1. MACRA From Meaningful Use to MIPS The “Doc Fix” Legislation
NOHIMSS: November 5, 2015
Cathy Costello, JD
Director of CliniSyncPLUS Services

2. OVERVIEW

3. Intersection of Cost/Quality/MU Metrics
Year
Legislation or Program
1997
SGR- Sustainable Growth Rate
2003
IQR
2006
PQRI
2009
HITECH
2010
Affordable Care Act (Alternative Payment)
2011
Stage 1 Meaningful Use (MU)
2012
Value-Based Purchasing
2013
Hospital Readmissions
2014
Stage 2 MU
2015
QRUR Reports (Cost/Quality)
SGR Repealed; MACRA Passed
2018
Stage 3 MU
2019
MIPS/Alternative Payment Models (APM)
Quality
Meaningful Use
Cost

4. Old/New Terms in the CMS Alphabet
SGR: “Sustainable Growth Rate” (1997): Now retired
MACRA: “Medicare Access and CHIP Reauthorization Act” (2015)
Two new payment avenues:
MIPS: “Merit Based Incentive Payment System” (modified traditional fee-for service payment)
APM: “Alternative Payment Model” (other payment models Medicare is encouraging)

5. Phases of MACRA
Phase 1 (2015 – 2019): Repeals SGR statute and implements a stepwise adoption of the 1st overall Physician Fee Schedule increase in over a decade. Consistent payment structure for all physicians.
Phase 2 (2019 – 2025): Begins new payment mechanisms through MIPS and Alternative Payment Mechanisms (APMs)
Phase 3 (2026 and Beyond): All incentives stop. Increase of fees by 0.25% for MIPS providers; increase of 0.75% for APM providers. Other changes unclear ????????????????
Notes
SGR, if not repealed, would have resulted in a 21% decrease in physicians Medicare Part B payments in 2015.
Net cost of MACRA is $102 billion
Additional updates of $500 million/year plus a 5% bonus will stop in Thus physicians would have a payment decrease in 2026.
“Absent a change in the method or level of update by subsequent legislation, we expect access to Medicare-participating physicians to become a significant issue in the long term.” Office of the Actuary for CMS

6. Who Is Covered by MIPS/APM
Current MU Providers: Already recognized EPs under the Medicare program:
Physicians
Dentists
Podiatrists
Optometrists
Chiropractors
2019: Expanded to include nurse practitioners (NPs), clinical nurse specialists (CNS), physician assistants (PAs) and certified registered nurse anesthetists (CRNAs). Although most previously covered by Medicaid EHR incentive program, now specifically covered for Medicare reimbursement.
2021: Other professionals may be included if have the performance thresholds developed.
Exclusions: Being developed for low volume providers and alternative payment models (APMs).
Notes
Remember: CMS works 2 years in advance on changes and reimbursement matters, so you must be reporting for providers in 2017 if they are going to be eligible in 2019 for MIPS payments/penalties.

7. Timeline between 2015 and 2019 2019 Last +0.5% PFS Begin MIPSl 2015
MU Blended 90 Days
PQRS
+0.5% PFS (6 Mo.)
No SGR
2016
MU Blended 365 Day
+0.5% PFS
2017
MU Blended 365 Days or Stage 3 90 Days
2018
Stage 3 MU 365 Days
eCQMs for PQRS
Last +0.5% PFS
Begin MIPSl
2019

8. Merit-Based Incentive Payment System
MIPS:
Merit-Based Incentive Payment System
Notes
MIPS is really the continuation of the fee-for-service model but includes quality and cost metrics.
MIPS is the combination of PQRS, MU and Value-Based Payment Modifier programs.

9. (1) MIPS Payment Structure
Meaningful Use
2019: 25%
Quality Reporting
2019: 30%
Resource Use
Clinical Practice Improvement
2019: 15%
Unsettled
Area
Notes
The provider is scored on a scale of 0 – 100 points.
Takes into account both benchmarking against a national average and also against a provider’s own performance from one year to another when compared the baseline.
Combines Meaningful Use with Cost, Quality and “Clinical Practice Improvement;” % can change each year.

10. Additional Physician Fee Schedule (PFS) Increases for MIPS Track
2015 – 2019: An additional 0.5% automatic increase in the Physician Fee Schedule, bringing total increase from 2015 – 2019 to 2.5% for the 4 years.
2020 – 2025: No increase in PFS.
2026:
If participating in MIPS (non-alternate payment), then 0.25% annual increase.
If participating in Alternative Payment Models (APMs) then receive a 0.75% annual increase.

11. Alternative Payment Model
APM:
Alternative Payment Model

12. (2) Alternative Payment Model (APM)
Meaningful Use
Quality Reporting
Resource Use
Clinical Practice Improvement
Combines areas of technology use, quality reporting, cost factors and care management into one bundle under the specific APM model; reporting is different than MIPS, driven by reporting requirements for that particular APM model

13. Alternative Payment Models (APMs)
Specifically lists Patient Centered Medical Homes (PCMH) as an Alternative Payment Model that does not rely on risk sharing to meet the APM requirements.
Includes Medicare Shared Savings Program, Comprehensive Primary Care Initiative (CPCI) and other payment models designated under CMS’s Innovation Center.
List of potential APM’s not completely identified yet.
Alternatives must include risk sharing for losses over a nominal amount or be PCMH.
May include some component of Chronic Care Management and Transitions Care Management programs initiated by CMS.

14. REWARDS
PENALTIES

15. A. What Are the Rewards/Penalties Under MIPS?
MIPS adjustment factor is for each MIPS EP/year in the form of a percentage:
Determined by comparing the composite performance score to the performance threshold
Scoring is either positive, negative , or zero
Potential rewards:
Besides the MIPS Adjustment Factor, EPs can also earn an additional positive percent (EPs composite performance score has to be ≥ to the performance threshold):
2019: 4% Maximum bonus for exceptional performance is 14.5%
2020: 5% Maximum bonus for exceptional performance is 15.0%
2021: 7% Maximum bonus for exceptional performance is 17.0%
2022 and beyond: 9%

16. All payment adjustments have to be budget neutral
A. What Are the Rewards/Penalties Under MIPS?
Potential penalties:
If falling below the national benchmarks and quality thresholds, then adjustment downward can be at the maximum:
2019: -4.0%
2020: -5.0%
2021: -7.0%
2022 – 2025: -9.0%
All payment adjustments have to be budget neutral

17. B. What Are the Rewards/Penalties Under APM?
2019 to 2024, APM providers will receive a 5% annual lump-sum bonus on MPFS payments at the end of the reporting year. Not all providers participating in APMs would be designated as APM providers; depends on % of Medicare patients covered by the APM in its billing structure:
2019 – 2020: 25% of Medicare payments for covered professional services must be attributable to APM.
2021 – 2022: 50% of Medicare payment for covered professional services must be attributable to APM.
2023 & Forward: 75% of Medicare payments for covered professional services must be attributable to APM OR 75% of all-payer revenue (with >25% from Medicare payments) attributable to APM.
N.B. If provider is close but doesn’t meet the Medicare threshold for APM participation, then may be exempted from MIPS penalties but will not receive the 5% bonus payment for APMs for that year.
Other Identified Risks/Payments: Subject to additional risk/reward under specific APM model.
Notes
If provider does not report any MIPS quality metrics, then will be given the lowest score with the greatest negative adjustment on fees, unless an exception applies:
APM participation
Partial qualification for APM but did not file MIPS measures
Low volume provider as determined by thresholds established by CMS

18. Rewards/Penalties for MIPS and APM Tracks
Year
MIPS Incentive Adjustment*
MIPS Potential Penalties
MIPS Maximum Bonus for Exceptional Performance
APM Adjustment
2019
+4.0%
-4.0%
14.0%
+5.0%
2020
-5.0%
15.0%
2021
+7.0%
-7.0%
17.0%
2022
+9.0%
-9.0%
19.0%
2023
2024
2025
N/A 0%
*MIPS positive adjustment can be increased up to 3x MIPS incentive adjustment, if sufficient funds available. No additional decrease in penalties. All payments must be budget neutral.

19. Areas Undecided:
Questions Raised by
CMS in RFI

20. Areas Undecided: Seeking Comments
Low volume threshold
Minimum # patients during reporting period
Minimum # items or services provided
Minimum allowed charges
Clinical practice improvement: what should be included to show additional value provider is adding to the healthcare system; some proposed areas looking for comments
Access to practice: same day appointments; 24/7 access
Monitoring of health conditions;
Participation in data registry
Care coordination; telehealth
Use of care plans; patient self-monitoring or assessment
Patient safety and practice assessments
Advanced certification of practice or provider
Participation in alternative payment model (APM) for private payers or Medicaid
How to document areas of clinical practice improvement

21. Areas Undecided: Seeking Comments
3. Other issues raised
Need for separate new identification # for providers for MIPS
MU: whether to make it an “all or nothing” attestation or to allow partial credit for measures met
MU: in APM track, what should be standard for legislative requirement for use of certified EHR technology? Should it be same as MU measures?
PCMH: in MIPS track, how to weight PCMH’s work in Medicaid medical home models
Areas affecting specialties
Establishes Physician Focused Payment Model Technical Advisory Committee to review new proposals for APM models and make recommendations as to their adoption
Asks for guidance as to how the committee should function and how to comment on new payment proposals going forward
The committee must put out criteria for Physician Focused Payment Models (PFPM) for the APM track by November 1, 2016

22. Areas Undecided: Seeking Comments
To comment on the RFI for MACRA, list CMS-3321-NC on all comments. Submit comments electronically to:
Link to the RFI:
To submit by mail:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-3321-NC,
P.O. Box 8016,
Baltimore, MD
Comments must be received by November 17, 2015

23. PREPARING FOR
MACRA

24. What to Do in 2016 MIPS Providers: APM Providers: Report PQRS
Follow federal reports as to PCMH status
Look for guidelines establishing low volume thresholds and clinical practice improvement initiatives
Change workflows to support chronic care management and transitional care management
APM Providers:
Analyze Medicare patient panels to determine % of Medicare professional services provided through APM
Analyze crosswalk between APM reporting and MIPS reporting, especially for quality metrics.

25. Cathy Costello 614-664-2607 ccostello@ohiponline.org
- While visiting our website don’t forget to sign up for our newsletter!