1. Understanding the MACRA Quality Payment Program
Achieving excellence as a provider of processes to maintain professional competency is one of the ACC’s six strategic priorities. As part of this effort, the College is committed to helping members understand and navigate the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as it is implemented.
MACRA created the Quality Payment Program, which streamlines the current Medicare reporting programs (PQRS, EHR Incentive, Value Modifier) into a single program.

2. MACRA Reducing the Cost of Care Improved Patient Experience
Encourage Alternative Payment Model participation
Improve Medicare quality reporting systems
MACRA
Recognize quality based on clinically, relevant evidence-based measures
Reducing the Cost of Care
Improved Patient Experience
MACRA was signed into law on April 16, It is the result of over a decade of collaboration by medical societies and members of Congress to find a permanent solution to repeal the SGR.
MACRA is a reflection of the transformation of care under a value-based payment landscape that should be aligned with the Triple Aim.
There is still work to be done as we work with CMS to ensure the proper implementation of this law. However, I would like you to also recognize the opportunity that MACRA provides us to improve the current Medicare quality reporting programs and innovate new payment models based on the delivery of patient-focused, evidence-based cardiovascular care.
Improving Population Health

3. MACRA Impact on Health Care Delivery Will be Profound
MACRA will have profound impacts on care delivery in the United States; some believe these changes will have effects of a similar magnitude to when the Medicare and Medicaid programs were established in 1965.
It is important to note; however, that CMS has been moving toward a value-based payment system over the past decade. While MACRA is a catalyst in this movement, clinicians already participating in the existing PQRS, EHR Incentive, and Value Modifier programs, or a Medicare alternative payment model may already be ahead of the curve.
The ACC has advocated for flexibility, especially for small practices, as MACRA is implemented

4. Medicare Quality Payment Program Pathways
MACRA Quality Payment Program
Merit-Based Incentive Payment System
(+/-4% in 2019)
Advanced Alternative Payment Models
(+5% lump sum in 2019 to Qualifying Participants)
Exempt
First-year Medicare participants
Low-volume threshold
(<$30,000 allowed charges and <100 Medicare beneficiaries)
Flexibility for:
Solo and small practices (≤15)
MIPS APM participants
The QPP rule finalized the two pathways for participation – MIPS (which will apply to most clinicians in the first years of the program) and the Advanced APM pathway. Some clinicians and groups will be exempt (first year and low-volume)
The first performance year begins Jan 1, 2017, which will impact Medicare Part B payments received by clinicians and most advance practice professionals (PAs, NPs) in 2019.

5. 2017 Performance/2019 Payment Year MIPS Composite
Advancing Care Information
Security Risk Analysis
E-Prescribing
Provide Patient Access
Send Summary of Care
Request/Accept Summary of Care
Bonus points include: Registry Reporting
Quality
Most PQRS measures
QCDR (non-MIPS) measures
Bonus: “High-priority measures”
Outcome, appropriate use, patient safety, efficiency, patient experience, care coordination
Quality
60%
Clinical Practice Improvement Activities
Expanded Practice Access
Population Management
Care Coordination
Beneficiary Engagement
Patient Safety
Practice Assessment (ex. MOC)
Patient-Centered Medical Home or specialty APM
The final rule incorporates input from the ACC and others. The Cost (Resource Use) category will not be counted toward the MIPS score during the 2017 performance/2019 payment year. The 10% originally allocated toward Cost will go toward the Quality score
Specific details on the reporting thresholds and scoring for each of these categories is available on acc.org/macra
Cost (0%) will be incorporated into the MIPS score starting with the 2018 performance period

6. Pick Your Pace in 2017
Report a minimum amount of data in at least one of the categories (for example, one quality measure, one CPIA, or all five required ACI measures)
Avoid a negative payment adjustment in 2019
Test the Quality Payment Program
Submit MIPS data across all categories for at least 90 days, which could begin anytime between Jan 1, and Oct 2, 2017
Potential for a small positive payment adjustment in 2019
Participate for part of the calendar year
Submit data across all MIPS categories covering the full year reporting period, starting Jan 1, 2017
Potential for a modest positive payment adjustment in 2019
Participate for the full calendar year
Participate in an recognized Advanced APM and meet the patient or payment threshold in 2017
5 percent incentive payment on Medicare Part B payments in 2019
Participate in an Advanced Alternative Payment Model
The ACC and many other stakeholders urged CMS to adopt a “hold harmless” period as clinicians transitioned to the MACRA Quality Payment Program. As a result of this feedback, CMS is implementing the “Pick Your Pace” option for the 2017 performance year.
Under this policy, clinicians and groups can avoid a penalty by reporting a minimum amount of data (top row), 90 days of data across all MIPS categories, or a full year of data across all MIPS categories. Historical CMS data shows that most cardiologists have been successfully participating in the current Medicare programs. If you are a successful participant in the current programs, you are likely well-prepared to immediately begin reporting a full year of data under MIPS. CMS expects that those practices that will receive the highest bonuses will be those reporting a full year of performance.
Over time, CMS intends to gradually phase out the Pick Your Pace option so that all clinicians and groups are reporting performance based on a full year.

7. 2019 Payment Year MIPS Scoring
MIPS Score
MIPS Adjustment
Positive adjustment plus additional adjustment for exceptional performance
Positive adjustment greater than 0 percent to 4 percent, multiplied by budget neutrality factor on a linear sliding scale
3.0
0 percent (Benchmark Score)
Negative adjustment greater than -4 percent and less than 0 percent on a linear sliding scale
0-0.75
Negative 4 percent adjustment
(Maximum 2019 Amount)
Tip:
2017 performance year benchmarks are now available at qpp.cms.gov. Compare your current quality measure performance to these benchmarks.
MIPS adjusts Medicare Part B payments based on performance.
Based on the weights shown on the previous slide, clinicians at either the individual or group practice level will receive a MIPS composite score of Before each performance year, CMS will announce a benchmark score. Those at the benchmark score will receive a neutral payment adjustment, those above the benchmark will see a positive payment adjustment, and those below the benchmark will see a negative adjustment. Because of the Pick Your Pace program introduced in the final rule, the benchmark for the 2017 performance/2019 payment year is 3.0 points, which reflects successful minimum performance in one of the MIPS categories.
CMS expects that those clinicians and practices eligible for the highest bonuses will be those that report a full calendar year.

8. Advanced Alternative Payment Models
2017
MSSP ACO Track 2
MSSP ACO Track 3
Next Generation ACO
Vermont Medicare ACO
Oncology Care Model (2-sided risk)
Comprehensive ESRD Care Model (Large Dialysis Organization and non-LDO)
Comprehensive Primary Care +
2018 (Anticipated)
Cardiac Rehabilitation Incentive Payment Models
Advancing Care Coordination through Episode Payment Models Tracks 1 and 2 (Mandatory CABG/AMI models)
MSSP ACO Track 1+
Medicare Diabetes Prevention Program Model
Comprehensive Care for Joint Replacement Model (CEHRT track)
5% incentive payment on Part B services in 2019 if:
Clinician is part of an Advanced APM entity
AND one of the following
25% or more of Part B payments are through the Advanced APM Or
20% of your Medicare patients are through the Advanced APM

9. Advocacy Efforts will Continue
2017 and 2018 will likely be transition years with ongoing refinements to the QPP
Those already familiar with the current Medicare programs (PQRS, EHR Incentive, Value Modifier) will be best prepared
ACC working with Congress, HHS and CMS to ensure that the QPP supports evidence-based, cost-effective, high quality care
The early years of MACRA implementation will pose some very real challenges to physicians and patients accustomed to the current system. The ACC is already engaging the Department of Health & Human Services (HHS), CMS and others to minimize these challenges and take advantage of opportunities under the new system to support policies that facilitate evidence-based, cost-effective and high quality care.

10. Recognizing NCDR Participation
NCDR registries as a way to meet reporting requirements under three MIPS components:
ACC staff is working towards creating specific NCDR Registry-based solutions to the Clinical Practice Improvement Activities participation requirement.  
Quality
Advancing care information
Clinical Practice Improvement Activities
The ACC commends CMS for continuing to recognize participation in NCDR registries as a way to meet reporting requirements under three Merit-Based Incentive Payment System (MIPS) components – quality, advancing care information, and clinical practice improvement activities. ACC staff is working towards creating specific NCDR Registry-based solutions to the performance Improvement participation requirement.  

11. The Quality Payment Program Began Jan 1, 2017
Ensure that you have been successful in the existing programs – PQRS, Meaningful Use, Value Modifier
Find out if you are participating in an alternative payment model
Work with your administrator to find and understand your cost and quality data
Make care coordination an organizational priority
Focus on proper documentation
Watch qpp.cms.gov and acc.org/macra for updates and tips
with questions
The first performance year of the QPP begins on Jan 1, 2017

12. There Will Be Additional Opportunities for ACC to Provide Input Into How the MACRA Quality Payment Program Will Function
MACRA
We will be at the table!
ACC Submits Comments on MACRA Final Rule
Dec 21, 2016
ACC News Story
On Dec. 19, the ACC submitted formal comments in response to a final rule released in November regarding the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive under the Physician Fee Schedule, and criteria for Physician-Focused Payment Models. 
In the comment letter to Acting Centers for Medicare and Medicaid Services (CMS) Administrator Andrew M. Slavitt, the College notes its support for the “depth of changes” included in the final rule as a result of public comments, including those from the ACC. However, the letter also cautions that CMS “still has a heavy lift ahead in ensuring that the [Quality Payment Program (QPP)] is implemented in a way that truly supports improved patient outcomes without distracting clinicians from their priority of treating patients.” As such, the letter highlights several key areas where further improvements are needed in order to achieve this goal, as well as encourages continued clarification and education on how best to implement 2017 QPP policies into practice.
In particular, the comments call for the QPP transition period to be extended beyond the 2017 performance/2019 payment year in order for clinicians and groups to understand and process the feedback on their performance. Additionally, the College also recommends that CMS preserve the “Pick Your Pace” reporting options for 2018 and continue to implement additional solutions that support clinicians and groups in the transition to the QPP. The letter also requests that CMS carefully test the concept of virtual groups as a reporting option for helping small practices succeed under MIPS.
“While CMS made many improvements to the MIPS policies in the final rule, CMS should continue to develop this pathway so that it truly is one seamless reporting program rather than the separate, disjointed legacy programs of Physician Quality Reporting System, the Electronic Health Record Incentive, and the Value-Based Payment Modifier,” the letter goes on to state. It also recommends that CMS continue to update the list of Advanced APMs and refine policies to make this QPP participation pathway available to more specialists and clinicians.
Moving forward, the ACC notes that “the continued refinement of the QPP will require ongoing dialogue between CMS and the clinicians, patients, vendors and other stakeholders affected by this program,” particularly as unforeseen issues arise. Read the complete comment letter. Learn more about MACRA and QPP implementation in the ACC’s online MACRA hub.

13. More information is available on the ACC’s online MACRA hub at Updates are provided via the hub and through the ACC’s Advocate newsletter.