1. Illinois Chapter Scientific Meeting 2017
BREAKING NEWS! – 2018 Quality Payment Program Rule Released November 2nd at 4:15pm
The Medicare Quality Payment Program (aka MACRA): What You Need to Know
Illinois Chapter Scientific Meeting 2017
November 17, 2017
8:15 am
Brian Outland, PhD
Director, Regulatory Affairs, American College of Physicians

2. April 2015 – Congress Passed Landmark, Bipartisan Law – MACRA…
Medicare Access and CHIP Reauthorization Act of (MACRA) – focused on Part B Medicare
Congressional Intent of MACRA:
Sustainable Growth Rate repeal
Improve care for Medicare beneficiaries
Change our physician payment system from one focused on volume to one focused on value
MACRA has been recast as the Quality Payment Program, or QPP

3. Major POSITIVE Policy Changes in 2018 (and some for 2017)!!!
Extreme and Uncontrollable Circumstances – blanket exceptions for areas of the country impacted by recent hurricanes (and other natural disasters)
In some cases this automatically applies for 2017 for clinicians in certain areas of the country
Applications will be available for others and for 2018
More options for small practices (WE ASKED FOR THESE!)
Increased low volume threshold
5 bonus points to the final scores for small practices
Virtual group option
Extra points if not able to meet data completeness requirements
MIPS Bonus for Complex Patients (WE ASKED FOR THIS TOO!)

4. Other Important New CMS Initiatives – Announced just over the past few days!
Patients Over Paperwork – Mirrors the goals of ACP’s own “Patients Before Paperwork” initiative, launched two years ago!
Check out ACP’s recent policy paper “Putting Patients First by Reducing Administrative Tasks in Health Care” – now formally supported by ACOG
Meaningful Measures - To ensure that quality measures are streamlined, outcomes-based, and truly meaningful to clinicians and their patients.
Reflective of a number of ACP’s recommendations, including in our letter regarding CMS’ Measure Development Plan.

5. Merit-based Incentive Payment System (MIPS)

6. This new MIPS “report card” will replace current Medicare reporting programs
There are currently multiple individual quality and value programs for Medicare physicians and practitioners:
Physician Quality Reporting Program (PQRS)
Value-Based Payment Modifier (quality and cost of care)
“Meaningful use” of EHRs
MACRA streamlines those programs into MIPS:
Merit-Based Incentive Payment System
(MIPS)

7. Who Participates in MIPS?
No change for 2018 – additional types of clinicians may be included in 2019 performance period
Excluded clinicians for 2018 (no change):
New to Medicare (first year enrolled in Part B)
Below low-volume threshold
Significant participation in Advanced APM
Types of eligible clinicians (ECs):
Clinical Nurse Specialists
Certified Registered Nurse Anesthetists
Physicians
Physician Assistants
Nurse Practitioners

8. Low-volume Threshold Transition Year 2017 Performance Period Year 2
Excluded individuals or groups must have:
≤ $30,000 Part B allowed charges OR
≤ 100 Part B patients
Note: ECs excluded under the low-volume threshold in 2017 or 2018 may voluntarily participate but will not receive a payment adjustment
≤ $90,000 Part B allowed charges OR
≤ 200 Part B patients
Note: CMS will seek comment on if/how to allow excluded ECs to opt-in in 2019 or later years.
The proposed 2018 threshold will exclude approximately 134,000 additional clinicians from MIPS from the approximately 700,000 clinicians that would have been eligible based on the low-volume threshold that was finalized in the CY 2017 Quality Payment Program final rule.
Almost half of the additionally excluded clinicians are in small practices and approximately 17 percent are clinicians from practices in designated rural areas. Applying this criterion decreases the percent of the MIPS eligible clinicians that come from small practices.
Approximately 37 percent of individual MIPS eligible clinicians and groups (or about 572,000 ECs) would be in MIPS based on the low-volume threshold exclusion (and the other exclusions). However, 65 percent of Medicare payments would still be captured under MIPS.

9. Performance Category Weighting for the Composite Score
Transition Year
(2017 performance → 2019 payment)
Year 2 Final
(2018 performance → 2020 payment)
Year 3 Proposed
(2019 performance → 2021 payment)
Quality
60%
50%*
30%
Cost 0%
10% *
Improvement Activities
15%
Advancing Care Information
25%
Under final rule, Cost in 2018 was 10 percent. The proposed rule zeros out the 10% and reweights it to quality.
The law gave flexibility to adjust the cost weight in the first two years before setting it at 30 percent permanently in year 3.
* Note: The proposed rule for 2018 set the Cost Performance Category weight in 2018 at 0%--CMS changed this in the final rule to 10%, which results in changing the quality weight to 50% in 2018.

10. What does ACP think?
Pleased that CMS wants to watch out for small practices via the low-volume threshold, BUT…
What if a practice below the threshold wants to participate? Or had participated in 2017, so is ready, but now cannot? There is no opt-in option—even if they wanted to be in a virtual group
The movement toward value-based payment is not stopping, but now these practices may be left behind and not ready at all!
Very disappointed that CMS did not keep cost at 0% for there are not yet adequate cost measures that have been developed.

11. How Much Can MIPS Adjust Payments?
Based on the MIPS composite performance score, physicians and practitioners will receive positive, negative, or neutral adjustments up to the percentages below.
MIPS adjustments are budget neutral.
MAXIMUM Adjustments
Merit-Based Incentive Payment System (MIPS) 5% 9%
-9%
onward
-7%
-5%
-4% 7% 4%
Adjustment to provider’s base rate of Medicare Part B payment
(including Part B drugs)
Those who score in top 25% are eligible for an additional annual performance adjustment of up to 10%, (NOT budget neutral)

12. “Pick Your Pace” for 2017 Reporting
Source:

13. “Pick Your Pace” for 2018 Reporting
Must earn 15 points to receive a neutral adjustment
Must earn 70 points to be eligible for exceptional performance bonus
Quality – full year of data required
Cost – full year of data will be assessed (no reporting required)
Improvement Activities & Advancing Care Information – 90-day performance period

14. Quality Performance Category
Policy
Transition Year
(2017)
Year 2 Final
(2018)
Measures Required
6 measures
Special Requirements
1 outcome/high priority measure
Data Completeness
50% for full credit
Other measures get 3 points
60% for full credit
Others get 1 point or 3 points for small practices
Performance Period
90-day minimum
Full year
Population-based Measures
All-cause readmissions *
Weight
60%
50% in 2018
30% for 2019 and after
Note: CMS Web Interface and CAHPS are covered by separate requirements for the number of measures and types of measures
Groups in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: Report quality measures through your APM. You do not need to do anything additional for MIPS quality
* All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases.

15. Cost Performance Category
Policy
Transition Year
(2017)
Year 2 Final
(2018)
Measures Used
Medicare Spending per Beneficiary (MSPB), Total per capita cost, and 10 episode-based measures
MSPB and total per capita cost, but NOT the episode-based measures*
Reporting/Scoring
Calculated by CMS, based on claims
No change
Performance Period
Full year
Weight 0%
10% in 2018
30% in 2019 and beyond
* New episode-based measures are currently under development, CMS will solicit feedback on them in 2018; additional new cost measures will be proposed in future rulemaking.

16. Improvement Activities
Policy
Transition Year
(2017)
Year 2 Final
(2018)
Measures/Activities Required
Most participants: Up to 4 improvement activities
Groups with fewer than 15 participants or in rural or health professional shortage areas: Up to 2 activities
No change
Activities Available 92
112
Special Options
PCMH & PCSP – Full credit*
Other APMs – Either full or partial credit
Overall no change, BUT PCMH and PCSP TINs must have 50% of practices certified/recognized
Reporting/Scoring
Attestation
Performance Period
90 days
Weight
15%
* If one practice in the TIN is a PCMH or PCSP

17. Improvement Activities
Attest to participation in activities that improve clinical practice
Examples: Shared decision making, patient safety, coordinating care, increasing access
Clinicians choose from 90+ activities under 9 subcategories:
1. Expanded Practice Access
2. Population Management
3. Care Coordination
4. Beneficiary Engagement
5. Patient Safety and Practice Assessment
6. Participation in an APM
7. Achieving Health Equity
8. Integrating Behavioral and Mental Health
9. Emergency Preparedness and Response

18. Advancing Care Information
Policy
Transition Year
(2017)
Year 2 Final
(2018)
Measures Required
4-5 Base Measures (50%)
Performance Score Measures
Bonus points available
Base measures – no change
Some small changes to performance score and bonus point measures
Certification Requirements
2014 or 2015 Edition CEHRT
No change
10% bonus if using 2015 Edition CEHRT
Performance Period
90 days
Exceptions
If not sufficient measures available for a clinician
NEW 21st Century Cures Act exceptions
Weight
25%

19. Advancing Care Information – 2018
Hardship applications now due December 31 of performance period – starting in 2017
New hardship exceptions available for 2018:
EHR decertification
Small practices (15 or fewer ECs)
Clinicians in ambulatory surgical centers (ASCs)
Hospital-based clinicians (clarifies previous policy)
For ECs granted a hardship exception, ACI is weighted 0% and the 25% from ACI is reweighted to quality
Hospital-based clinicians must furnish at least 75% of services in inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), or emergency room (POS
23) setting.

20. What does ACP think?
Quality – increasing the data completeness per measure to 60% goes against the new CMS “Patients Over Paperwork” and “Meaningful Measures” initiatives
Again, disappointed that CMS did not keep cost at 0% for 2018
Improvement Activities – you now get credit for CME activities! Also an overall increase in options (still reviewing)
ACI – still too complex!!! BUT the new exceptions are good

21. Virtual Groups – NEW for 2018
At least 2 TINs with 10 or fewer clinicians each (can be solo) can join – but each one must exceed the LVT – and it requires a formal written agreement
Can get the benefits of a MIPS APM, if one TIN meets those criteria
Must elect for 2018 between now and December 31, 2017
All ECs will have their performance assessed as part of the group

22. New Bonus Points in MIPS
Complex patient bonus
1-5 bonus points toward composite score
Calculated as average HCC risk score
Boost to practices with medically complex patients
Small practice bonus
Small practice – 15 ECs or fewer
5 bonus points toward composite score
Must submit data in 1 performance category to be eligible
The score calculated is the average of the HCC risk score for all patients for an EC or group. It is calculated using the model adopted for Medicare Advantage. The bonus is added to the composite performance score (overall, not per patient). The maximum bonus is three points. The EC, group, virtual group or APM Entity must submit data on at least one measure or activity in a performance category during the performance period to receive the complex patient bonus.

23. Performance Threshold – Year 2
Examples of how to achieve 15 points (neutral adjustment) in year 2:
Report all required improvement activities
Meet ACI base score and report 1 quality measure that meets data completeness
Meet ACI base score and submit 1 medium-weighted improvement activity
Submit 6 quality measures that meet data completeness criteria

24. Advanced Alternative Payment Models (APMs)

25. Advanced Alternative Payment Models (APMs)
As defined by MACRA, advanced APMs must meet the following criteria:
The APM requires participants to use certified EHR technology.
The APM bases payment on quality measures comparable to those in the MIPS quality performance category.
The APM either: (1) requires APM Entities to bear more than nominal financial risk for monetary losses; OR (2) is a Medical Home Model expanded under CMMI authority.
Initial definitions from MACRA law, APMs include:
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

26. How does MACRA Provide Additional Rewards for Participation in Advanced APMs?
Most clinicians who participate in APMs will be subject to MIPS and will receive favorable scoring under the MIPS improvement activities performance category – these are called MIPS APMs.
APM
participants
Those who participate in the most Advanced APMs may be determined to be qualifying APM participants (“QPs”). As a result, QPs:
Are not subject to MIPS
Receive 5% lump sum bonus payments for years
Receive a higher fee schedule update for 2026 and onward
Advanced APMs
QPs
The 2020 APM Incentive Payment will be based on 2018 services

27. Advanced APMs (2018) include:
Comprehensive Primary Care Plus (CPC+)
Medicare Shared Savings Programs – Tracks 1+, 2 & 3
Next Generation ACO Model
Comprehensive End-Stage Renal Disease Care Model (Two- Sided Risk Arrangements)
Oncology Care Model (Two-Sided Risk Arrangement)
Comprehensive Care for Joint Replacement (CJR) Model – Track 1 with CEHRT requirement
Vermont Medicare ACO Initiative (as part of the Vermont All- Payer ACO Model)
Coming soon: New APMs to be announced later this year

28. APM Snapshot Dates
To determine QP status, CMS uses 3 “snapshots” to determine whether an APM entity meets the threshold:
March 31st
June 30th
August 31st
Reaching the QP threshold for any snapshot dates will result in QP status for the eligible clinicians in the Advanced APM Entity
Starting in 2018, CMS has added a fourth snapshot on December 31st to determine any additional ECs for MIPS APMs only
These snapshots have a claims runout period following the date, so actual notifications of QP status may be 2–3 months after the snapshot date. QP determinations must be based off of the first three snapsots in order to ensure that ECs know whether they meet the threshold in time to be able to submit data for MIPS if necessary.

29. How to Determine Participation Status
MIPS Lookup Tool: lookup
APM Lookup Tool:

30. Advanced APMs: Nominal Risk Standard
Transition year nominal risk standards:
8% of average estimated Parts A & B revenue for the APM entities (originally planned to count as an option only for and 2018); or
3% of the expected expenditures for which an APM entity is responsible
Year 2 final rule:
Extends the 8% Parts A&B revenue standard for 2 additional years (through 2020 performance period); or
3% of the expected expenditures is still an option
The 3% of expected expenditures is still an option. The 8% of Parts A&B revenues was added in the final rule as a second option for nominal risk. It was only proposed as an option at that level for the first two years. The rule leaves 8% as an option for an additional two years. I believe the Track 1+ ACO fits under the 8% A & B standard.

31. Advanced APMs: Medical Home Model
A Medical Home Model is an APM with the following features:
Primary care practices or multispecialty practices that include primary care clinicians
Empanelment of each patient to a primary care clinician
At least four of the following 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

32. Advanced APMs: Medical Home Model
Year 2 changes:
CPC+ Round 1 participants are not limited to having fewer than 50 clinicians in parent organization to be an Advanced APM
CPC+ Round 2 participants and future medical home models must have fewer that 50 clinicians in the parent organization to be an Advanced APM
The medical home model nominal amount standard is modified to increase risk more slowly as outlined in chart
Medical home nominal risk standard: percentage of estimated average of Parts A & B revenue at risk
Performance
Year
Transition Year Rule
Year 2 Final
2017
2.5%
2018 3%
2.5%*
2019 4%
2020 5%
2021 and after
* This was proposed to be 2%

33. ACP Advocacy At Work…
ACP member, Louis Friedman, DO, FACP – Testified before the House Energy & Commerce Health Subcommittee on MACRA/QPP APMs
In 4-physician private practice in Woodbridge, New Jersey
NCQA-certified as a patient centered medical home, level 3, since 2008
Participated in the Comprehensive Primary Care Initiative (CPCi) for three years
Now enrolled in the Comprehensive Primary Care Plus (CPC+) program, track two.

34. Independent PFPM Technical Advisory Committee (PTAC)
Physician-Focused Payment Model
Goal to encourage new APM options for Medicare clinicians
Technical Advisory Committee 
Submission of model proposals by Stakeholders
 
Secretary comments on CMS website, CMS considers testing proposed models
11 appointed care delivery experts that review proposals, submit recommendations to HHS Secretary
For more information on the PTAC, go to: physician-focused-payment-model-technical-advisory-committee

35. PTAC Basics 11-member panel appointed to 3-year terms
Quarterly public meetings
Next meeting scheduled for December 18-20
Reviews physician-focused payment models and makes a recommendation to HHS on implementation
Secretary of HHS must post a response to recommendations it receives from PTAC
No requirement for HHS to implement recommended proposals

36. What is a MIPS-APM – According to the formal definition…
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.

37. How does a being a MIPS APM help?
Streamlines MIPS reporting & scoring for ECs in certain APMs (e.g., no add’l quality reporting beyond APM)
MIPS scores aggregated at the APM entity level
All ECs in an APM receive the same MIPS final score – category weighting is slightly different
Full credit in the Improvement Activities category
Continued participation in APM’s reward program
Added advantage for virtual groups in 2018

38. Overview of ACP’s Approach to Help You!
Communication & Outreach Resources & Tools

39. ACP’s Main Website for the QPP

40. ACP Web Information for the QPP
ACP’s QPP webpage:
Information on the QPP rules & ACP’s comments
Link to our Quality Payment Advisor (QPA)
Basics on the QPP – what is it, what are the tracks, what is pick your pace? Also, Glossary and Video
Latest Updates/News
Links to further information – 10 Things You Should Know, FAQs, Additional Tools
Member Forum for MACRA/QPP:
Questions:

41. ACP Quality Payment Advisor

42. Related ACP Web Information for Value-Based Payment
ACP’s Practice Transformation webpage:
ACP’s Support and Alignment Network Grant
High Value Care Resources
HVC Care Coordination Toolkit
Practice Redesign Support
Quality Improvement and Registries
Engaging Patients and Families

43. ACP Resources for QPP – and Value-Based Payment Overall
Physician & Practice Timeline (text alerts–acptimeline to ) -
Will help you to know key deadlines and prepare for them!
ACP Practice Advisor® -
Interactive web tool to assist with quality improvement, practice transformation, and more
ACP Genesis Registry -
Registry software option to assist with reporting to CMS on PQRS and/or MU.
It is designed to meet quality, improvement activities, and ACI requirements of MIPS
Questions:

44. Centers for Medicare and Medicaid Learning Collaborative
>$785 million
Prepare 140,000+ clinicians for value-based payments
↑health outcomes for millions of patients
↓unnecessary hospitalization, tests and procedures
Generate $1-$4 billion in savings
Build evidence base for practice transformation
Two Major Parts:
Practice Transformation Networks
Support and Alignment Networks
One of many but the most broad reaching and inclusive (small rural underserved practices)
>$785 million in funding from CMMI
Prepare 140,000+ clinicians for value-based payments
↑health outcomes for millions of patients
↓unnecessary hospitalization, tests and procedures
Generate $1-$4 billion in savings
Build evidence base of practice transformation

45. ACP Practice Advisor® Improve process and structure of care
Spotlighted practices
Practice biopsy
Links to tools based on biopsy results
CME and MOC
New Modules
Avoid Unnecessary Testing
Improve Patient Access
Improve Care Coordination
Improve Medication Adherence
Patient Experience
Patient Engagement
Advanced Care Planning

46. What is the Genesis Registry?
National, “EHR-Ready”, CMS Qualified Clinical Data Registry (QCDR)
Supports continuous exchange of standard EHR
data
Pulls data to populate eMeasures aligned w/ EHR data readiness
64 eMeasures 2016 / All NQS Domains/ All MIPS measures
Benchmarks Across Multiple Specialties
User friendly and approved feedback reports to drive continuous practice improvement and high quality scores on measures
30,000+ Providers
21,000,000+ Patients

47. Contact Information
webpage:

48. Appendix

49. Individual v. Group Reporting
A unique billing TIN and NPI combination
Group
A single TIN with 2 or more clinicians (NPIs) who have assigned billing rights to the TIN
An APM Entity
A virtual group (new for 2018)
Clinicians reporting for MIPS as a group must do so for all 4 performance categories

50. Submission Mechanisms
Same submission mechanisms as transition year
New in 2018 – can use multiple submission mechanisms for a single performance category
Performance Category
Submission Mechanisms for Individuals
Submission Mechanisms for Groups
Quality
Claims
QCDR
Qualified registry EHR
Qualified registry EHR
CMS Web Interface (groups of 25 or more)
CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with another data submission mechanism.)
Administrative claims (for readmission measure – no submission required)
Cost
Administrative claims
(no submission required)
Administrative claims (no submission required)
Advancing Care Information
Attestation
Improvement Activities

51. Overview of Quality Performance Category
Weight: 60% for years 1 and 2; 30% in subsequent years
Most participants: Report up to 6 quality measures, including an outcome measure
Full year of data required for year 2 (2018); increase from 90-day minimum in transition year (2017)
Three population measures automatically calculated from administrative claims, but only one* used for performance score.
Groups using the web interface: Report 15 quality measures for a full year.
Groups in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: Report quality measures through your APM. You do not need to do anything additional for MIPS quality.
CAHPS for MIPS reporting is voluntary (and credit is provided under Improvement Activities)
Population measure to be kept: all-cause hospital readmissions (ACR) measure and will apply it to groups with 16 or more clinicians instead of the proposed approach of groups of 10 or more. A 200 case minimum must be met for the measure to count as part of a group’s quality performance score.
* All-cause readmissions – but only for groups with 16 or more clinicians with at least 200 attributed cases.

52. Quality – Data Completeness Criteria
Policy
Transition Year
(2017)
Year 2 Proposed
(2018)
Data Completeness
Claims only: 50% of Medicare Part B patients
Other reporting mechanisms: 50% of patients from all payers
Points Based on Completeness
3 points for measures that do not meet data completeness
1 point for measures that do not meet data completeness;
3 points for measures that small practices report that do not meet data completeness
For the CMS Web Interface and CAHPS, clinicians report on all of the measures within the reporting mechanism for the sample of the Medicare Part B patients CMS provides. So groups reporting under these mechanisms don't have the traditional 6 measures including one outcome measure requirement.
The CMS Web Interface has something like 15 measures, and you report on the first 248 consecutively ranked patients for all of the measures.
CAHPS counts as one quality measure, but the survey is not a traditional quality measure. The CAHPS survey can count as a high priority measure in absence of an outcome measure. Groups using the CAHPS survey must also report 5 additional quality measures.
Note: For CMS Web Interface and CAHPS, groups must meet data submission requirements on the sample of the Medicare Part B patients CMS provides

53. Quality – Scoring of Measures Data
Policy
Transition Year
(2017)
Year 2 Proposed
(2018)
Measures Scored Against a Benchmark*
3-point floor up to 10-point maximum
Measures without a Benchmark
3 points
Measures Not Meeting Case Minimums
Measures Not Meeting Data Completeness
1 point;
3 points for small practices
Bonuses
Up to 10% - additional high priority measure
Up to 10% - end-to-end electronic reporting
* Must meet data completeness criteria to be scored against a benchmark

54. Quality – Topped Out Measures
Year 2 proposed rule policies for topped out measures:
Starting with 2018 performance period, 6-point cap for measures considered “topped out”
Measures identified as topped out will be removed after 3 years, through rulemaking for in the 4th year
CMS Web Interface measures are excluded from the topped out measures policies

55. Quality – Topped Out Measures
Topped Out Measures Proposed for Special Scoring Standard in 2018
Measure Name ID
Type
Specialty Set
Perioperative Care: Selection of Prophylactic Antibiotic – 1st or 2nd Generation Cephalosporin 21
Process
General Surgery, Orthopedic Surgery, Otolaryngology, Thoracic Surgery, Plastic Surgery
Melanoma: Overultilization of Imaging Studies in Melanoma
224
Dermatology
Perioperative Care: Venous Thromboembolism Prophylaxis (When Indicated in ALL Patients) 23
Image Confirmation of Successful Excision of Image-Localized Breast Lesion
262
n/a
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for CT Imaging Description
359
Diagnostic Radiology
COPD: Inhaled Bronchodialator Therpy 52
The ID is the CMS quality identifier. The NQF numbers could be added if necessary. There were not any topped out measures identified for 2017.

56. Cost Measures Defined
Represent the Medicare payments for care furnished to a patient during an episode of care
Based on episode groups that:
Identify items and services furnished in addressing a condition
Serve as a unit of comparison
For example, an episode group for meniscus repair identifies care services furnished for this procedure and enables comparison of clinicians providing these services
Informs clinicians on the costs of their patients for which they are responsible
Can be aligned with quality assessment to tie quality outcomes to cost
Calculated using Medicare claims data so no additional data submission is required
This is CMS language

57. Components of a Cost Measure
Defining an episode group
Assigning costs to the episode group
Attributing episode groups to clinicians
Risk adjusting episode groups
Aligning cost with quality
This is CMS language

58. Adding New Improvement Activities
New improvement activities can be added annually
Solicited by CMS through a “call for activities” process similar to call for quality measures
March 1 – deadline to submit improvement activities for consideration for performance period in next calendar year
E.g., submit by March 1, 2018 for performance period in 2019
Process for removing improvement activities to be added in future rulemaking
The “call for measures” process is longer than the “call for activities” because quality measures go through pre-rulemaking and the MAP, which takes an additional year

59. Advancing Care Information – Base Measures
Advancing Care Information Objectives and Measures:
Base Score Required Measures
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
** Transition measures utilize 2014 CEHRT Edition

60. Advancing Care Information – Performance Score Measures
Advancing Care Information Transition** Objectives and Measures:
Performance Score Measures
Advancing Care Information Objectives and Measures:
Performance Score 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
* Indicates performance measure that is included in base measures
** Transition measures utilize 2014 CEHRT Edition

61. Improvement Activities Eligible for ACI Bonus Score - 2017
Quality Payment Program
Improvement Activities Eligible for ACI Bonus Score
Improvement Activity Performance Category Subcategory
Activity Name
Weight
Expanded Practice Access
Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's
medical record
High
Population Management
Anticoagulant management improvements
Glycemic management services
Chronic care and preventative care management for empanelled patients
Medium
Implementation of methodologies for improvements in longitudinal care management for high risk patients
Implementation of episodic care management practice improvements
Implementation of medication management practice improvements
Care Coordination
Implementation of use of specialist reports back to referring clinician or group to close referral loop
Implementation of documentation improvements for practice/process improvements
Implementation of practices/processes for developing regular individual care plans
Practice improvements for bilateral exchange of patient information
Beneficiary Engagement
Use of certified EHR to capture patient reported outcomes
Engagement of patients through implementation of improvements in patient portal
Engagement of patients, family and caregivers in developing a plan of care
Patient Safety and Practice Assessment
Use of decision support and standardized treatment protocols
Achieving Health Equity
Leveraging a QCDR to standardize processes for screening
Integrated Behavioral and Mental Health
Implementation of integrated PCBH model
Electronic Health Record Enhancements for BH data capture
Medium32
From Table 6 in the proposed rule

62. Improvement Activities Eligible for Bonus Score - 2018
In addition to the improvement activities eligible for the ACI bonus in 2017, CMS proposes to add the following new eligible activities for 2018:
Improvement Activity Performance Category Subcategory
Activity Name
Weight
Patient Safety and Practice Assessment
Communication of unscheduled visit for adverse drug event and nature of event
Medium
Consulting AUC using clinical decision support when ordering advanced diagnostic imaging
High
Population Management
Glycemic screening services
Glycemic referring services
Provide clinical-community linkages
Advance care planning
Achieving Health Equity
Promote use of patient-reported outcome tools
Care Coordination
Practice improvements that engage community resources to support patient health goals
Primary care physician and behavioral health bilateral electronic exchange of information for shared patients
PSH care coordination
Beneficiary Engagement
Engage patients and families to guide improvement in the system of care
These are additional new IAs that are eligible for the bonus starting in The 2017 IAs will remain in place as options as well.

63. Advancing Care Information – Basic Scoring
Base measures:
Must report all required base measures to get any credit for ACI
4-5 measures depending on CEHRT edition
All base measures are numerator/denominator or yes/no measures
Worth 50% of ACI score
Performance score measures:
Choose to submit from up to 9 measures for additional credit toward remaining 50% of ACI score
Bonus credits:
5% bonus - Report Public Health and Clinical Data Registry Reporting measures
10 % bonus - Use certified EHR technology to complete certain Improvement Activities
The MIPS eligible clinician must be in active engagement with one or more additional public health agencies or clinical data registries that is/are different from the agency or registry that they identified to earn a performance score in order to receive the ACI 5% bonus score.

64. Advancing Care Information – Exemptions for 2017
Will have ACI score reweighted into quality
If these clinicians choose to submit data for ACI, CMs will score their performance and weight ACI accordingly
These exemptions largely mirror those under MU.
Hospital-based clinicians have at least 75% of their billing from place of service (POS)

65. Advancing Care Information – Exemptions for 2017
Beginning in 2017, clinicians may apply to have ACI reweighted to zero
Insufficient internet connectivity
Extreme and uncontrollable circumstances
Lack of control over the availability of CEHRT
Certain clinicians may be exempted from ACI automatically
Non-patient-facing clinicians
NPs, PAs, CNRAs, CNSs
Hospital-based clinicians
25% weight will be reweighted to quality
Hospital-based clinicians have at least 75% of their billing from place of service (POS): inpatient, on-campus outpatient department, or emergency department

66. Advancing Care Information – 2018 Proposals
Can use 2014 or 2015 CEHRT edition
Bonus for using 2015 CEHRT (10 percentage points)
Additional improvement activities with ACI bonus available
Immunization registry reporting – if registry not available, can earn 5% each for reporting to public health agency or clinical data registry, maximum of 10% toward performance score
Bonuses for registry reporting – now must report to a different registry than reported to for performance score to earn 5 % bonus

67. Facility-based Measurement
Optional voluntary facility-based scoring mechanism
Eligible individuals: must have at least 75 % of services in inpatient hospital or ED settings
Eligible groups: 75% of group must meet individual eligibility requirements
Uses Hospital Value-Based Purchasing measures
Hospital performance score converted into quality and cost scores
This proposal isn't meant to exclude more people from volume thresholds. It is intended to reduce reporting burden on facility-based MIPS eligible clinicians by leveraging existing quality data sources and value-based purchasing experiences and aligning incentives between facilities and the MIPS ECs who provide services there. CMS believes that facility-based MIPS ECs contribute substantively to their respective facilities’ performance on facility-based measures of quality and cost, and that their performance may be better reflected by their facilities’ performance on such measures. Groups are still defined by TIN. For a group to be eligible for this option, 75 percent of the ECs in the TIN must meet the hospital-based EC definition. (The hospital-based EC is a term that has been around under MU for exemption purposes since hospitals have a separate MU program from physicians. Clinicians meeting the hospital-based definition can be exempted from ACI already.)

68. Scoring Improvements – Proposed for 2018
Quality
Based on rate of improvement
More points awarded for those not performing well previously
Up to 10 percentage points available for category
Cost
Based on statistically significant changes at measure level
Will not affect final score for 2018 performance since cost category has 0% weight
Scoring improvements for the ACI and Improvement Activities categories may be incorporated in the future
it is probably accurate to assume that the highest performers will never be able to benefit very substantially from any bonuses awarded for improving over previous scores. Whereas the people who score on the lower end of the spectrum have a lot more ability to benefit from any bonuses given for improvement.

69. CMS Scoring Approach for MIPS
Year 2 approach same as in transition year
MIPS Category
Measures
Top Score
Total Percentage Weight
Quality
Each measure worth up to 10 points and evaluated based on performance relative to benchmarks
Bonus for reporting additional outcome or high-priority measures and for end-to-end reporting
60 + more for bonus reporting
60%
Advancing Care Information
Base score 0-50 points +
Performance score 0-90 points +
Bonus points 0-15 points
100 (even though you can actually get up to 155)
25%
Improvement Activities
High weighted activities = 20 points
Medium weighted activities = 10 points
40 (small practices or those in rural or HPSA areas, each activity worth double points)
15%

70. Performance Threshold
Performance threshold = points needed for neutral adjustment
Increases from 3 points in transition year to 15 points in year 2
Transition Year
Final Score
Transition Year Payment Adjustment
Year 2
Year 2 Proposed Payment Adjustment
≥ 70 points
Positive adjustment
Eligible for exceptional performance bonus
4-69 points
16-69 points
3 points
Neutral adjustment
15 points
0-2 points
Negative 4% adjustment
0 points = does not participate
0-14 points
Negative 5% adjustment

71. Advanced APMs: Partial QPs
Partial QPs meet a lower APM threshold
In 2017 & 2018 performance periods, must have 20% of payments through an Advanced APM or 10% of patients
Do not qualify for 5% Advanced APM bonus
Continue to receive any shared rewards from APM
May opt into MIPS participation under MIPS APM scoring standard
Benefit from streamlined MIPS reporting and scoring based on APM, so may have good opportunity for positive MIPS adjustment

72. Advanced APMs: All-payer Combination Option
Available beginning with 2019 performance period
For ECs who do not meet Advanced APM thresholds based on Medicare APM participation alone
Must meet a lower Medicare APM participation threshold before other-payer APMs can be considered through the all-payer option
Other payer APMs must meet similar requirements to Medicare (i.e., require use of CEHRT, use quality measures comparable to MIPS, and meet nominal risk standards)

73. Advanced APMs: All-payer Combination Option
Proposals for other-payer APMs in year 2 rule:
Have option of meeting the 8% revenue-based risk standard
QP determinations made at individual EC level only rather than at APM entity level
Payer-initiated process established to determine whether APM requirements are met
EC-initiated process established to allow ECs to submit information on payment arrangements not submitted by payers

74. Advanced APMs: All-payer Combination Option
Additional details on process for determining other-payer APMs:
Other-payer Advanced APM determinations made by CMS prior to performance period
Payer-initiated process limited to Medicaid, MA, and multi-payer CMMI models for 2019; other payers in future
ECs and APM entities can submit info on payer arrangements if not submitted by payer
Guidance and submission forms available to payers and ECs early in year prior to performance period

75. APM Snapshot Dates
A – claims data period for APM entities captured at point B
C – claims runout period, with finalized determinations at D
Snapshot #4 for MIPS APM determinations for full TIN APMs, not for QP or Partial QP determinations
Jan 2017
Feb 2017
Mar 2017
Apr 2017
May 2017
Jun 2017
Jul 2017
Aug 2017
Sep 2017
Oct 2017
Nov 2017
Dec 2017
Fourth assessment date of December 31 is for ECs in a full TIN APM only to determine MIPS APM status. Full TIN APMs (every clinician in the TIN in the APM) include MSSP ACOs. The rationale is that clinicians who join the APM TIN late in the year would be forced to participate in MIPS while the rest of their TIN was under the MIPS APM scoring standard. A B C D #1 A B C D #2 A B C D #3 A B #4
MIPS APMs only

76. PTAC Process
HHS (ASPE) staff received proposal and reviews for completeness
Proposal posted for public comment (3 week period) and assigned to a Preliminary Review Team (PRT)
PRT reviews proposal, gathers additional information from submitter and/or others, and evaluates proposal based on 10 established criteria
PRT makes recommendation and prepares report for full PTAC consideration
PTAC reviews proposal at public meeting, scores it on 10 criteria, and determines a recommendation to HHS Secretary
Comments from submitter and public can be vocalized during this meeting
PTAC prepares recommendation in report and submits to HHS Secretary
HHS Secretary must post response to recommendation from PTAC
Each Preliminary Review Team (PRT) is composed of PTAC members appointed by the chair/vice chair, consisting of 2-3 members including at least 1 physician.

77. PTAC Recommendation Options
The PTAC may choose from the following in making a recommendation to the Secretary:
Do not recommend;
Recommend for:
Limited Scale Testing (meets criteria but lacks sufficient data to evaluate some aspects);
Implementation; or
Implementation as a high priority.

78. PTAC – Proposals Already Reviewed
Completed review process for the following proposals:
Project SONAR – gastroenterology IBD model – recommended for limited testing
COPD and Asthma model – not recommended (needs technical assistance)
American College of Surgeons’ model – recommended for limited testing

79. PTAC – Pending Proposals
Proposals under review include AAFP model, an ESRD model, etc. Proposals available at – click on “Proposal Submissions” tab.

80. Are you a Qualifying Participant?
Payments
Patients QP
25%
20%
Partial QP
10%
Year 2 thresholds are same as in transition year
QPs are eligible to receive a 5% bonus payment plus any rewards associated with the APM, and are excluded from MIPS.
Partial QPs have the option to participate in MIPS, and are eligible for APM rewards.
If in an APM that is not advanced OR in an Advanced APM but do not meet the thresholds to be excluded from MIPS, you are in a MIPS APM with favorable scoring and APM rewards.
You can be a QP by meeting the payment or patient threshold.

81. MIPS APMs Scoring Proposed in year 2 rule:
Transition Year (2017)
Year 2 Proposed (2018)
Performance Category
MSSP & Next Gen ACOs
Other MIPS APMs
All MIPS APMs
Quality
50% 0%
Cost
Improvement Activities
20%
25%
Advancing Care Information
30%
75%
Proposed in year 2 rule:
Non-ACO APM participants will now receive a score for the quality component based on their APM participation; same weighting used across all APMs
A 4th snapshot date of December 31st will be used to determine if additional ECs in full TIN APMs should be included under MIPS APM scoring
Essentially, the ACOs use the CMS web interface, which is also a reporting option in MIPS. Their data was easy to translate into something to compare with others participating via the MIPS pathway. Those in other APMs are not submitting data in a format that was easy to covert into a comparison with other MIPS participants. Therefore, CMS did not count their quality score in the first year while CMS determined how to compare it with others. 
Due to limitations in how quality data is submitted for the non-ACO APMs (the non-ACOs do not submit data through a MIPS reporting mechanism), CMS could not easily translate the quality data into a MIPS score. However, beginning in the second performance period, CMS will be able to account for the quality data for all APMs. Therefore, all MIPS APMs will be under the same performance category weighting system.
The first column represents anyone in a Medicare/CMMI ACO, regardless of whether it is advanced. So it would include Track 1 MSSP ACO participants as well as those in Track 2, 3, and Next Gen that fall below the threshold.  

82. What is a MIPS APM? – Interpreted…
A special scoring standard for participants in certain APMs
Initially, most MIPS APMs will be one of the following:
Partial QPs in Advanced APMs who opt into MIPS
ECs in Advanced APMs below the Partial QP threshold
ECs in certain APM tracks that do not meet the nominal risk or other Advanced APM standards (i.e., MSSP Track 1, etc.)

83. Genesis Registry Quality Reporting
Meets reporting requirements for MIPS composite score
Quality (60%)
Continuous Practice Improvement Activity (CPIA) ( 15%)
Advancing Care Information (ACI) (25%)
Gap analysis performance results and measure feedback
Comparisons by practice and
specialty to:
National benchmarks
Peer comparators

84. Proposed FINAL Rule (and beyond) Advanced APMs
Proposed in 2017
New for 2017
New for 2018
Shared Savings Program (Tracks 2 and 3)
Track One Plus (details recently released)
Next Generation ACO Model
Adding new participants (applications in 2017)
Comprehensive ESRD Care (CEC) (large dialysis organization)
CEC for non-LDOs with 2-sided risk
Comprehensive Primary Care Plus (CPC+)
Adding more payers & practices (applications in 2017)
Oncology Care Model (OCM) announced to start in 2018
OCM – 2-sided risk (now starting in 2017)
Comprehensive Care for Joint Replacement Payment Models (originally planned for 2018)
 Vermont Medicare ACO Initiative
Advancing Care Coordination through Episode Payment Models Track 1
Cardiac Rehabilitation (CR) Incentive Payment Model
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