2. AGENDA Overview of MACRA Quality Payment Program
MIPS
APM
Determining Eligibility
Timeline

3. What Is MACRA? Medicare Access and CHIP Reauthorization Act of 2015
MACRA’s Quality Payment Program (QPP) replaces the Sustainable Growth Formula
Changes clinician reimbursement from volume- based to quality and value-based
Reforms Medicare Part B payments for >600,000 clinicians
Only affects clinician reimbursement under Medicare Part B
MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

4. MACRA: Medicare Access and CHIP Reauthorization Act of 2015
United States Government Publishing Office. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Published 11/4/ Accessed 12/6/2016.

5. Quality Payment Program (QPP) Performance-Based Payment Adjustment
How Does MACRA Work?
Quality Payment Program (QPP)
Focus: Delivery of High-Quality Patient Care
Report data
to CMS
Receive Feedback
Performance-Based Payment Adjustment
Shift from VOLUME-based to VALUE-based payment adjustments
MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

6. What Happens If I Don’t Participate?
Providers who are eligible, but do not participate in the Quality Payment Program in 2017 will receive a 4% negative payment adjustment in 2019
APM = Alternative Payment Model; MIPS = Merit-Based Incentive Payment System.
CMS. Quality Payment Program. Accessed 12/8/16.

7. How Does MACRA Help Clinicians?
Combines 3 existing programs (PQRS, VBM, and MU) under a single umbrella, reducing administrative burden
Adds a new category to provide incentives to clinicians for activities that improve clinical practice
Avoids potential negative adjustments of 11% or more in 2019 that could have occurred under the previous system
Under MACRA, the maximum negative payment adjustment in 2019 is only 4%
MU = Meaningful Use; PQRS = Physician Quality Reporting System; VBM = Value-Based Modifier.
American Medical Association. Medicare Access and CHIP Reauthorization Act (MACRA). Quality Payment Program Final Rule. Accessed 12/8/16.

8. What Are The Anticipated Benefits of MACRA for Patients?
Enhanced care coordination with a patient- centered focus
Increased access to better care
Improved patient outcomes
CMS. Quality Payment Program. Updated 11/29/16. Accessed 12/12/16.

9. Quality Payment Program (QPP) Strategic Objectives
Improve beneficiary outcomes
Enhance clinician experience
Increase adoption of Advanced APMs
Maximize participation
Improve data and information sharing
Ensure operational excellence in program implementation
APM = Alternative Payment Model. MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

10. POLLING QUESTION
Do you believe the Quality Payment Program will bring value to your clinical practice?
Yes No
Remains to be seen

11. What Are The 2 Reimbursement Tracks Under the MACRA Quality Payment Program?
Merit-Based Incentive Payment System (MIPS)
Folds 3 current programs (PQRS, VBM, MU) into a single program
Adds a new 4th component – Improvement Activities
Opportunity to earn a performance-based payment adjustment
Advanced Alternative Payment Model (APM)
Adds incentives to encourage participation in certain APMs
Qualifying clinicians are eligible for a 5% bonus and are exempt from MIPS
MU = Meaningful Use; PQRS = Physician Quality Reporting System; VBM – Value-Based Modifier. MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

12. Am I Eligible for MIPS? Eligible Clinicians 2017 Eligible Physicians
PAs
NPs
CNSs
CRNAs
Not 2017 Eligible
1st year Medicare Part B participants
Below low patient threshold:
Medicare Part B billing charges ≤$30K
≤100 Medicare Part B patients/year
Qualifying APM participants
The ABCs of MIPS October 19, 2016 (Healthcare NOW Radio)
who bill >$30K/yr under Medicare Part B and provide care for >100 Medicare patients/yr (and groups that include these clinicians)
APM = Alternative Payment Model; CNS = clinical nurse specialist; CRNA = certified registered nurse anesthetist; MIPS = Merit-Based Incentive Program; NP = nurse practitioner; PA = physician assistant. MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16

13. What is an APM? Alternative Payment Model (APM):
Payment approach that provides incentive payments to provide high-quality and cost- efficient care
Can apply to a specific clinical condition, care episode, or a population
CMS. What are Alternative Payment Models? Accessed 12/8/16.

14. What is an Advanced APM? Advanced APMs: Subset of APMs
Practices earn more for taking on risk related to patients’ outcomes
Qualifying Advanced APM Participants = 5% lump sum bonus in 2019 – 2024, with potential for higher incentive in subsequent years
No payment reduction in this track
5% bonus is on top of existing Advanced APM-specific rewards
APM = Alternative Payment Model.
MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

15. How Do I Know if I Qualify for MIPS or APM?
The majority of clinicians will be subject to MIPS
However, clinicians who participate in APMs at a certain threshold will be QPs and excluded from MIPS
CMS is working to notify clinicians of their QP status so they will know if they are excluded from MIPS prior to having to submit data
APM = Alternative Payment Model; CMS = Centers for Medicare & Medicaid Services; MIPS = Merit-Based Incentive Payment System; QP = Qualifying [APM] Participant.
MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

16. What are the Requirements to be an Advanced APM?
Must use CEHRT*
Payment must be tied to quality measures comparable to those in MIPS
Must bear a certain amount of financial risk OR qualify as a Medical Home Model
Meet revenue-based standard (≥8% of revenues at risk)
Meet benchmark-based standard (≥ 3% maximum possible loss of spending target)
* 2014 or 2015 edition CEHRT in 2017; 2015 edition CEHRT only in 2018.
APM = Alternative Payment Model; CEHRT = Certified Electronic Health Record Technology; MIPS = Merit-Based Incentive Payment System. MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

17. What are the Requirements to be an Advanced APM? (cont.)
In addition, to be eligible for the Advanced APM track and qualify to receive the 5% incentive payment, clinicians must:
Receive 25% of their Medicare-covered services through Advanced APMs OR
See 20% of their Medicare patients through Advanced APM
Services provided at CAHs, RHCs, and FQHCs that meet certain criteria can contribute to the QP determination using patient counts
Clinicians in traditional APMs can become eligible to participate in Advanced APMs by strategically increasing the amount of traditional Medicare payments or patient counts tied to the Advanced APM
However, clinicians who already qualify for the Advanced APM track cannot opt out and choose the MIPS track instead
APM = Alternative Payment Model; CAH = Critical Access Hospitals; FQHC = Federally Qualified Health Center; MIPS = Merit-Based Incentive Payment System; RHC = Rural Health Clinic; QP = Qualifying [APM] Participant. MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

18. What Qualifies as an Advanced APM?
2017
Future
CJR Payment Model (CEHRT)
Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)
ACO Track 1+
New Voluntary Bundled Payment Model
Vermont Medicare ACO Initiative
MSSP Tracks 2 and 3
Next Generation ACO model
The Oncology Care Model Two-Sided Risk Arrangement
Comprehensive End Stage Renal Disease Care model
CPC+ model (Medical Home Model)
See for the most up-to-date list of qualified Advanced APMs.
ACO = Accountable Care Organization; APM = Alternative Payment Model; CEHRT = Certified Electronic Health Record Technology; CPC+ = Comprehensive Primary Care Plus; CJR = Comprehensive Care for Joint Replacement; MSSP = Medicare Shared Savings Program.
CMS. What are Alternative Payment Models? Accessed 12/8/16.

19. What Do I Need to Do in 2017 if I am in an Advanced APM?
You will earn the 5% incentive payment in 2019 if you participate in an Advanced APM in 2017 and:
You receive 25% of your Medicare Part B payments through an Advanced APM
Or you see 20% of your Medicare patients through an Advanced APM
And you submit the quality data required by your Advanced APM, including one outcome measure
APM = Alternative Payment Model.
CMS. What are Alternative Payment Models? Accessed 12/8/16.

20. Future Advanced APM Opportunities
Coming in 2021 – “All-Payer Combination Option”
Based on 2019 performance year
Clinicians can use “other payers” to help meet the revenue or patient count thresholds to qualify for the Advanced APM track
E.g., Medicare Advantage contracts
Providers must still meet Advanced APM criteria
APM = Alternative Payment Model.
MACRA Final Rule, October 14, CMS. Quality Payment Program. Accessed 12/6/16.

21. What is a MIPS APM?
APMs that include MIPS eligible clinicians and hold their clinicians accountable for cost and quality of care
Participants receive special MIPS APM scoring
Most Advanced APMs are also MIPS APMs
Eligible clinicians who do not meet the payment or patient requirements for Advanced APM will be scored under MIPS APM
APM = Alternative Payment Model; MIPS = Merit-Based Incentive Payment System.
CMS. Alternative Payment Models in the Quality Payment Program Updated 10/14/16. Accessed 12/12/16.

22. MIPS & Advanced APMs for 2017
MIPS APM
Advanced APM
Comprehensive ESRD Care (CEC) Model
(non-LDO 1-sided risk arrangement) 
Comprehensive ESRD Care (CEC)Model
(LDO arrangement, non-LDO 2-sided risk arrangement)
Comprehensive Primary Care Plus (CPC+) Model
(Medical Home Model)
Medicare Shared Savings Program (MSSP) Track 1
Medicare Shared Savings Program (MSSP) Tracks 2, 3
Next Generation ACO Model
Oncology Care Model (OCM)
(1-sided risk arrangement)
(2-sided risk arrangement)
* See for the most up-to-date list of APMs.
APM = Alternative Payment Model; ESRD = End Stage Renal Disease; MIPS = Merit-Based Incentive Payment System. CMS. Alternative Payment Models in the Quality Payment Program Updated 10/14/16. Accessed 12/12/16.

23. What If I’m In a Small, Rural, or Health Professional Shortage Area?
Exempt from MIPS if:
≤$30,000 in Medicare Part B allowed charges or ≤100 Medicare patients
Reduced reporting requirements in some categories
Increased opportunities for clinicians at CAHs, RHCs, and FQHCs to participate in Advanced APMs
Support is available:
Transforming Clinical Practice Initiative (TCPI)
QPP-Small, Rural, Underserved Support (QPP-SURS)
APM = Alternative Payment Model; CAH = Critical Access Hospital; FQHC = Federally Qualified Health Center; MIPS = Merit-Based Incentive Payment System; QPP = Quality Payment Program; RHC = Rural Health Clinic.
CMS. Quality Payment Program. Accessed 12/9/16.

24. What If I’m a Non-Patient Facing Clinician?
Eligible to participate in MIPS if the MIPS requirements are met
Non-patient facing definitions:
Individual MIPS-eligible clinicians: ≤100 patient facing encounters
Group: >75% of NPIs billing under the group’s TIN are labeled as “non-patient facing”
There are special reporting adjustments for non-patient facing clinicians
MIPS = Merit-Based Incentive Payment System; NPI = National Provider Identifier; TIN = Tax Identification Number.
CMS. Quality Payment Program /29/16. Accessed 12/13/16.

25. Summary: How Do I Know If I’m Eligible for the Quality Payment Program?
Am I in an APM? No
Yes
Is this my first year in Medicare OR
am I below the low volume threshold?
Am I in an eligible Advanced APM?
Yes No
Do I have enough payments or patients through my eligible Advanced APM?
Yes No
Not subject to MIPS
Subject to MIPS No
Yes
Qualifying Advanced APM Participant
5% lump sum bonus payment ( )
Higher fee schedule updates (2026+)
APM-specific rewards
Excluded from MIPS
Subject to MIPS
Favorable MIPS scoring
APM-specific rewards
APM = Alternative Payment Model; MIPS = Merit-Based Incentive Payment System. CMS. Quality Payment Program. Accessed 12/8/16.

26. POLLING QUESTION
Are you eligible to participate in the Quality Payment Program in 2017?
Yes, under MIPS
Yes, under MIPS APM
Yes, under an Advanced APM
I’m not eligible
I don’t know

27. What is the Timeline for the Quality Payment Program?
2017 Performance Year
MIPS Track: record data for MIPS measure(s) for at least 90 consecutive days
Advanced APM Track: provide care during the year through the Advanced APM
Feedback
CMS provides feedback about your performance
Jan. 1, 2017
Jun. 30, 2017
Oct. 2, 2017
Dec. 31, 2017
Mar. 31, 2018
Jan. 1,
2019
Deadline to Register as a Group
Last Day to Start Collecting Data
to participate in
MIPS in 2017
Submit Performance Data
MIPS Track: submit data for MIPS measures to avoid the negative payment penalty and potentially earn a positive payment adjustment
Advanced APM Track: submit quality data through your Advanced APM to earn the 5% incentive payment
Payment Adjustment
MIPS Track: maximum ±4% payment adjustment
Advanced APM Track: 5% incentive payment
APM = Alternative Payment Model; MIPS = Merit-Based Incentive Payment System.
CMS. Quality Payment Program. Accessed 12/8/16.

28. POLLING QUESTION
To what extent are you concerned about implications of the MACRA program on your practice?
1.Not concerned at all 2. 3. 4.
5. Extremely concerned

29. Where Can I Go For More Information & Support?
CMS Quality Payment Program
Online Portal & Service Center
Available Monday – Friday, 8 AM – 8 PM ET

30. Key Takeaways
MACRA’s QPP replaces the Sustainable Growth Formula & reforms Medicare Part B payments
Shift from volume-based to value-based payments
2 reimbursement tracks: MIPS & APM with distinct eligibility criteria
Exceptions for non-patient facing and small, rural, and HPSA clinicians
Starts in 2017 with payment adjustments in 2019
Eligible clinicians who don’t participate will receive a 4% negative payment adjustment in 2019
APM = Alternative Payment Model; HPSA = Health Professional Shortage Area; MACRA = Medicare Access and CHIP Reauthorization Act of 2015; MIPS = Merit-Based Incentive Payment System; QPP = Quality Payment Program