Achieving Compliance with the MIPS Quality Reporting Program: Practical MIPS reporting considerations in 2018 Pay - for - Performance Pay - for - Reporting.

Achieving Compliance with the MIPS Quality Reporting Program: Practical MIPS reporting considerations in 2018 Pay - for - Performance Pay - for - Reporting Fee - for - Service Presented by A. Andrews Dean MS HIMSS Conference May 17, 2018

Medicare payments under MACRA
* Additional bonus available for exceptional performance Baseline PFS Updates 0.5% 0% 0.25% ±4% ±5% ±7% ±9% MIPS* Under MACRA, qualifying APM participants in “eligible” APMs: Are exempt from MIPS Receive annual 5% lump sum bonus payments from Receive a higher fee schedule update for 2026 and onward 5% lump sum bonus 0% +0.5% PFS APMs 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

MIPS 2019 and 2020 penalty risks compared
Legacy programs Potential adjustments PQRS -2% MU -5% VBM -4% or more* Total penalty risk -11% or more* Bonus potential (VBM only) Unknown (budget neutral)* MIPS factors 2019 scoring 2020 scoring Quality measurement 60% of score 50% of score Promoting Interop. (ACI) 25% of score No change Cost 0% of score 10% of score Improvement Activities 15% of score Total penalty risk Max of -4% Max of -5% Bonus potential Max of 4%, plus potential 10% for high performers Max of 5%, plus potential 10% for high performers; bonus points available for complex patients, small practices *VBM was in effect for 3 years before MACRA passed, and penalty risk was increased in each of these years; there were no ceilings or floors on penalties and bonuses, only a budget neutrality requirement.

MIPS Payment adjustments 2019 and 2020
2017 final score 2019 payment adjustment > 70 points Positive adjustment Eligible for exceptional performance bonus of at least 0.5% 4-69 points Not eligible for exceptional performance bonus 3 points No adjustment 0 points -4% negative adjustment 2018 final score 2020 payment adjustment > 70 points Positive adjustment Eligible for exceptional performance bonus of at least 0.5% points Not eligible for exceptional performance bonus 15 points No adjustment points Negative adjustment between 0% to -5% points -5% negative adjustment

MIPS checklist & considerations
Are you exempt from MIPS? Low volume provider? Qualified participant in an advanced APM? Do you want to participate as an individual or as a group? Do you meet requirements for small, rural, non-patient-facing accommodations? Do you/ can you participate in a qualified clinical data registry? Did your past PQRS, QRUR, and MIPS 2017 reports reveal areas for improvement? Which Improvement Activities are you engaged in now? What are you interested in doing? Is your EHR certified? If so, is it the 2014 or 2015 edition? Does your vendor support Medicare quality reporting?

Quality Payment Program (QPP) Reporting Eligibility - 2018
NO CHANGES: Individuals & Groups Consisting of these Eligible Providers: Physician (MD, DO, DMD, DDS) beyond 1st year of Medicare Part B participation Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Meeting the Following Eligibility Thresholds During 1 of 2 Determination Periods: Sept. 1, – Aug. 31, OR Sept. 1, 2017 – Aug. 31, (Includes a 30-day claims runout) Bill Medicare more than $90,000 of allowed charges a year (Medicare Advantage claims do not apply to the required threshold) Provide care for more than 200 Medicare patients a year (Medicare Advantage patients do not apply to the required threshold) It is estimated that about a third of Medicare clinicians will fall below the volume participation threshold in 2018, creating a more competitive program

MIPS Low-volume threshold exemption
Eligibility calculated by CMS Based on 12-month historical data (previous September-August) Visit enter your NPI to check eligibility for the current year For group reporting: low-volume physicians who are members of a group that exceeds the threshold must still participate in MIPS Exempted physicians receive annual fee schedule updates, but no bonuses or penalties

MIPS Merit-Based Incentive Program
Quality Payment Program (QPP) Path #1: MIPS MIPS Merit-Based Incentive Program One of the Two Quality Payment Programs (QPP) Consists of Four Categories: Quality Clinical Performance Improvement Activities Advancing Care Information (now Promoting Interoperability) Cost

Eligible for MIPS Reporting for 2018
Eligible Individual Providers (EPs) Group of Eligible Providers – TIN with multiple NPI numbers Virtual Groups – Groups of practices (TINs) each with 10 or less clinicians and solo practitioners exceeding low-volume threshold that are scored for MIPS as if a group sharing a single TIN No location nor specialty restrictions on the formation of virtual groups Practices must sign agreement and apply to CMS by December 31st MIPS APMs – Defined as certain APMs that include eligible MIPS providers as participants Partial Qualifying Advanced APMs *Reporting optional

MIPS Payment Adjustment Timeline
MIPS payment adjustments (+4%/-4% in 2019) are based on Medicare Part B annual payments for covered services and items Medicare Part B drug payments are now EXCLUDED in the calculation of MIPS incentive and penalty payments Annual inflationary increases of .5% to the CMS fee schedule applies to the payment years of 2016 – 2019 An annual inflationary increase of .25% to the CMS fee schedule applies to the payment year of 2026, onward (X = Budget Neutrality Factor ) 2016 2017 2018 2019 2020 2021 2022+ Last performance year for PQRS, MU & VM Last payment year for PQRS, MU & VM MIPS +4%*X MIPS +5%*X MIPS +7%*X MIPS +9%*X 3/31 Deadline for submitting 2017 MIPS data 3/31 Deadline for submitting 2018 MIPS data First performance year for MIPS Second performance year for MIPS First MIPS payment year Second MIPS payment year MIPS -4% MIPS -5% MIPS -7% MIPS -9%

MIPS Payment Adjustment Timeline – View 2
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 on Fee Schedule Updates MIPS QPs in Adv. APMs 0.25% or 0.75% 0.5% annual baseline updates No annual baseline updates 4% 5% 7% 9% 9% 9% 9% Max Adjustment (additional bonuses possible) 5% bonus

Performance Year MIPS Reporting Weights

2018 Performance Year MIPS Reporting Weights for Hospital-Based & Non-Patient Facing Providers
Hospital-Based Providers are defined as those performing 75% of services in POS 19, 21, 22, or 23 for twelve months beginning with 9/1 of the calendar year preceding the performance year Beginning in 2019, Hospital-Based Providers will have the option to be scored according to their facility’s performance. Non-Patient Facing are defined as individual eligible providers who perform fewer than 100 procedures with patient facing codes annually and/or groups where at least 75% of eligible clinicians within the group or virtual group are designated as non-patient facing

2018 Performance Year MIPS Reporting Basics
12-Months 90-Days Promoting Interoperability (Advancing Care Information) Clinical Practice Improvement Activities Quality Cost 50 Points 15 Points 25 Points 10 Points 100 Points Any MIPS EP or small group in a small practice (15 or fewer EPs) may earn up to 5 points to be added to their final composite score, as long as data is submitted on at least 1 performance category in an applicable performance period Do Not Participate or Report and Receive a negative 5% payment penalty in 2020

MIPS Reporting & Scoring – Quick Summary
MIPS component Category weight Reporting period Reporting options Points Bonuses available Quality 50% 12 months Claims (individuals), EHR, qualified registry, QCDR, web interface (groups 25+) 3 for complete measures 1 point for incomplete measures (special rules for topped out measures, small practices, benchmarked measures) Up to 10% for high priority measures Up to 10% for end-to-end electronic reporting 10 points possible for improvement Promoting Interoperability (ACI) 25% 90 days EHR, attestation, GCDR, qualified registry, QCDR, web interface (groups 25+) 100 total 50% base score Up to 10% for each performance measure 5% for public health or QCDR reporting 10% for using CEHRT for IA 10% bonus for using only 2015 CEHRT, Stage 3 measures IA 15% Attestation, EHR, qualified registry, QCDR, web interface (groups 25+) 10 points for medium 20 points for high 40 points = full score Points doubled for small practices Cost 10% Calculated by CMS Average of 2 measures (or 1 if both can’t be scored) 1 point possible for improvement

Ways clinicians can report for MIPS
Individual NPI and TIN Group 2 or more clinicians (NPIs) who have reassigned their rights to a single TIN APM entity Virtual Group (New) Solo practitioners and groups of 10 or fewer EPs who come together virtually

MIPS 2018 Performance Year Timeline
March 31, 2019 2019 2020 2018 Performance Year Opens Jan. 1 Closes Dec. 31 Clinicians care for patients and record data during the year Deadline for submitting data CMS provides performance feedback after data submission, before start of next payment year Payment adjustments prospectively applied to each claim starting Jan. 1

2017 & 2018 MIPS Hardship Waivers for Extreme and Uncontrollable Circumstances
CMS is extending hardship waivers to EPs which have been affected by natural disasters across the country which occurred during the 2017 MIPS performance period, including Hurricanes Harvey, Irma, Maria and the California wildfires An interim final rule with comment period (CMS-5522-IFC) was published in the CY 2018 QPP final rule with comment period CMS will use enrollment data listed in PECOS to identify EPs located in FEMA-designated disaster areas including FL, GA, LA, PR, SC and some parts of TX and CA EPs will automatically be exempt from a 2017 performance period / 2019 payment year MIPS penalty, no exemption application required EPs that do submit data /report for 2017 performance period will be scored on the data submitted This final rule with comment period applies to the 2018 MIPS performance period as well EPs will need to submit a hardship exception application by 12/31/2018 This policy does not apply to APMs

MIPS Performance Thresholds (PT) & Payment Adjustments
In 2018 the break even performance threshold (PT) is 15, for Providers to receive a 0% neutral payment adjustment To achieve a PT = 15 one of the following reporting scenarios must be met: Report all required Improvement Activities (for maximum of 40 points) Meet the Promoting Interoperability (Advancing Care Information) base score and submit 1 Quality measure that meets data completeness Meet the Promoting Interoperability (Advancing Care Information) base score, by reporting the 5 base measures, and submit one medium-weighted Improvement Activity Submit 6 Quality measures that meet data completeness Providers meeting a performance threshold (PT) above 15 may earn base incentives up to 5% PT = eligible for positive adjustment greater than 0% PT = 70+ eligible for positive adjustment greater than 0% AND exceptional performance/additional performance bonus at 0.5%+ Providers not meeting a performance threshold (PT) of 15 will receive a negative payment adjustment PT = will receive a negative payment adjustment greater than -5% and les than 0% PT = will receive a negative payment adjustment of -5%

MIPS Performance thresholds and payment adjustments – 2017 vs 2018 & Examples
Threshold for bonuses/cuts set at 3 points Potential adjustments in /-4% Threshold for exceptional bonus set at 70 points Additional performance threshold starts at 0.5 and goes up to 10% 2018 Threshold for bonuses/ cuts set at 15 points Potential adjustments in /- 5% Threshold for exceptional bonus remains 70 points Complex patient bonus up to 5 points Small practice bonus 5 points Adjustment applied to Medicare paid amount 15 point examples from CMS: Report all Improvement Activities Meet PI/ACI base score and report 1 quality measure that meets data completeness criteria Meet PI/ACI base score and one medium weighted Improvement Activity Submit 6 quality measures that meet data completeness criteria

MIPS Budget Neutrality Factor
Due to the budget-neutral design of MIPS, the total amount of performance threshold bonuses awarded to EPs will continue to be equal to the total amount of penalties assessed CMS’ adjustment to the 2018 low-volume participation threshold is expected to reduce the number of participating EPs by 35%; making the program more competitive CMS has set aside an additional $500 million each year between , to fund high performing bonuses awarded to EPs with a composite performance score of 70 points or higher The budget neutrality factor, X, is determined by total composite scores of all MIPS-eligible providers falling below, meeting or exceeding performance thresholds (PT) Ex: If total number of providers achieving a high composite score is low, the neutrality factor, X, can be increased up to a factor of 3 Ex: If total number of providers achieving a high composite performance score is higher, the neutrality factor, X, can be lowered down to 1 to ensure budget neutrality The budget neutrality factor, X, is capped at 3.0 Reaching the 3.0 cap would only be feasible if more providers received penalties rather than incentives as a result of their overall composite performance scores, since the budget neutrality must be maintained Ex: For performance year 2018, maximum base incentive payment adjustment could = 5% x budget neutrality factor of 3.0 = 15% Ex: For performance year 2018, maximum possible incentive for exceptional performance could = 5% x budget neutrality factor of % bonus = 25%

MIPS QUALITY Reporting for 2018
For 2018, report at least 6 measures or 1 specialty-specific measure set on 60% of applicable patient encounters (meeting the data completeness threshold) for a period of 12 months, one of which much be an Outcome measure or High-priority measure, to receive a score of 15 points which is sufficient to avoid a negative payment adjustment in 2019 Over 270 individual quality measures and 30 specialty measure sets published Find them here at CMS’ interactive website: 3-point floor for all measures 60% data completeness threshold for all submission methods except for Web Interface and CAHPS Measures that do not need data completeness criteria will earn 1 point instead of 3 Small practices with less than 15 EPs will continue to get 3 points when data completeness is not met 20-case minimum for all measures except for all-cause hospital readmission measure, which has a 200–case minimum requirement for groups of 16 or more

Quality Measures are worth from 1-10 points each, with the exception of topped out measures Topped out measures with benchmarks that have been topped out for at least 2 consecutive years will be worth only up to 7 points and not up to 10 Measures are defined as topped out when meaningful distinctions and improvement in performance can no longer be made 6 Quality Measures have been finalized as topped out in 2018 which will be scored on a maximum of 7 points, including: Perioperative Care – Quality Measure ID: 21 Melanoma – Quality Measure ID: 224 Perioperative Care – Quality Measure ID: 23 Image Confirmation of Successful Excision of Image-Localized Breast Lesion – Quality Measure ID: 262 Optimizing Patient Exposure to Ionizing Radiation – Quality Measure ID: 359 Chronic Obstructive Pulmonary Disease – Quality Measure ID: 52

MIPS Quality component—full year reporting
6 measures (or one specialty set) Partial credit allowed Flexibility in measure choice No domains required Bonuses for electronic reporting 60% data completeness required for successful measure reporting 2017 modifications mostly retained Completeness threshold raised from 50% to 60% Incomplete measures earn 1 point (3 for small practices) New and modified specialty measure sets available Cross cutting measures removed from most sets (except IM, FM, Ped)

CMS measure selection tool
Explore Measures Explore Quality Measures

Total Quality performance score is the sum of the points assigned, divided by the total points available, and then weighted to count for 50% of total MIPS score Quality performance scoring will be based on the rate of improvement at the performance category level Bonus for additional high priority measures  10% of possible total Bonus for end-to-end electronic reporting  up to 10% of denominator for performance category Bonus for the treatment of complex patients  based on a combination of Hierarchical Condition Categories (HCCs) and number of dually eligible patients treated (up to 5 points)

MIPS Quality Performance

MIPS QUALITY Reporting Methods for 2018
Claims (individual providers only) Qualified Registry or QCDR EHR Vendors QCDR CMS Web Interface (groups of 25 or more) Individual providers reporting via Claims must report on at least 50% of all MIPS eligible provider’s Medicare Part B patients If reporting via Registry, EHR, or Qualified Clinical Data Registries (QCDR) data must be submitted on at least 50% of all MIPS eligible provider or group’s patients; regardless of payer If reporting via Qualified Clinical Data Registries (QCDR), data must be reported on all approved measures If reporting via CMS Web Interface, data must report on all included measures & must populate data for first group of consecutively ranked and assigned beneficiaries

MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITY (CPIA) Reporting for 2018
The Clinical Practice Improvement Activity (CPIA) category does not replace any existing legacy reporting programs, and is meant to emphasize improving patient outcomes CPIA score is determined by dividing the sum of points earned by the provider by 40 maximum points, and then weighted to count for 15% of total MIPS score 40 maximum points available based on 112 activities in 9 categories found here at CMS’ interactive website: Heavy weighted activities = 20 points Medium weighted activities = 10 points Expanded Patient Access Population Management Care Coordination Beneficiary Assignment Patient Safety & Practice Assessment Participation in APM Achieving Health Equity Integrating Behavioral & Mental Health Emergency Preparedness & Response

MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITY (CPIA) Reporting for 2018
Groups that are small (less than 15 providers), rural, or located in a health professional shortage area (HPSA), or non-patient facing providers must only complete 1 high-weighted or 2 medium-weighted activities for 90 days to receive full credit of 40 points If reporting as a group or a virtual group, only 1 eligible provider needs to report on CPIA for the entire group or virtual group to get full credit Eligible providers participating in a certified Comprehensive Primary Care Plus (CPC+), Patient-Centered Medical Home (PCMH), Shared Savings Program Track 1, 2, 3, or Oncology Care Model will receive full credit of 40 points 50% of practice sites within a TIN or TINs that are part of a virtual group must be recognized as a PCMH to receive full credit for CPIA in 2018 Eligible providers participating in other APM’s will earn half credit of 20 points and can report additional activities to increase their score

CMS Web Group (groups of 25 or more)
MIPS CLINICAL PRACTICE IMPROVEMENT ACTIVITY (CPIA) Reporting Methods for 2018 Qualified Registry QCDR EHR CMS Web Group (groups of 25 or more) Attestation For 2018, all eligible providers, groups and third party entities submitting CPIA data must use a “YES/NO” response, certifying that all activities have been performed Administrative claims method is meant to be utilized only when feasible Ex: Eligible providers or groups using telehealth modifier “GT”, could get automatic credit for this activity

MIPS Improvement Activities -- 90-day reporting
2017 IAs Intended to give credit for practice innovations that improve access and quality 92 activities across 8 categories No required categories 40 points needed for larger practices (2-4 activities) 1-2 activities required for groups of 15 or less, rural and HPSA practices, non-patient facing specialists (most physicians fall into these categories) Participation in MIPS APMs and certified PCMHs earn full score in 2017 2018 changes Requirements and scoring unchanged More activities added for total of 112, including NDPP referrals CPC+ added to the MIPS APM models that earn full score in 2018 50% of practice sites within a TIN must be recognized as certified PCMHs to receive full IA credit

MIPS Promoting Interoperability (formerly ACI) Reporting for 2018
Replaces Meaningful Use program for Medicare Part B eligible clinicians Comprises 25% of total MIPS score for all eligible providers CMS will reweight the PI/ACI performance category to 0 and reallocate the 25% to the Quality performance category for EPs meeting special status criteria Automatic reweighting for: hospital-based providers non-physician practitioners non–patient facing EPs & groups ambulatory surgical center-based EPs Reweighting through an approved application (due by 12/31 of the performance period) for: EPs in small practices (15 or fewer clinicians) facing hardship EPs whose EHR was decertified EPs facing providers facing significant hardship

Promoting Interoperability (formerly ACI)
CMS recently announced the overhaul of MU & MIPS PI/ACI; the objectives for the Base Score & Performance Scores are expected to change Base Score and Performance Score Base Score Objectives: Protect Patient Health Information Electronic Prescribing Patient Electronic Access to Health Information Care of Coordination Through Patient Engagement Health Information Exchange Public Health and Clinical Data Registry Reporting Look for more updates from CMS with upcoming rule releases. The base score will be yes/no statement for the applicable measures, with only “yes” counting for credit toward 50 percent of the advancing care information category. The performance score will be based on performance in the objectives and measures for Patient Electronic Health Access, Coordination of Care through Patient Engagement, and Health Information Exchange Half score still based on yes/no attestation. Providers have some flexibility because they can receive partial credit for some measures. Also opportunity for bonus points for reporting to multiple public health and clinical data registries.

Qualified Registry EHR CMS Web Interface (groups of 25 or more) Attestation QCDR Find PI/ACI objectives and measures here at CMS’ interactive website: Based on the Burden Reduction Aim, EPs may use either the 2014 or 2015 Certified Electronic Health Technology (CEHRT) Two separate measure sets are available based on EHR technology utilized 2018 transitional measures (modified state 2 meaningful use) 2018 measures (stage 3 measures)

Base Score = Possible 50 points Report a 1 in the numerator and denominator or “yes” for selected measures as required CMS finalized exclusions for certain measures: E-prescribing exclusion Health Information Exchange Measures exclusions Send summary of Care Measure exclusion applies to EPs who transfers or refers a patient <100 times during performance year Request/Accept Summary of Care Measure exclusion applies to EPs who have encountered patient <100 times during performance year Select “YES” to the exclusion and submit a null value for the measure Successfully meeting and reporting all of the Base Score Measures is required and failure to do so will result in a zero in the ACI category for MIPS reporting

Performance Score = Possible 90 points Each measure reported will be calculated individually by dividing the numerator by the denominator Some performance measures are also included in the base measure category, but will earn additional points towards performance score for values higher than 1 in numerator EPs and groups will earn 10% for reporting to any one of the Public Health and Clinical Data Registry Reporting measures as part of the performance score Bonus Score = Possible 25 points 5 bonus points for reporting to a public health or clinical registry that was not included under the ACI performance score 10 bonus points for using a certified EHR (CEHRT) for at least 1 of 21 identified Improvement Activities under CPIA category 10 bonus points for reporting ACI Objectives and Measures for exclusively using only edition CEHRT CMS intends this to be a one-time only bonus offered in performance period 2018

MIPS Promoting Interoperability (Formerly Advancing Care Information)

MIPS PI/ACI requirements: 90-day reporting
Legacy Meaningful Use 100% score required on all measures Included redundant quality measures Included problematic CPOE, CDS measures Full-year reporting (although twice reduced in Q4) 2017 Promoting Interoperability (formerly ACI) Pass/ fail replaced with base and performance scoring 4 base measures required, partial credit allowed for performance measures Fewer measures; no CPOE, CDC, or clinical quality measures Performance score thresholds eliminated 90-day reporting Bonuses available for registry reporting and use of CEHRT in IA 2018 changes 2017 improvements retained Will not require updates to 2015 CEHRT in 2018 (10% bonus if using) May report modified MU stage 2 measures instead of advancing to new stage 3 measures Increased opportunities for bonus points Hardship exemptions created for small practices, physicians with decertified EHRs, hospital-based clinicians (including off-campus) , ASC-based clinicians

MIPS COST Reporting for 2018
Replaces 2 cost measures formerly used in Value-Based Modifier program Total per capita cost of care for attributed beneficiaries Medicare spending per beneficiary (MSPB) Comprises 10% of total 2018 MIPS performance year score for eligible providers When MACRA first became law in 2015, it allowed CMS flexibility to apply a relatively low weight to the MIPS Cost category during the first two years of the program. The agency chose to weigh the Cost category at 0% of providers' final MIPS score in performance year 2017 and 10% in Under current law, CMS can weigh the Cost category anywhere between 10% and 30% through 2021, and will be required to set the category at 30% from 2022 on. Administrative claims will be used to calculate EP and group performance, and no other reporting is necessary The 10 episode-based cost measure adopted for the 2017 MIPS performance period will not be used for the 2018 performance period CMS is developing new episode-based measures with input from stakeholders and plans to solicit feedback on some of these measures during the fall of 2018 New proposed measures are expected to be introduced in future rulemaking before they are included in MIPS

MIPS COST Reporting for 2018
The Cost Performance category is scored using both achievement points earned and by calculating improvement Total MIPS Cost score = total # of Cost achievement points earned by EP / total # of available achievement points + the cost improvement score EP performance compared to performance of other MIPS EPs and groups during the same/current performance period Can’t see performance benchmarks ahead of time Cost achievement points earned are calculated using the average of the per capita cost and MSPB measures If only 1 measure can be scored, that score will equal the performance achievement score the per capita cost of attributed beneficiaries and Medicare spending per beneficiary (MSPB) used to score the Cost performance category in the performance year 2018 Cost improvement scores are calculated by comparing performance in current MIPS performance period to performance in immediately preceding performance period Improvement scoring based on statistically significant changes at the measure level Improvement score only calculated when there is sufficient data showing EP used same identifier in 2 consecutive performance periods and was scored on the same cost measures for 2 consecutive periods Up to 1% is available for Cost improvement

MIPS Cost component (calculated by CMS via claims)
Legacy value-based modifier Included both quality and resource-use measures Double jeopardy; PQRS failure penalized twice Measured total cost of care per capita and Medicare spending per (hospitalized) beneficiary Part B (but not Part D) drugs included in calculation Flawed measures with poor risk adjustment penalized those treating sickest patients No statutory limits on penalty risk 2017 Cost Focus solely on cost No double-jeopardy 10 contractor-developed episode measures added Contractors and clinical panels developing others Drug calculations unchanged 0% MIPS component weight in 2017; informational reports on legacy measures provided FYI only 2018 changes 2017 structural improvements maintained Weight increased to 10% 10 episode groups eliminated Clinical panels working to develop and refine others Cost scores based on two legacy measures Part B drugs excluded in calculations and no longer subject to MIPS-related pay adjustments due to Bipartisan Budget Act of 2018

MIPS 2018 Accommodations for Small Practices
Low-volume threshold raised to $90K/200 patients Eased requirements for Improvement Activities component / Doubled IA scores continued Technical assistance grants continued Virtual group option created Promoting Interoperability (ACI) hardship exemption for small practices Favorable Quality scoring due to weighting Bonus points added to final score for small practices $100 million in grants for technical assistance to small practices via QIOs, regional health cooperatives, etc. Participation in rural health clinics sufficient for full Improvement Activities score for rural and small practices

New provision: Improvement scoring for Quality and Cost MIPS Categories
MACRA calls for rewarding improvement as well as overall score Second year of QPP provides first opportunity For Quality: improvement score based on rate of improvement in total Quality score Greater improvement results in more points; lower performance in transition year could produce highest improvement score Up to 10 percentage points available For Cost: score based on statistically significant changes at the measure level Up to 1 percentage point available If data are insufficient in either category, improvement score will be 0 percentage points Only positive adjustments are possible. No penalties for falling scores.

MIPS Bonus points Formerly available
Up to 5% PI/ACI bonus for reporting to one or more additional public health and clinical data registries Up to 10% PI/ACI for reporting certain Improvement Activities via CEHRT Additional Quality points for: (1) electronic reporting; (2) reporting on CG-CAHPS survey measure; (3) additional outcome or high priority measure New for 2018 For complex patients, up to 5 points available based on combination of Hierarchical Conditions Category (HCC) risk score and number of dual eligibles treated Small practice bonus of 5 points added to final score for practices of 15 or fewer 10% bonus for using only 2015 CEHRT Potential points for improvements in Cost and Quality components

New provision: Virtual Groups
Must include at least 2 solo and small group (<10) clinicians No restrictions on locations or specialties or number of TINs that may participate MIPS Virtual Group Identifiers will be created by CMS; individual clinicians identified through combination of VGI, TIN, and NPI All practices in virtual groups must be eligible for MIPS A participating group may include a clinician who is not eligible (e.g., does not meet LVT), but group as a whole must be eligible All eligible clinicians under the TIN would be included in the virtual group Requirements Formal written agreement between each virtual group member (model agreement being developed) Must elect by December prior to performance year (for 2018, election process ran from 10/11-12/31) May only participate in one virtual group during a performance period

Potential advantages of virtual groups
Share burden of MIPS reporting Combine credit for MIPS categories like Improvement Activities Combine patient counts in quality reporting for more reliable sample sizes Maintaining independence Take advantage of group reporting options Non-patient facing MIPS clinician and small practice, rural area, and HPSA designation would apply CMS will provide technical assistance Challenges: IT infrastructure lacking Different EHR systems Workflow and staff training changes

AAPMs Advanced Alternative Payment Models
Quality Payment Program (QPP) Path #2 AAPMs Advanced Alternative Payment Models One of the Two Quality Payment Programs (QPP) Subset of APMs which Provides Incentives for High Quality and Cost-Effective Care, Requiring Shared Risk Related to Performance Standards

Qualifying Advanced APM (AAPM) Entities for 2018
Comprehensive Care for Joint Replacement (CEHRT track) Comprehensive Primary Care Plus (CPC+) Model Medicare Shared Savings Program ACOs Tracks 1+,2 & 3 Comprehensive ESRD Care Model (Two-Sided Risk Arrangement)* Oncology Care Model (Two-Sided Risk Arrangement)* Next Generation ACO Model CMS estimates 185,000 – 250,000 clinicians will participate in AAPMs in * Indicates not currently accepting new applicants

Advanced APM (AAPM) Specifics for 2018
Exempt from MIPS reporting Report Quality Measures as normally required by CMS using GPRO Web Interface at the group TIN level The Qualifying Participant (QP) performance period for each payment year will be from January 1 – August 31, of the calendar year that is 2 years prior to the payment year Receive annual lump sum payment bonus = 5% of previous year’s Part B annual payments for covered professional services; regardless of level of performance Receive a 0.5% higher fee schedule update from 2026 forward

Eligibility for Advanced APM (AAPM) Participation in 2018
Qualifying Advanced APM Requirements: Requires APM group participants use certified EHR technology (CEHRT) Provides services for payment based on quality measures comparable to those in MIPS Either bears more than a nominal financial risk for monetary losses (representing at least 8% of average estimated total Medicare A & B revenues or 3% of the AAPM Entity’s expected expenditures), or is a Medical Home expanded under CMS Innovation Center Authority with total potential risk of 2.5% of average estimated total Medicare A & B revenues Medical Home model revenue-based standard applies to entities with <50 EPs in their parent organization Entities enrolled in Round 1 of the CPC+ model is exempt from this EP volume requirement Meeting the Following Thresholds: Receive 25% of total Medicare payments through an Advanced APM (AAPM) Treat 20% of Medicare patients through an Advanced APM (AAPM) Starting in 2019 performance period, “All-Payer Advanced APMs” can contribute to thresholds

APM Timeline for determining eligibility and bonuses
APM participants will be identified by CMS via 3 “snapshots” March 31, June 30, August 31 Physicians listed as participants on one of those dates will be considered participants for that performance year Performance year ends August 31 Provides time for MIPS reporting for those not meeting thresholds 5% bonus will be calculated on Medicare revenues for second calendar year Lump sum payment provided in third calendar year Example: 2017 performance year determines eligibility (as of August 31) 2018 year-end revenues provide base for calculating 5% bonus Lump sum bonus payment mid-2019 after all 2018 claims are submitted

MIPS APMs for 2018 MIPS APM entities meet the following criteria:
Participate under an agreement with CMS (not another payer) Have at least one eligible provider on an APM participation list Base payment incentives determined by performance, cost and quality measures It is possible for an APM to be a MIPS APM, an Advanced APM (AAPM), both or neither Not eligible to receive the 5% APM lump sum incentive payment MIPS APM eligible providers belong to an APM (advanced or non-advanced) who are also subject to MIPS reporting Eligible providers must be on an APM participation list on one of the four snapshot dates of March 31, June 30, or August 31 during the performance period Fourth snapshot to determine participation in Full TIN MIPS APMs (MSSP) on December 31

MIPS APM Reporting for 2018 MIPS APM classification provides streamlined reporting and special scoring for participating eligible providers and all MIPS APM payment adjustments are applied at the TIN/NPI Level All scores from eligible providers participating in a MIPS APM entity are aggregated so that each provider receives the same final MIPS score MIPS APM QPs automatically receive full credit for Improvement Activities category MSSP ACOs & Next Generation ACOs Scored as MIPS APMs CATEGORY REPORTING METHOD SUBMISSION METHOD % Quality CMS Web Portal Group Submission for Entire ACO’s TIN # 50% Improvement Activities Any Approved Submission Method *Group Submission for Each TIN # Participating in ACO for Averaged Score 20% Advancing Care 30%

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Achieving Compliance with the MIPS Quality Reporting Program: Practical MIPS reporting considerations in 2018 Pay - for - Performance Pay - for - Reporting.

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