MACRA MIPS and CME Working Group 3/17/16 MACRA, MIPS and CME - - PowerPoint PPT Presentation

MACRA MIPS and CME

Working Group 3/17/16

MACRA, MIPS and CME

• Enacted in April 2015
• Eliminates SGR; Requires EHR interoperability by 2018
• Creates Two New Payment Paths for Medicare Eligible

Provider Reimbursement

• Path 1: Alternative Payment Model (APM’s)
• Path 2: Merit Based Incentive Payment System (MIPS)
• MIPS 2017 performance measures determines 2019

Payments

• APM selection is necessary before 2019

Healthcare Reform and Transformation

• Legislation and Healthcare Change
• 1985 eClaims and eRemits Available – Limited Use
• 1996 – HIPAA Enacted (Kennedy-Kassebaum Act)

▪Standardization of Electronic Admin. and Financial Data

▪ Unique Health Identifiers

▪Security and Privacy

• Today, ‘Care/’Caid and Commercial nearly 100% Electronic
• 2008 – MIPPA – ePrescribing

▪4% of Physicians used eRx in 2004 ▪Today, 73% Physicians use eRx; 58% of ALL Prescriptions!

• 2009 – ARRA/HITECH – Certified EHR Technology …
• 30% of physicians used EHR in 2009
• Today 78% Use EHR

In the HIMSS analysis of results, only 3 percent of respondents said they believe their organization is highly prepared to make the transition to pay for value from the current reimbursement approach of fee-for- service.

http://s3.amazonaws.com/rdcms-himss/files/production/public/FileDownloads/2016-cost%20-accounting- survey-executive-summary.pdf

Payment Evolution

Today – MACRA → Two Payment Paths Alternative Payment Model Differential FFS based on measured performance (MIPS)

Path 1: Alternative Payment Models (APMs)

• 2019-24 → 5% Medicare Bonus
• Under MACRA, APM includes the following for Medicare

patients:

− PCMHs − CMMI Models (except grant awards), including:

▪ Bundled Payments ▪ Primary Care Transformation

− ACOs under Medicare Shared-Savings Program (MSSP) − Select Medicare demonstrations − Other demonstrations required by law

• APM must accept more than nominal risk
• All Programs are Data Capture and Reporting

Path 2: Merit Based Incentive Payment System (MIPS)

• Incorporates three existing programs into one program
• Meaningful Use (Started in 2011)
• Physician Quality Reporting System (Started in 2007)
• Value Based Modifier (First applied in 2015)
• Adds an additional category “Clinical Practice

Improvement Activities” (CPIA)

• MIPS Scores will
• Drive reimbursement levels, and
• Posted publicly on Physicians Compare Website

Eligible Professionals in MIPS

• Eligible professionals (EPs) for 2017 and 2018 include:
• Physicians, physician assistants, nurse practitioners, clinical

nurse specialists, and nurse anesthetists.

• In 2019, more professionals become eligible for MIPS,

including:

• Physical or occupational therapists, speech language

pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dieticians or nutrition professionals.

Some Providers Exempt from MIPS

• Providers who do not meet the "low volume threshold"
• Medicare Shared Savings Program Accountable Care Organization

providers and other participants in alternative payment models and

• First Year Medicare providers
• The aforementioned "low volume threshold" can be one of three

things:

• The minimum number of individuals enrolled under Medicare who are

treated by the EP for the performance period;

• The minimum number of items and services furnished to individuals enrolled

under Medicare by the EP for the performance period or;

• The minimum amount of allowed charges billed by the EP under Medicare

for the performance period.

MIPS Consolidation of Current CMS Programs

Year Meaningful Use Quality – PQRS Resource Use - VBM Clinical Practice Improvemen t Total Points 2017 Reporting 2019 Payments 25 Pts 50 Pts 10 Pts 15 Pts 100 Pts 2018 Reporting 2020 Payments 25 Pts 45 Pts 15 Pts 15 Pts 100 Pts 2019 Reporting 25 Pts 30 Pts 30 Pts 15 Pts 100 Pts

MIPS Payment Adjustments

• 15%
• 8%

0% 8% 15% 23% 30%

• 9%
• 9%
• 7%
• 5%
• 4%

27% 27% 21% 15% 12%

Positive Adjustment Negitive Adjustment

• 2019
• Negative Adjustment

2020 2021 2022 2023 and Beyond

Physician Quality Reporting System (PQRS)

• Standardized federal reporting on Medicare Quality Measures
• Combining Several Sources of Measures for MIPS
• Several Methods of Reporting

• Electronic Health Record (EHR Direct)

• Qualified Clinical Data Registry (QCDR)

• Group Practice Reporting Option (GPRO)

• CMS-Certified Survey Vendor
• Important that Physicians Understand which Quality Measures are More

Important than others and evidence behind them,

• CE Education Is Important for learning the basics of reporting quality

measures and providing context to the MIPS program

https://www.facs.org/~/media/files/advocacy/regulatory/ 2013_pqrserx_experience_report.ashx

Meaningful Use

• Medicare EHR Incentive Program
• Based on usage of EHR System and How it is implemented
• Core Objectives
• Patient Access to Medical Records
• Interoperability of Data
• Training is provided by the EHR Companies but Often Missing

Clinical Context

• Need for Education on How EHR and other health IT can help

improve patient outcomes

Low Number of EP’s Attested 
 to Meaningful Use

• Eligible Providers
• Approx. 1,000,000 Total EPs
• 303,801 EPs had attested in 2014 - 30% of EP’s
• 303,588 Successfully
• 213 Unsuccessfully
• 59,605 for Stage 2 - 6.0% of EP’s
• Hospitals
• 5,414 Total Hospitals
• 4,444 Hospital had attested
• All successfully for Stage 1
• 1,835 for Stage 2

Source https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ HITPC_January2016_Fulldeck.pdf

Value Based Payment Modifier (VM)

• Based on Quality and Efficiency Tiering
• Some Credit for Participating in Data Registry
• Quality and Efficiency Tiers based on Peer Performance Data
• IOM’s → 6 Areas of Quality Measurement (2001) – “Crossing the Quality

Chasm”

• Per Capita Costs for All Attributed Beneficiaries and Per Capita Costs

for Beneficiaries with Specific Conditions measures

• The four condition-specific per capita cost measures include the costs of

beneficiaries with diabetes, chronic obstructive pulmonary disease, coronary artery disease, and heart failure.

• Claims Data
• Consumer Assessment of Healthcare Providers & Systems (CAHPS) and

Physician Quality Reporting System (PQRS) measures

• Little Knowledge of this System, High Failures to Capture Data

Consistently and Accurately; and, Report Correctly

Performance on VBM 2016 Physician Fee Schedule

13,813

Physician groups with 10+ eligible professionals (EPs) were subject to the VM

588,167

Physician/TIN combinations impacted

30.9

Billion dollars in 2014 payments reviewed

128

Groups exceed quality and efficiency benchmarks against national mean = eligible for an upward payment adjustment (factor +15.92% or +31.48%) .9% of Eligible Groups received bonus, representing 4,273 physicians

59

Groups in the lower quality/efficiency performance quadrant and subject to a negative payment adjustment (-1.0% to -2.0%)

5,418

Groups were unsuccessful in minimum reporting requirements compliance (PQRS) = decrease in 2016 Medicare payments (-2.0%) – outside budget neutral calculations 39% failed in submission of paperwork. – Penalties represented 141,382 Physicians

8,208

Groups met minimum reporting requirements for unchanged 2016 reimbursement 59% saw no changes in reimbursement

Failure to report (technology/compliance issue) or measure strong performance in relation to quality and efficiency measures impacts reimbursement. Note: Physicians participating in a CMS ACO are not subject to the ACA VM https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-VM-Overview-PDF-Memo.pdf

Total Incentive Performance

Program Participation Incentive Payment No Difference Penalties

PQRS 51% 39% 12% 49% Meaningful Use 48% 48% Stage 1 6% Stage 2 52% Value Based Modifier 61% 01% 60% 39%

Clinical Practice Improvement Activity (CPIA)

• Brand New Measurement Category
• Definition: The term "Clinical Practice Improvement Activity"

is defined as an activity that relevant eligible professional

• rganizations and other stakeholders identify as one that

improves clinical practice or care delivery and that the Secretary determines is likely to result in improved outcomes.

• Desired Results: The CPIA will assess healthcare professionals
• n their effort to engage in continuing education and working

to improve their practices and facilitate future participation in APMs.

CME

Reasons To Have CME Recognized In MIPS

• CME has long been recognized as a means by which physicians (aka

Eligible Providers) demonstrate that they are engaging in Continuing Professional Development (CPD) to maintain the knowledge, skills, and practice performance that lead to optimal patient outcomes.

• Lifelong learning, assessment and improvement are integrally
• related. Learning is a necessary component of the change process

that results in meaningful, sustained Clinical Performance Improvement.

• Without learning, assessment and professional development, the

measurement of adherence to quality metrics, and health information technology usage on their own are insufficient to produce clinical performance improvement.

More Reasons

• Society will continue to need Health Care Professionals (HCPs), also known as

Eligible Providers (EP’s) to engage in lifelong learning, assessment and improvement in practice. Thus, it is important that those activities be recognized and rewarded in the value-based payment constructs that are increasingly being promulgated by private payers and by CMS (MACRA).

• If CME/CE is not recognized within the new Value Based Payment constructs, there is a real

risk that CME/CE/CPD may become a defacto “unfunded mandate” – a professional obligation without incentives or other reinforcing mechanisms.

• EP’s should be credited for their efforts to stay current with clinical practice and

quality measures by utilizing CME. The inclusion of CME as a Clinical Practice Improvement Activity recognized by CMS will help EP’s retain credit for the time EP’s invest in learning about practice improvement.

• EP’s Sources of Information on QI requirements are limited and participation can
• nly be increased with education.
• Failure to learn about rampant change afoot under healthcare reform will place

HCPs at risk financially, operationally and clinically

• Accredited Education is an understandable, predefined measure.

Another Key Reason: Accredited CME in MIPS Utilizes Existing Structures for Change

• There are mechanisms in place to ensure that

accredited/certified CME activities are:

• Designed to address clinicians’ practice-relevant

learning needs and practice gaps;

• Evaluated to measure the educational and clinical

impact of those learning activities;

• Planned and provided independent from commercial

influence or other biases.

MARCA Implementation Timeline

Important Event Dates

MACRA Draft Rule Summer 2016 MACRA Final Rule 4th Qtr. 2016 MIPS Initial Reporting Period (Application Year 2019) 2017 MIPS Initial Feedback – Confidential Quarterly Reporting July 1, 2017 Information about Plurality of Care and Medicare Spending Per Beneficiary (MSPB) July 1, 2018 Payment Adjustment – 1st Year 2019 APM Election deadline for 2019 TBD

MEDX SURVEY RESULTS

Q1: Are you familiar with the Triple Aim and the six priorities of National Quality Strategy? (n=403)

Yes No 80.1% 19.6%

MEDX SURVEY RESULTS

(Statement before Question 2) The National Quality Strategy was first published in March 2011 and is led by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Health and Human Services. Established as part of the Affordable Care Act, the National Quality Strategy serves as a catalyst and compass for a nationwide focus on quality improvement efforts and approach to measuring quality. The National Quality Strategy is guided by Three Aims: provide better, more affordable care for individuals and the community.

MEDX SURVEY RESULTS

Q2: Would attending a CME conference that aligns clinical education with the NQS Priorities be of value to you? (n=403)

Yes No 7.0% 93.0%

There is a great need to organize, design, and offer programs that align to the Triple Aim of access, quality, and cost.