Final Requirements for the Quality Payment Program (QPP) Update on - - PowerPoint PPT Presentation

Final Requirements for the Quality Payment Program (QPP)

Update on the Medicare Access and CHIP Reauthorization Act (MACRA)/QPP Final Rule with Comment Period

Infectious Diseases Society of America (IDSA)

November 14, 2016

CHRISTINE G GROSSMAN, E ESQ. HART RT HEALTH S STRATEGIES, I INC NC.

MACRA FINAL RULE

THE MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS), ALTERNATIVE PAYMENT MODEL (APM) INCENTIVE, AND CRITERIA FOR THE PHYSICIAN-FOCUSED PAYMENT MODELS (PFPMS)

AGEN ENDA

Overview of QPP Payment Adjustments Alternative Payment Models (APMs) The Merit-based Incentive Payment System (MIPS)

For Infectious Diseases, there are really two main considerations:

• Employment model
• Inpatient vs Outpatient

Inpatient Outpatient Employed MIPS or Possibly APMs MIPS or Possibly APMs Private Practice MIPS MIPS

MEDICARE’S QUALITY PAYMENT PROGRAM (QPP)

MIPS

• Consolidates existing physician-focused Medicare quality

improvement programs

• Creates a FINAL SCORE to inform physician payment based on

four performance categories:

• Quality (formerly PQRS)
• Advancing Care Information (formerly the EHR Incentive

Program)

• Resource Use (formerly the Value-based Payment Modifier)
• Improvement Activities (IAs) (new)

ADVANCED APMs

• Clinicians determined to be Qualifying APM Participants (QPs) in

an Advanced APM are excluded from participation in MIPS AND qualify for a 5% bonus

• To be an Advanced APM, an APM must meet the following three

criteria:

• Require participants to use certified EHR technology;
• Provide payment for covered professional services based on

quality measures comparable to those used in MIPS; and

• Either (1) be a Medical Home Model explained under CMS

Innovation Center authority; or (2) require participating APM Entities to bear more than a nominal amount of financial risk for monetary losses.

AGEN ENDA

Overview of QPP Payment Adjustments Alternative Payment Models (APMs) The Merit-based Incentive Payment System (MIPS)

Alternative Payment Models (APMs) in the QPP

ADVANCED APMS

• 7 models identified by CMS, including:
• Accountable Care Organization (ACO) model:
• Medicare Shared Savings Program – Track 2

Medicare Shared Savings Program – Track 3

• Comprehensive Primary Care Plus (CPC +) Model
• Next Generation ACO

MIPS APMS

• 10 models identified by CMS, including:
• Accountable Care Organization (ACO) model:
• Medicare Shared Savings Program – Track 1

Medicare Shared Savings Program – Track 2 Medicare Shared Savings Program – Track 3

• Comprehensive Primary Care Plus (CPC +) Model
• Next Generation ACO

What about Bundled Payment Models, such as the Comprehensive Care for Joint Replacement (CJR) Model?

AGEN ENDA

Overview of QPP Payment Adjustments Alternative Payment Models (APMs) The Merit-based Incentive Payment System (MIPS)

The he M Mer erit-ba based ed I Incen entive P e Paymen ent S System em ( (MIPS) ( (2019 P 019 Paymen ent Y Year)

Quality (at least 60%) + Resource Use (0%) + Improvement Activities (15%) + Advancing Care Information (25%) = MIPS FINAL SCORE

MIPS Mandates Payment Shift Towards Quality

Four Categories Determine MIPS Score: Quality, Cost, Improvement Activities (IA), Advancing Care Information (ACI) Relative Weight of Each Component of the MIPS score (2019 and Beyond)

* Weight could decrease depending on how many clinicians are meaningful users.

Category 2019 2020 2021+ Quality 60% 50% 30% Cost 0% 10% 30% IA 15% 15% 15% ACI 25% 25%* 25%*

MIPS PARTICIPATION FOR THE 2019 PAYMENT YEAR

QUALITY (60-70 PTS.)

• Report on six quality

measures or a “specialty measure set”

• One outcome/high priority

measure

• Threshold reduced to 50%
• For groups of 16 or more

eligible clinicians, CMS will apply the All-Cause Readmission Measure

ADVANCING CARE INFORMATION (100+ PTS.)

• Base Score : Provide

numerator/denominator and “yes/no” for 5 measures

• Performance Score: Report

performance on up to 9 measures to earn up to 10% for each measure

• Bonus Points: Bonus available for

reporting one public health registry (beyond the immunization category) + completing IAs using CEHRT

IMPROVEMENT ACTIVITIES (40 PTS.)

• More than 90 weighted options

in nine categories, including participation in APMs

• Activities range from 10-20 pts.
• Activities must be performed for

a continuous 90 days

• 40 points to achieve a maximum

score, but some are given special consideration (small practices, rural and geographic HPSA practices and non-patient facing MIPS eligible clinicians)

COST (0 POINTS)

• Calculated based on Medicare

claims

• The cost category will not be

factored into the final score for 2017.

• However, CMS still intends to

calculate performance on cost measures for informational purposes.

• Finalized inclusion of 10

episode-based measures previously in sQRURs.

MIPS EXCLUSIONS

FINAL EXCLUSIONS:

• New Medicare-Enrolled Eligible Clinician
• Qualifying APM Participant
• Low-Volume Threshold
• CMS finalized for 2017, the low-volume

threshold at less than or equal to $30,000 in Medicare Part B allowed charges OR less than or equal to 100 Medicare patients, representing 32.5% of pre-exclusion Medicare clinicians but only 5% of Medicare Part B spending

PICK CK YOUR P R PACE CE

Participating in an Advanced APM

• CMS classified 7 models as Advanced APMs
• CMS will “broaden opportunities” for clinicians to

participate in Advanced APMs Meeting the Full Reporting Requirements

• CMS finalized reduced requirements for full participation

in MIPS

• Cost Category = 0

Avoid the Penalty

• To avoid the penalty in 2019, eligible clinicians can choose to

report one measure in the quality performance category; one activity in the improvement activities performance category; or report the required measures of the advancing care information performance category Partially Participate Clinicians may be eligible for a small positive adjustment by submitting MIPS data “more than one quality measure, more than

• ne improvement activity, or more than the required measures in

the advancing care information performance category” to avoid a penalty in 2019.

The final rule with comment period follows a September 8, 2016 blog post, where Acting Administrator Andy Slavitt announced the agency’s plans to provide flexibility in 2017 by offering clinicians four options to participate in the QPP to avoid a penalty in 2019.

ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

HOW DO ELIGIBLE CLINICIANS WHO ARE TYPICALLY HOSPITAL-BASED PARTICIPATE IN THE ADVANCING CARE INFORMATION PERFORMANCE CATEGORY?

• Definition of a Hospital-based Eligible Clinician: 75 percent of

payments for covered professional services associated with claims with Place of Service (POS) Codes 21 (inpatient hospital) or 23 (emergency department)

• Significant Hardship
• Participate in the ACI category, even if you haven’t before

ADVANCING CARE INFORMATION PERFORMANCE CATEGORY: HARDS DSHI HIPS

Clinicians Not Previously Eligible to Participate in the EHR Incentive Program: NPs, PAs, CNSs, CRNAs MIPS Eligible Clinicians Facing a Significant Hardship: Including lacking control over availability of CEHRT and lack of face-to-face patient interaction

Hospital-based MIPS Eligible Clinicians

IMPROVEMENT ACTIVITIES CATEGORY

Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Achieving Health Equity Emergency Preparedness and Response Integration of Primary Care and Behavioral Health Participation in an APM

Possible CPIAs for ID Physicians

Population Management: Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/or conduct periodic, structured medication reviews. Medium. For example, prescribing Outpatient Parenteral Antibiotic Therapy (OPAT). Patient Safety and Practice Assessment: Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and

• therapeutics. Medium.

Emergency Response and Preparedness: Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response. Medium. For example, preparation, implementation, and when necessary execution of a bio-preparedness plan.

QU QUALITY PERFORMA MANC NCE CAT ATEGORY

The quality performance category has over 200 final measures, including new specialty sets. Requirements are similar to the PQRS Data Submission Mechanisms:

• Individuals: Claims, Qualitied Registry, EHR, QCDR
• Groups: Qualified Registry, EHR, QCDR, CMS Web Interface, CAHPS for MIPS

Data Submission Threshold: 50% Report 6 weighted measures, including one outcome measure. If an outcome measure is not available, report another high priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures) Report on a specialty measure set Scoring:

• May earn up to 10 points for each reported measure
• Performance based on measure benchmarks
• 3-point floor minimum
• Can earn bonus points for reporting high priority measures (beyond the 1

required) and submitting quality measure data using CEHRT

Counts for at least 60% of the FINAL SCORE.

If the ACI performance category is reweighted to zero as it could be for hospital-based ID physicians, the weight for the ACI performance category would be redistributed to the quality performance category. Therefore, the quality performance category could count for up to 85% of the FINAL SCORE.

QUALITY MEASURES FOR ID CLINICIANS

REPORTING 6 MEASURES

1. 407: Appropriate Treatment of MSSA Bacteremia (!!) 2. 130: Documentation of Current Medications 3. 226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention 4. 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 5. 111: Pneumonia Vaccination Status for Older Adults 6. 110: Preventive Care and Screening: Influenza Immunization Note: Existing measures with finalized substantive changes are noted with an asterisk (*), new finalized measures are noted with a plus symbol (+), core measures as agreed upon by Core Quality Measure Collaborative (CQMC) are noted with the symbol (§), high priority measures are noted with an exclamation point (!), and high priority measures that are appropriate use measures are noted with a double exclamation point (!!).

HOSPITALISTS SPECIALTY MEASURE SET

1. 005: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) (§) 2. 008: Heart Failure (HF) Beta Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (*) (§) 3. 032: Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy 4. 047: Care Plan 5. 076: Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections (!) 6. 128: Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 7. 130: Documentation of Current Medications in the Medical Record 8. 226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention 9. 317: Preventative Care and Screening: Screening for High Blood Pressure and Follow-up Documented (*) 10. 374: Closing the Referral Loop: Receipt of Specialist Report 11. 402: Tobacco Use and Help with Quitting Among Adolescents 12. 407: Appropriate Treatment of MSSA Bacteremia (!!) 13. 431: Preventative Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

MACRA PAYMENT ADJUSTMENTS

2016-2018 Current Programs Continue 2019

• 4% through

+4% (x3)+10% 2020

• 5% through

+5% (x3)+10% 2021

• 7% through

+7% (x3)+10% 2022 & Beyond

• 9% through

+9% (x3)+10%

2019 - 2024 +5% bonus 2025 & Beyond no bonus

MIPS PAYMENT ADJUSTMENTS APM BONUS

MIPS IMPLEMENTATION TIMELINE

• January 1: MIPS Performance Period for PY 2019 Begins
• June 30: Group Registration Deadline (CMS Web Interface/CAHPS for MIPS users)
• July 1: Mid-Year MIPS Performance Feedback Report
• October 1: Last Day to Begin Reporting for the 90-day Period
• December 31: MIPS Performance Period for the 2019 Payment Year Ends

2017

• March 31, 2018: Data Submission Deadline
• July 2018: 2nd Feedback Report
• July 31 – September 30, 2018: Targeted Review Period
• December 1, 2018: Deadline for CMS to Notify Clinicians the Result of the MIPS Adjustment Factors
• December 31, 2018: Last Payment Adjustments by Legacy Programs
• January 1, 2019: Negative Adjustments for 2019 Payment Year Begins

2018/2019

MACRA SIMPLIFIED

FOR EMPLOYED PHYSICIANS

• Contact practice administrator for details on

group reporting under MIPS.

• Groups (TINS) will get one payment

adjustment based on the group’s performance.

• Groups must register with CMS by June 30,

2017 in order to submit quality data via the CMS Web Interface. FOR PRIVATE PRACTICE PHYSICIANS

• Pick Your Pace – CMS finalized 4 options for

participation in 2017.

• Four Performance Categories – Quality, Advancing

Care Information, Improvement Activities, and Cost.

• Participation in 2017 can begin as early as January

1, 2017, but can start as late as October 1, 2017 (must report data for 90 continuous days).

• If physician participates in an Advanced APM,

physician does not have to report quality data under MIPS. To just get by in 2017 report on one measure, one CPIA, or report on a portion of the ACI component. One must only do any single one of these items , not all three to avoid a penalty in 2019.

WH WHAT A ARE WE WE WAITING NG FOR?

• Benchmarks on quality measures
• Confirmation on what specific activities count as

an Improvement Activity

• Example: Bio Preparedness
• Tool to attest to Improvement Activities
• Additional information and tools to understand

the scoring component of MIPS

Useful Resource: AMA MACRA Estimator

https://apps.ama-assn.org/pme/#/

QUESTIONS?

my email: cgrossman@hhs.com

CMS RESOURCES FOR THE QPP

 Quality Payment Program Website: https://qpp.cms.gov/  Quality Payment Program Final Rule with Comment Period: https://s3.amazonaws.com/public- inspection.federalregister.gov/2016-10032.pdf  Executive Summary of the Final Rule with Comment Period: https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf  Educational Tools: https://qpp.cms.gov/education  Questions on the QPP: QPP@cms.hhs.gov  More Help?: The Quality Payment Program Service Center is available to help.

 1-866-288-8292 TTY: 1-877-715-6222 Available Monday – Friday, 8:00AM – 8:00PM Eastern Time

CMS RESOURCES FOR THE QPP

Appendix: ADVANCING CARE INFORMATION PERFORMANCE CATEGORY

BASE SCORE = 50%

Security Risk Analysis

E-Prescribing

Provide Patient Access Send a Summary of Care

Request/ Accept Summary of Care

PERFORMANCE SCORE = 90%

Earn up to 10% for each measure reported in the performance score.

Patient-Specific Education Clinical Information Reconciliation View, Download, or Transmit (VDT) Secure Messaging Patient- Generated Health Data Immunization Registry Reporting Provide Patient Access Send a Summary of Care Request/Accept a Summary of Care

Public Health/Clinical Data Registry Reporting: 5 percent for reporting to one or more public health or clinical data registries beyond the Immunization Registry Reporting measure Submitting IAs Using CEHRT: 10 percent bonus if a MIPS eligible clinician attests to completing at least one of the improvement activities specified in Table 8 using CEHRT

MAX ACI SCORE =

155%

(capped at 100%)

BONUS = 15%