour
Partner with Telligen on practice improvement activities
Participation with a QIO in a self-management training program (diabetes)
Implementation of antibiotic stewardship program
Educational Learning Modules for eligible clinicians with “free” CME/CEUs:
QPP webinars:
Telligen QPP SURS Website:

43. THANK YOU! Telligen Sandy Swallow, Program Specialist 515.223.2105
Michelle Brunsen, Health IT Advisor
Websites