1. Quality Payment Program Office Hours: QPP Changes You Should Know About in 2019

2. Presentation Overview
General MIPS Updates
MIPS Category-Specific Updates
Advanced APM Updates
Action Plan
Resources

3. atom Alliance Partners
Multi-state alliance for powerful change composed of three nonprofit, healthcare quality improvement consulting companies

4. Questions and Discussion
If you have questions or comments please remember to:
Press *9 to “Raise your Hand”
Please introduce yourself and your facility
Feel free to enter questions / comments directly into the chat at any time
We will be asking the audience to participate in polling questions during the event. They will pop up on your WebEx screen. Please participate and remember to click the submit button to record your answer.

5. MIPS Advanced APM Both Unsure
Poll: Which Quality Payment Program track (MIPS or Advanced APM) will you be participating in for 2019?
MIPS
Advanced APM
Both
Unsure

6. Poll: Do you know about the 2019 QPP changes?
Yes, all of them
Some of them No
Unsure

7. Quality Payment Program
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program:
Two different pathways to participate in the Quality Payment Program:
Merit-based Incentive Payment System
MIPS
Advanced Alternative Payment Models
Advanced APMs OR
Positive or negative adjustment based upon performance and applied to all Part B PFS allowable charges
Receive greater financial reward for taking on some risk related to patient outcomes

8. Merit-Based Incentive Payment System (MIPS) Updates

9. Account Management System Change
New name:
From Enterprise Identity Data Management system (EIDM) to HCQIS Access Roles and Profile system (HARP)
Benefit:
Single location for registering/managing access and viewing/reporting data
Doesn’t impact those with existing accounts

10. MIPS Eligible Clinician Type Updates
Previous MIPS eligible clinicians:
Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists
AND Newly Included:
Clinical Psychologists
Physical Therapists
Occupational Therapists
Speech-Language Pathologists
Audiologists
Registered Dieticians or Nutrition Professionals

11. Change to the Payment Adjustment Amount
Performance
Period
Also referred
to as…
Corresponding Payment Year
Corresponding Adjustment
2017
2017 “Transition” Year
2019
Up to + or -4%
2018
“Year 2”
2020
Up to + or -5%
“Year 3”
2021
Up to + or -7%

12. Exceptional Performance Threshold
MIPS Performance Threshold Requirements
Performance Period
Minimum
Performance
Threshold
Exceptional Performance Threshold
2017 3 70
2018 15
2019 30 75

13. MIPS Performance Threshold and Payment Adjustments
Final Score 2019
Payment Adjustment 2021
>75
points
Positive adjustment greater than 0%
Eligible for additional payment for exceptional performance —minimum of additional 0.5%
30.01-
74.99
Not eligible for additional payment for exceptional performance 30
Neutral payment adjustment
7.51-
29.99
Negative payment adjustment is from less than 0% to -6.9%
0-7.5
Negative payment adjustment of -7%

14. Provide >200 Covered Professional Services
Low-volume Threshold Determination
Required to participate if the following are met:
New
Bill >$90,000 a year in allowed Medicare Physician Fee Schedule charges
Furnish covered professional services to >200 Medicare Part B beneficiaries
Provide >200 Covered Professional Services
AND
AND
*Excluded from the MIPS in 2019 if all three criteria aren’t met

15. Voluntary Participation
Excluded but Want to Participate
Two options:
New
Opt-in
Voluntary Participation
If a MIPS eligible clinician and meet or exceed at least one of the low-volume threshold criteria
Submit data to CMS and receive performance feedback
You will receive a positive or negative MIPS payment adjustment
You will not receive a positive or negative MIPS payment adjustment

16. New Opt-in Policy Important Things to Remember
Once an election has been made, the decision to opt-in to MIPS would be irrevocable and could not be changed
Clinicians or groups who opt-in are subject to all of the MIPS rules, special status, and MIPS payment adjustment
APM Entities interested in opting-in to participate in MIPS under the APM Scoring Standard would do so at the APM Entity level

17. Change to the MIPS Determination Period
First Determination: Changed from Sept. 1, 2016-Aug. 31, to Oct. 1, 2017-Sept. 30, 2018 (including a 30-day claims run out)
Second Determination: Changed from Sept. 1, 2017 to Aug. 31, (including a 30-day claims run out) to Oct. 1, 2018-Sept. 30, 2019 (does not include a 30-day claims run out)
* Multiple timeframes, to determine such things as special status, were consolidated and aligned with the fiscal year
** MIPS eligible clinicians with a special status designation are still included in MIPS but qualify for special rules.

18. New Terminology
Collection Type: set of quality measures with comparable specs and data completeness criteria
eCQMs, MIPS CQMs, QCDR Measures, Part B Claims Measures
Submission Type: mechanism by which data gets submitted to CMS
Direct, Login and upload, Part B claims, Login and Attest, CMS Web Interface (group of 25+)
Submitter Type: the individual or entity that submits the data
Individual, Group, Virtual Group, Third Party Intermediary

19. MIPS Category-Specific Updates

20. General Performance Category Weight Changes
2017 Category Weights
2018 Category
Weights
2019 Category
Quality
60%
50%
45%
Cost 0%
10%
15%
Improvement Activities
Promoting Interoperability
25%
-10%
-5%
+10%
+5%

21. Quality Category Updates
Topic
What’s New?
Meaningful Measures
Removed 26 quality measures, Added 8 new measures (4 Patient-Reported Outcome Measures), 6 of which are high-priority. Total of 257 quality measures for 2019, as opposed to 275 in 2018.
Small Practice Bonus Points
Bonus of 6 points for MIPS eligible clinicians in small practices who submit data on at least 1 quality measure. *this replaces the previous 5 bonus points added to the final score for small practices.
Scoring Considerations
Measures impacted by clinical guideline changes will be given a score of zero, and the physician who reports the measure will have his or her quality performance category denominator score reduced by 10.
Topped out Measures
Continuation of 2018 policy plus Extremely Topped-Out Measures (average mean performance is within the 98th to 100th percentile range) can be proposed for removal during next rulemaking cycle. *QCDR measures are excluded from topped out measure and special scoring policies

22. Quality Category Updates cont.
Topic
What’s New?
New Specialty Measure Sets
Urgent Care – 15 measures, Skilled Nursing Facility – 13 measures
Third-party Intermediaries
All QCDR measure owners must now enter into license agreements permitting any approved QCDR to submit data on the QCDR measure (without modification) for purposes of MIPS, or risk having their measure rejected. – over 600 QCDR measures available

23. MIPS CQMs (Registry/QCDR)
Quality Category Updates cont.
Collection Type
What’s New?
Claims
65 measures – 7 measures removed, 34 are topped out with a 7 point cap applied, while another 9 measures are topped out without point cap, 13 measures are without benchmark data. Can no longer be reported by individual eligible clinicians in large groups (16+ clinicians)
eCQMs (EHR)
50 measures – 4 measures removed, 5 are listed as topped out with a 7 point cap applied, while another 4 measures are topped out without point cap, 7 measures are without benchmark data.
MIPS CQMs (Registry/QCDR)
233 measures, 15 less than are topped out with a 7 point cap, while another 51 measures are topped out without point cap, 77 measures are without benchmark data.
Web Interface
High priority measure bonus removed. Submission deadline aligned with other submission types.

24. Facility-based Scoring Option
Quality/Cost Category Updates cont.
Topic
What’s New?
Facility-based Scoring Option
Clinicians can be scored for purposes of the MIPS quality and cost performance categories based on their attributed hospital’s performance in the Hospital Value-Based Purchasing Program. Facility-based scores for the 2019 performance period/2021 payment determination are based on the 12 measures included in the fiscal year 2020 Hospital VBP Program.

25. Facility-based Scoring Details
Hospital-based designation:
Attribution:
Individual EC: Provide 75% or more covered professional services in a hospital setting. Group: 75% or more of eligible clinicians
billing under the group’s T IN are eligible for facility-based measurement as individuals
Clinician would be attributed to hospital where most services provided.
Group would be attributed to hospital where most clinicians are attributed.
Election:
Performance Score:
Automatically applied. No submission requirements for individual clinicians but Groups would need to submit data for Improvement Activity and Promoting Interoperability categories to be measured as facility-based group.
Based on attributed hospital’s performance in the Hospital Value-Based Purchasing Program.

26. Cost Category Updates 100 Total points: up to *previously 20 Topic
What’s New?
New Measures
8 episode-based measures; 5 procedural and 3 Acute inpatient medical condition.
Measure Case Minimums
TPCC still 20, MSPB still 35 and now with the addition of Episode-based measures Procedural ones are 10 and Acute Inpatient Medical Conditions are 20

27. Cost Category Updates cont.
Measure
Measure Type
Maximum Points
Medicare Spending Per Beneficiary (MSPB)
N/A
10 points
Total Per-Capita Cost for All Attributed Beneficiaries (TPCC)
Episode-based Measures
Elective Outpatient Percutaneous Coronary Intervention (PCI)
Procedural
Knee Arthroplasty
Revascularization for Lower Extremity Chronic Critical Limb Ischemia
Routine Cataract Removal with Intraocular Lens (IOL) Implantation
Screening/Surveillance Colonoscopy
Intracranial Hemorrhage or Cerebral Infarction
Acute inpatient medical condition
Simple Pneumonia with Hospitalization
ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)

28. Improvement Activities Updates
Topic
What’s New?
Measure Changes
Added 6, modified 5 existing measures, and removed 1 for a total of 118 active measures.
Bonus
Removed CEHRT bonus for reporting certain measures that goes towards the Promoting Interoperability category score

29. Promoting Interoperability Updates
Topic
What’s New?
Measurement Changes
Eliminated base and performance score. Performance-based scored at individual measure level and must report the required measures under each Objective and submit a numerator of 1 or “yes” or claim an exclusion (where applicable) Objective categories: eRx, HIE, Provider to Patient Exchange, Public Health and Clinical Data Exchange
Measure Changes
Added two new measures to the eRx Objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement. Both measures are optional for 2019.
Bonus
Removed bonus for reporting certain Improvement Activity measures that goes towards the Promoting Interoperability category score and for reporting one or more Public Health and Clinical Data Registry measure. 10 bonus points available for optionally reporting two new measures.
CEHRT Requirement
Must use 2015 Edition Certified EHR Technology (CEHRT)

30. Promoting Interoperability Updates cont.
Objectives
Measures
Maximum Points
e-Prescribing
e-Prescribing*
10 points
Query of Prescription Drug Monitoring Program (PDMP) (new and optional)
5 bonus points
Verify Opioid Treatment Agreement (new and optional)
Health Information Exchange
Support Electronic Referral Loops by Sending Health
Information (formerly Send a Summary of Care)*
20 points
Support Electronic Referral Loops by Receiving and Incorporating Health Information*
Provider to Patient Exchange
Provide Patients Electronic Access to their Health Information (formerly Provide Patient Access)
40 points
Public Health and Clinical Data Exchange
Immunization Registry Reporting*
Electronic Case Reporting*
Public Health Registry Reporting*
Clinical Data Registry Reporting*
Syndromic Surveillance Reporting*
*Exclusion available. Points reweighted to another measure.

31. Numerator/ Denominator
Promoting Interoperability Updates cont.
Objectives
Measures
Maximum Points
Numerator/ Denominator
Performance Rate
Score
e-Prescribing
10 points
200/250
80%
10 x 0.8 = 8 points
Health Information Exchange
Support Electronic Referral Loops by Sending Health Information
20 points
135/185
73%
20 x 0.73 = 15 points
Support Electronic Referral Loops by Receiving and Incorporating Health Information
145/175
83%
20 x 0.83 = 17 points
Provider to Patient Exchange
Provide Patients Electronic Access to their Health Information
40 points
350/500
70%
40 x 0.70 = 28 points
Public Health and Clinical Data Exchange
Immunization Registry Reporting
Public Health Registry Reporting
Yes
N/A
Total:
78 Points

32. Reweighting Description
Measure Exclusion Reweighting
Measure
Reweighting Description
ePrescribing
The 10 points will be redistributed equally among the measures associated with the Health Exchange objective.
HIE Objective: …Sending Health Information
An exclusion is available, but it was not address in the proposed rule how the points would be redistributed if an exclusion is claimed. “We intend to propose in next year’s rulemaking how the points will be redistributed if an exclusion is claimed.”
HIE Objective: …Receiving and Incorporating Health Information
The 20 points would be redistributed to the Send Health Information measure in the HIE Objective
Public Health and Clinical Data Exchange
If an exclusion is claimed for one measure, but the MIPS eligible clinicians submits a “yes” response for another measure, they would earn the 10 points for the Public Health and Clinical Data Exchange objective. If a MIPS eligible clinician claims exclusions for both measures they select to report on, the 10 points would be redistributed to the Provide Patients Electronic Access to Their Health Information measure

33. Promoting Interoperability Updates cont.
Topic
What’s New?
Category Reweighting
*Same as 2018 plus: Extended the automatic reweighting for:
Physical Therapists
Occupational Therapists
Clinical Psychologists
Speech-Language Pathologists
Audiologists
Registered Dieticians or Nutrition Professionals

34. Category Reweighting Scenarios
Quality
Cost
Improvement Activities
Promoting Interoperability
No Reweighting Needed
Performance Category Scores
45%
15%
25%
Reweight One Performance Category
No Cost
60% 0%
No Promoting Interoperability
70%
No Quality
40%
No Improvement Activities
Reweight Two Performance Categories
No Cost and no Promoting Interoperability
85%
No Cost and no Quality
50%
No Cost and no Improvement Activities
75%
No Promoting Interoperability and no Quality
No Promoting Interoperability and no Improvement Activities
No Quality and no Improvement Activities

35. Promoting Interoperability Alignment
MIPS APM Updates
Topic
What’s New
Criteria
Reworded to emphasize importance of basing payment on quality measures and cost
Promoting Interoperability Alignment
Align MIPS so eligible clinicians in any MIPS APMs can report Promoting Interoperability at either the individual or group level

36. Advanced APMs

37. Advanced APM Updates Topic What’s New?
CEHRT
Increased CEHRT use requirement to 75% of eligible clinicians in each Medicare Advanced APM entity. *Required for Other Payer Advanced APMs in 2020.
MIPS Comparable Measures
2020 quality measures must meet new standards; On MIPS final measure list, be endorsed by a consensus-based entity, or determined to be evidence-based, reliable, and valid by CMS
New for 2019 *Other Payer Advanced APM
QP status is achieved based upon a combination of participation in Medicare Advanced APM/s and Other Payer Advanced APMs – referred to as the All-Payer Combination. QP determinations made at the EC, APM Entity level, and at the TIN level (for cases where the entire TIN participates in a single APM Entity).
QP Determination
Must receive either 50 percent of Medicare Part B Payments or 35 percent of Medicare patients through an Advanced APM entity during a determination period. *Partial QP is 40 and 25, respectively.

38. Action Plan

39. 2019 Action Plan Seek to better understand the QPP and MIPS
Analyze current and future state
Determine eligibility (
Prepare a plan for success
Create a Team
Assign responsibilities
Assess areas to maximize performance and revenue
Establish performance and financial goals
Create an audit folder, both paper and electronic, where possible
Get Started
Monitor progress and make adjustments

40. Poll: Do you have any questions, comments, or concerns about the MIPS or Advanced APMs?
Yes – please explain over phone or in chat
No – please explain over phone or in chat

41. Quality Payment Program Technical Assistance
Medicare Learning Network (select Quality Initiatives under the Training Catalog)
atom Alliance/Qsource Quality Payment Program Assistance
Resource Center Website: Providers.Exchange
Support:
Toll-Free Phone Support:
Quality Payment Program Service Center
Phone:

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This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS policy. 19.SURS-QPP